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Ajanovic S, Madewell ZJ, El Arifeen S, Gurley ES, Hossain MZ, Islam KM, Rahman A, Assefa N, Madrid L, Abdulahi M, Igunza KA, Murila F, Revathi G, Christopher M, Sow SO, Kotloff KL, Tapia MD, Traor CB, Mandomando I, Xerinda E, Varo R, Kincardett M, Ogbuanu IU, Nwajiobi-Princewill P, Swarray-Deen A, Luke R, Madhi SA, Mahtab S, Dangor Z, du Toit J, Akelo V, Mutevedzi P, Tippett Barr BA, Blau DM, Whitney CG, Bassat Q. Neurological Symptoms and Cause of Death Among Young Children in Low- and Middle-Income Countries. JAMA Netw Open 2024; 7:e2431512. [PMID: 39226053 PMCID: PMC11372484 DOI: 10.1001/jamanetworkopen.2024.31512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
Abstract
Importance The emergence of acute neurological symptoms in children necessitates immediate intervention. Although low- and middle-income countries (LMICs) bear the highest burden of neurological diseases, there is a scarcity of diagnostic and therapeutic resources. Therefore, current understanding of the etiology of neurological emergencies in LMICs relies mainly on clinical diagnoses and verbal autopsies. Objective To characterize the association of premortem neurological symptoms and their management with postmortem-confirmed cause of death among children aged younger than 5 years in LMICs and to identify current gaps and improve strategies to enhance child survival. Design, Setting, and Participants This cross-sectional study was conducted between December 3, 2016, and July 22, 2022, at the 7 participating sites in the Child Health and Mortality Prevention Surveillance (CHAMPS) network (Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa). Minimally invasive tissue sampling was performed at the CHAMPS sites with specimens from deceased children aged younger than 5 years. This study included deceased children who underwent a premortem neurological evaluation and had a postmortem-confirmed cause of death. Data analysis was performed between July 22, 2022, and January 15, 2023. Main Outcomes and Measures Descriptive analysis was performed using neurological evaluations from premortem clinical records and from postmortem determination of cause of death (based on histopathology, microbiological testing, clinical records, and verbal autopsies). Results Of the 2127 deaths of children codified during the study period, 1330 (62.5%) had neurological evaluations recorded and were included in this analysis. The 1330 children had a median age of 11 (IQR, 2-324) days; 745 (56.0%) were male and 727 (54.7%) presented with neurological symptoms during illness before death. The most common postmortem-confirmed neurological diagnoses related to death were hypoxic events (308 [23.2%]), meningoencephalitis (135 [10.2%]), and cerebral malaria (68 [5.1%]). There were 12 neonates with overlapping hypoxic events and meningoencephalitis, but there were no patients with overlapping meningoencephalitis and cerebral malaria. Neurological symptoms were similar among diagnoses, and no combination of symptoms was accurate in differentiating them without complementary tools. However, only 25 children (18.5%) with meningitis had a lumbar puncture performed before death. Nearly 90% of deaths (442 of 511 [86.5%]) with neurological diagnoses in the chain of events leading to death were considered preventable. Conclusions and Relevance In this cross-sectional study of children aged younger than 5 years, neurological symptoms were frequent before death. However, clinical phenotypes were insufficient to differentiate the most common underlying neurological diagnoses. The low rate of lumbar punctures performed was especially worrying, suggesting a challenge in quality of care of children presenting with neurological symptoms. Improved diagnostic management of neurological emergencies is necessary to ultimately reduce mortality in this vulnerable population.
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Affiliation(s)
- Sara Ajanovic
- Barcelona Institute for Global Health, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigaçao em Saúde de Manhiça, Manhiça, Mozambique
| | - Zachary J Madewell
- Global Health Center, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Shams El Arifeen
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Emily S Gurley
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | | | - Kazi Munisul Islam
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Afruna Rahman
- International Center for Diarrhoeal Diseases Research, Dhaka, Bangladesh
| | - Nega Assefa
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
| | - Lola Madrid
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mohammednur Abdulahi
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Ayder Specialized Comprehensive Hospital, Mekelle University, Mekelle, Ethiopia
- Addis Ababa University, Addis Ababa, Ethiopia
| | | | | | - Gunturu Revathi
- Department of Pathology, Aga Khan University Hospital, Nairobi, Kenya
- Kisumu County of Department of Health, Kisumu, Kenya
| | | | - Samba O Sow
- Centre pour le Développement des Vaccins, Ministère de la Santé, Bamako, Mali
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Karen L Kotloff
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | - Milagritos D Tapia
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore
| | | | - Inacio Mandomando
- Barcelona Institute for Global Health, Barcelona, Spain
- Centro de Investigaçao em Saúde de Manhiça, Manhiça, Mozambique
- Instituto Nacional de Saude, Maputo, Mozambique
| | - Elisio Xerinda
- Centro de Investigaçao em Saúde de Manhiça, Manhiça, Mozambique
- Instituto Nacional de Saude, Maputo, Mozambique
| | - Rosauro Varo
- Barcelona Institute for Global Health, Barcelona, Spain
- Centro de Investigaçao em Saúde de Manhiça, Manhiça, Mozambique
| | - Milton Kincardett
- Centro de Investigaçao em Saúde de Manhiça, Manhiça, Mozambique
- Instituto Nacional de Saude, Maputo, Mozambique
| | - Ikechukwu U Ogbuanu
- Crown Agents, Freetown, Sierra Leone
- World Hope International, Freetown, Sierra Leone
| | | | - Alim Swarray-Deen
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, Accra, Ghana
| | - Ronita Luke
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Shabir A Madhi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sana Mahtab
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ziyaad Dangor
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jeanie du Toit
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Victor Akelo
- US Centers for Disease Control and Prevention, Nairobi and Kisumu, Kenya
| | - Portia Mutevedzi
- South African Medical Research Council Vaccines and Infectious Diseases Analytics Research Unit, Infectious Diseases and Oncology Research Institute, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Beth A Tippett Barr
- US Centers for Disease Control and Prevention, Nairobi and Kisumu, Kenya
- Nyanja Health Research Institute, Salima, Malawi
| | - Dianna M Blau
- Global Health Center, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Cynthia G Whitney
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Quique Bassat
- Barcelona Institute for Global Health, Barcelona, Spain
- University of Barcelona, Barcelona, Spain
- Centro de Investigaçao em Saúde de Manhiça, Manhiça, Mozambique
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain
- Pediatrics Department, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
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Zulu MD, Msuku H, Stanley CC, Phiri VS, Topazian HM, Chinkhumba J, Hoffman IF, Juliano JJ, Mathanga DP, Mvalo T. An intervention to improve lumbar puncture rates for meningitis surveillance in children at four secondary health facilities in Malawi: A before/after analysis. Trop Med Int Health 2024; 29:499-506. [PMID: 38584312 DOI: 10.1111/tmi.13991] [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] [Indexed: 04/09/2024]
Abstract
OBJECTIVES A lumbar puncture (LP) procedure plays a key role in meningitis diagnosis. In Malawi and other sub-Saharan African countries, LP completion rates are sometimes poor, making meningitis surveillance challenging. Our objective was to measure LP rates following an intervention to improve these during a sentinel hospital meningitis surveillance exercise in Malawi. METHODS We conducted a before/after intervention analysis among under-five children admitted to paediatric wards at four secondary health facilities in Malawi. We used local and World Health Organization (WHO) guidelines to determine indications for LP, as these are widely used in low- and middle-income countries (LMIC). The intervention comprised of refresher trainings for facility staff on LP indications and procedure, use of automated reminders to perform LP in real time in the wards, with an electronic data management system, and addition of surveillance-specific clinical officers to support existing health facility staff with performing LPs. Due to the low numbers in the before/after analysis, we also performed a during/after analysis to supplement the findings. RESULTS A total of 13,375 under-five children were hospitalised over the 21 months window for this analysis. The LP rate was 10.4% (12/115) and 60.4% (32/53) in the before/after analysis, respectively, and 43.8% (441/1006) and 72.5% (424/599) in the supplemental during/after analysis, respectively. In our intervention-specific analysis among the three individual components, there were improvements in the LP rate by 48% (p < 0.001) following the introduction of surveillance-specific clinical officers, 10% (p < 0.001) following the introduction of automated reminders to perform an LP and 13% following refresher training. CONCLUSIONS This analysis demonstrated a rise in LP rates following our intervention. This intervention package may be considered for planning future facility-based meningitis surveillances in similar low-resource settings.
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Affiliation(s)
- Madalitso D Zulu
- University of North Carolina Project Malawi (UNCPM), Lilongwe, Malawi
| | - Harrison Msuku
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Christopher C Stanley
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Vincent S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Hillary M Topazian
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Jobiba Chinkhumba
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Irving F Hoffman
- University of North Carolina Project Malawi (UNCPM), Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Jonathan J Juliano
- University of North Carolina Project Malawi (UNCPM), Lilongwe, Malawi
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
| | - Don P Mathanga
- MAC-Communicable Diseases Action Centre, Kamuzu University of Health Sciences, Blantyre, Malawi
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Tisungane Mvalo
- University of North Carolina Project Malawi (UNCPM), Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
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Waldrop GE, Cocuzzo K, Schneider CL, Kim CY, Goetz TG, Chomba MS, Delaurentis CE, Smithgall MC, Francis RO, Thakur KT. Accuracy of automated analyzers for the estimation of CSF cell counts: A systematic review and meta-analysis. Int J Lab Hematol 2024; 46:234-242. [PMID: 38323691 DOI: 10.1111/ijlh.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 01/11/2024] [Indexed: 02/08/2024]
Abstract
This systematic review evaluates the evidence for accuracy of automated analyzers that estimate cerebrospinal fluid (CSF) white blood cell counts (WBC) compared to manual microscopy. Inclusion criteria of original research articles included human subjects, English language, and manual microscopy comparator. PUBMED, EMBASE and Cochrane Review databases were searched through 2019 and QUADAS-2 Tool was used for assessment of bias. Data were pooled and analyzed by comparison method, using random effects estimation. Among 652 titles, 554 abstracts screened, 104 full-text review, 111 comparisons from 41 studies were included. Pooled estimates of sensitivity and specificity (n = 7) were 95% (95%-CI 93%-97%) and 84% (95%-CI: 64%-96%), respectively. Pooled R2 estimates (n = 29) were 0.95 (95%-CI: 0.95-0.96); Pooled spearman rho correlation (n = 27) estimates were 0.95 (95% CI 0.95-0.96). Among those comparisons using Bland-Altman analysis (n = 11) pooled mean difference was estimated at 0.98 (95% CI-0.54-2.5). Among comparisons using Passing-Bablok regressions (n = 14) the pooled slope was estimated to be 1.05 (95% CI 1.03-1.07). Q tests of homogeneity were all significant with the exception of the Bland-Altman comparisons (I2 10%, p value 0.35). There is good overall accuracy for CSF WBC by automated hematologic analyzers. These findings are limited by the small sample sizes and inconsistent validation methodology in the reviewed studies.
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Affiliation(s)
- Greer E Waldrop
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Kaitlyn Cocuzzo
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Colleen L Schneider
- Medical Scientist Training Program, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Carla Y Kim
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Teddy G Goetz
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
| | - Mashina S Chomba
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
- School of Medicine, University Teaching Hospital and University of Zambia, Lusaka, Zambia
| | - Clare E Delaurentis
- Department of Infectious Disease, Columbia University Irving Medical Center, New York, New York, USA
| | - Marie C Smithgall
- Department of Pathology, Weill Cornell Medicine, New York, New York, USA
| | - Richard O Francis
- Department of Pathology & Cell Biology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Kiran T Thakur
- Department of Neurology, Columbia University Irving Medical Center-New York Presbyterian Hospital, New York, New York, USA
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Shrestha GS, Nepal G, Prust ML. Developing Systems of Emergency and Inpatient Neurologic Care in Resource-Limited Settings. Semin Neurol 2024; 44:105-118. [PMID: 38485125 DOI: 10.1055/s-0043-1778638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Neurologic diseases represent a significant global health challenge, leading to disability and mortality worldwide. Healthcare systems in low- and middle-income countries are disproportionally affected. In these resource-limited settings, numerous barriers hinder the effective delivery of emergency and inpatient neurologic care, including shortages of trained personnel, limited access to diagnostics and essential medications, inadequate facilities, and absence of rehabilitation services. Disparities in the neurology workforce, limited access to neuroimaging, and availability of acute interventions further exacerbate the problem. This article explores strategies to enhance global capacity for inpatient neurologic care, emphasizing the importance of workforce development, context-specific protocols, telehealth solutions, advocacy efforts, and collaborations.
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Affiliation(s)
- Gentle Sunder Shrestha
- Department of Critical Care Medicine, Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu, Nepal
| | - Gaurav Nepal
- Department of General Medicine, Rani Primary Healthcare Centre, Rani, Biratnagar, Nepal
| | - Morgan Lippitt Prust
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Nwamekang Belinga L, Espourteille J, Wepnyu Njamnshi Y, Zafack Zeukang A, Rouaud O, Kongnyu Njamnshi A, Allali G, Richetin K. Circulating Biomarkers for Alzheimer's Disease: Unlocking the Diagnostic Potential in Low- and Middle-Income Countries, Focusing on Africa. NEURODEGENER DIS 2024; 24:26-40. [PMID: 38555638 PMCID: PMC11251669 DOI: 10.1159/000538623] [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: 12/13/2023] [Accepted: 03/28/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Alzheimer's disease (AD) is emerging as a significant public health challenge in Africa, with predictions indicating a tripling in incidence by 2050. The diagnosis of AD on the African continent is notably difficult, leading to late detection that severely limits treatment options and significantly impacts the quality of life for patients and their families. SUMMARY This review focuses on the potential of high-sensitivity specific blood biomarkers as promising tools for improving AD diagnosis and management globally, particularly in Africa. These advances are particularly pertinent in the continent, where access to medical and technical resources is often limited. KEY MESSAGES Identifying precise, sensitive, and specific blood biomarkers could contribute to the biological characterization and management of AD in Africa. Such advances promise to improve patient care and pave the way for new regional opportunities in pharmaceutical research and drug trials on the continent for AD.
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Affiliation(s)
- Luc Nwamekang Belinga
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Geneva, Switzerland
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Jeanne Espourteille
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Yembe Wepnyu Njamnshi
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Geneva, Switzerland
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
- Neuroscience Lab, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
- Division of Health Operations Research, Ministry of Public Health, Yaoundé, Cameroon
| | - Ariole Zafack Zeukang
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Geneva, Switzerland
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
| | - Olivier Rouaud
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Alfred Kongnyu Njamnshi
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Geneva, Switzerland
- Department of Translational Neuroscience, Brain Research Africa Initiative (BRAIN), Yaoundé, Cameroon
- Neuroscience Lab, Faculty of Medicine and Biomedical Sciences, The University of Yaoundé I, Yaoundé, Cameroon
- Department of Clinical Neuroscience and Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Gilles Allali
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Kevin Richetin
- Department of Psychiatry, Center for Psychiatric Neurosciences, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
- Leenaards Memory Center, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
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Masood S, Farrukh R, Naseer A, Saqib M, Kadri A, Shakoor I, Mustafa S, Mumtaz H. Factors influencing refusal of lumbar puncture in children under age 10: a cross-sectional study. Ann Med Surg (Lond) 2023; 85:5372-5378. [PMID: 37915635 PMCID: PMC10617865 DOI: 10.1097/ms9.0000000000001176] [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] [Received: 06/05/2023] [Accepted: 08/06/2023] [Indexed: 11/03/2023] Open
Abstract
Background This study aimed to investigate the factors associated with refusal of lumbar puncture (LP) in children aged 1-10 years who presented to a paediatric department in our hospital. Methods A sample of parents and guardians of children who presented to the paediatric department were surveyed to gather information about their educational background and decision-making processes. Attending doctors were also interviewed using a questionnaire to gather their perspectives on the reasons for LP refusal in children. Attending doctors then tried to convince the parents or guardians to see if it changed their decision. Results The study found that the majority of parents and guardians had a lower educational background, with over half being illiterate. Refusal of LP was seen most frequently in parents or guardians who were illiterate. The decision-making process was found to be heavily dependent on the father in a male-dominated society. Peer pressure and lack of knowledge were found to be factors that contributed to LP refusal. Conclusion Refusal of a LP was linked to having a lower educational background and to societal influences in this cross-sectional study of children aged 1-10 years. More than half of the parents and guardians were illiterate, indicating that they had a lower level of education. Refusing LP was influenced by a number of factors, including social pressure and a lack of information. However, these obstacles were overcome thanks to the efforts of the attending doctors who dispelled myths and reassured the parents and guardians of the necessity and safety of the procedure. Possible roadblocks include a lack of financial resources and common misconceptions about LP. These results highlight the significance of addressing educational and societal factors to enhance children's healthcare.
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Affiliation(s)
- Shaheen Masood
- Abbasi Shaheed Hospital, Karachi Medical and Dental College
| | - Riffat Farrukh
- Abbasi Shaheed Hospital, Karachi Medical and Dental College
| | - Amber Naseer
- Abbasi Shaheed Hospital, Karachi Medical and Dental College
| | | | | | | | - Sultan Mustafa
- Abbasi Shaheed Hospital, Karachi Medical and Dental College
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Mupeta F, Sivile S, Toeque MG, Fwoloshi S, Zulu PM, Chanda D, Mbewe N, Mwitumwa M, Chanda C, Kandiwo N, Ziko L, Mwansa T, Matibula P, Mugala A, Traver EC, Tripathi RK, Heil EL, Patel DM, Riedel DJ, Hachaambwa L, Mulenga L, Claassen CW. The UTH-UMB Global Health Education Collaboration: Building a Bidirectional Exchange Based on Equity and Reciprocity. Ann Glob Health 2023; 89:52. [PMID: 37575336 PMCID: PMC10418132 DOI: 10.5334/aogh.3718] [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: 01/25/2022] [Accepted: 06/26/2023] [Indexed: 08/15/2023] Open
Abstract
The global health exchange program between the University Teaching Hospitals (UTH) of Lusaka, Zambia and the University of Maryland, Baltimore (UMB) has been operating since 2015. As trainees and facilitators of this exchange program, we describe our experiences working in Lusaka and Baltimore, and strengths and challenges of the partnership. Since 2015, we have facilitated rotations for 71 UMB trainees, who spent four weeks on the Infectious Disease (ID) team at UTH. Since 2019 with funding from UMB, nine UTH ID trainee physicians spent up to six weeks each rotating on various ID consult services at University of Maryland Medical Center (UMMC). Challenges in global health rotations can include inadequate preparation or inappropriate expectations among high-income country trainees, low-value experiences for low- and middle-income country trainees, lack of appropriate mentorship at sites, and power imbalances in research collaborations. We try to mitigate these issues by ensuring pre-departure and on-site orientation for UMB trainees, cross-cultural mentored experiences for all trainees, and intentional sharing of authorship and credit on scientific collaborations. We present a description of our medical education collaboration as a successful model for building equitable and reciprocal collaborations between low- and middle-income countries and high-income countries, and offer suggestions for future program initiatives to enhance global health education equity among participants and organizations.
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Affiliation(s)
- Francis Mupeta
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Suilanji Sivile
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Ministry of Health, Ndeke House, Lusaka, ZM
| | - Mona-Gekanju Toeque
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sombo Fwoloshi
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Paul Msanzya Zulu
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Duncan Chanda
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Nyuma Mbewe
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Department of Internal Medicine, Ndola Teaching Hospital, Ndola, ZM
| | - Mundia Mwitumwa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Chitalu Chanda
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Zambia National Public Health Institute, Lusaka, ZM
| | - Nyakulira Kandiwo
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Luunga Ziko
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Tilele Mwansa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Peter Matibula
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Anchidinka Mugala
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | | | | | - Emily L. Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Devang M. Patel
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J. Riedel
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lottie Hachaambwa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lloyd Mulenga
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Ministry of Health, Ndeke House, Lusaka, ZM
| | - Cassidy W. Claassen
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
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8
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Saylor D, Elafros M, Bearden D, Dallah I, Mathews M, Muchanga G, Mwale M, Mwenechanya M, Siddiqi OK, Winch PJ, Somwe SW, Birbeck GL. Patient, Provider, and Health Systems Factors Leading to Lumbar Puncture Nonperformance in Zambia: A Qualitative Investigation of the "Tap Gap". Am J Trop Med Hyg 2023; 108:1052-1062. [PMID: 36972691 PMCID: PMC10160901 DOI: 10.4269/ajtmh.22-0699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 01/22/2023] [Indexed: 03/29/2023] Open
Abstract
Lumbar puncture (LP) and cerebrospinal fluid (CSF) diagnostics are critical for evaluating central nervous system infections but are often not conducted, resulting in the "Tap Gap." To investigate patient, provider, and health systems factors contributing to the Tap Gap in Zambia, we conducted focus group discussions with adult caregivers of hospitalized inpatients and in-depth interviews with nurses, clinicians, pharmacy workers, and laboratory staff. Transcripts were independently thematically categorized by two investigators using inductive coding. We identified seven patient-related factors: 1) alternative understandings of CSF; 2) alternative information about LPs, including misinformation; 3) mistrust of doctors; 4) consent delays; 5) fear of blame; 6) peer pressure against consent; and 7) association between LP and stigmatized conditions. Four clinician-related factors were identified: 1) limited LP knowledge and expertise, 2) time constraints, 3) delays in LP requests by clinicians, and 4) fear of blame for bad outcomes. Finally, five health systems-related factors were identified: 1) supply shortages, 2) constrained access to neuroimaging, 3) laboratory factors, 4) availability of antimicrobial medications, and 5) cost barriers. Efforts to improve LP uptake must incorporate interventions to increase patient/proxy willingness to consent and improve clinician LP competencies while addressing both upstream and downstream health system factors. Key upstream factors include inconsistently available consumables for performing LPs and lack of neuroimaging. Critical downstream factors include laboratory services that offer poor availability, reliability, and/or timeliness of CSF diagnostics and the reality that medications needed to treat diagnosed infections are often unavailable unless the family has resources to purchase privately.
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Affiliation(s)
- Deanna Saylor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Internal Medicine, University Teaching Hospitals—Adult Hospital, Lusaka, Zambia
| | - Melissa Elafros
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - David Bearden
- Department of Child Neurology, University of Rochester Medical Center, Rochester, New York
| | - Ifunanya Dallah
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
| | - Manoj Mathews
- Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia
| | | | | | - Musaku Mwenechanya
- Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia
| | - Omar K. Siddiqi
- Department of Internal Medicine, University Teaching Hospitals—Adult Hospital, Lusaka, Zambia
- Global Neurology Program, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Center for Vaccines and Virology Research, Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Peter J. Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Somwe wa Somwe
- Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia
| | - Gretchen L. Birbeck
- Department of Neurology, University of Rochester Medical Center, Rochester, New York
- Department of Pediatrics, University Teaching Hospitals Neurology Research Office, Lusaka, Zambia
- School of Medicine, University of Zambia, Lusaka, Zambia
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9
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Muppidi P, Wright E, Wassmer SC, Gupta H. Diagnosis of cerebral malaria: Tools to reduce Plasmodium falciparum associated mortality. Front Cell Infect Microbiol 2023; 13:1090013. [PMID: 36844403 PMCID: PMC9947298 DOI: 10.3389/fcimb.2023.1090013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
Cerebral malaria (CM) is a major cause of mortality in Plasmodium falciparum (Pf) infection and is associated with the sequestration of parasitised erythrocytes in the microvasculature of the host's vital organs. Prompt diagnosis and treatment are key to a positive outcome in CM. However, current diagnostic tools remain inadequate to assess the degree of brain dysfunction associated with CM before the window for effective treatment closes. Several host and parasite factor-based biomarkers have been suggested as rapid diagnostic tools with potential for early CM diagnosis, however, no specific biomarker signature has been validated. Here, we provide an updated review on promising CM biomarker candidates and evaluate their applicability as point-of-care tools in malaria-endemic areas.
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Affiliation(s)
- Pranavi Muppidi
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Emily Wright
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samuel C. Wassmer
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Himanshu Gupta
- Department of Infection Biology, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Biotechnology, Institute of Applied Sciences & Humanities, GLA University, Mathura, UP, India
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10
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Adewale BA, Coker MM, Ogunniyi A, Kalaria RN, Akinyemi RO. Biomarkers and Risk Assessment of Alzheimer's Disease in Low- and Middle-Income Countries. J Alzheimers Dis 2023; 95:1339-1349. [PMID: 37694361 DOI: 10.3233/jad-221030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
Dementia is a chronic syndrome which is common among the elderly and is associated with significant morbidity and mortality for patients and their caregivers. Alzheimer's disease (AD), the most common form of clinical dementia, is biologically characterized by the deposition of amyloid-β plaques and neurofibrillary tangles in the brain. The onset of AD begins decades before manifestation of symptoms and clinical diagnosis, underlining the need to shift from clinical diagnosis of AD to a more objective diagnosis using biomarkers. Having performed a literature search of original articles and reviews on PubMed and Google Scholar, we present this review detailing the existing biomarkers and risk assessment tools for AD. The prevalence of dementia in low- and middle-income countries (LMICs) is predicted to increase over the next couple of years. Thus, we aimed to identify potential biomarkers that may be appropriate for use in LMICs, considering the following factors: sensitivity, specificity, invasiveness, and affordability of the biomarkers. We also explored risk assessment tools and the potential use of artificial intelligence/machine learning solutions for diagnosing, assessing risks, and monitoring the progression of AD in low-resource settings. Routine use of AD biomarkers has yet to gain sufficient ground in clinical settings. Therefore, clinical diagnosis of AD will remain the mainstay in LMICs for the foreseeable future. Efforts should be made towards the development of low-cost, easily administered risk assessment tools to identify individuals who are at risk of AD in the population. We recommend that stakeholders invest in education, research and development targeted towards effective risk assessment and management.
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Affiliation(s)
- Boluwatife Adeleye Adewale
- Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training (IAMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Motunrayo Mojoyin Coker
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training (IAMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Adesola Ogunniyi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training (IAMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurology, University College Hospital, Ibadan, Nigeria
| | - Rajesh N Kalaria
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training (IAMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria
- Translational and Clinical Research Institute, Newcastle University, United Kingdom
| | - Rufus Olusola Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training (IAMRAT), College of Medicine, University of Ibadan, Ibadan, Nigeria
- Department of Neurology, University College Hospital, Ibadan, Nigeria
- Centre for Genomic and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Translational and Clinical Research Institute, Newcastle University, United Kingdom
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11
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Mortel D, Kawatu N, Steiner TJ, Saylor D. Barriers to headache care in low- and middle-income countries. eNeurologicalSci 2022; 29:100427. [PMID: 36212617 PMCID: PMC9539775 DOI: 10.1016/j.ensci.2022.100427] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 09/26/2022] [Indexed: 11/23/2022] Open
Abstract
Headache disorders are a common cause of disability globally and lead not only to physical disability but also to financial strain, higher rates of mental health disorders such as depression and anxiety, and reduced economic productivity which negatively impacts gross domestic product (GDP) on a national scale. While data about headache are relatively scarce in low- and middle-income countries (LMICs), those available suggest that headache disorders occur on a similar scale in LMICs as they do in high-income countries. In this manuscript, we discuss common clinical, political, economic and social barriers to headache care for people living in LMICs. These barriers, affecting every aspect of headache care, begin with community perceptions and cultural beliefs about headache, include ineffective headache care delivery systems and poor headache care training for healthcare workers, and extend through fewer available diagnostic and management tools to limited therapeutic options for headache. Finally, we review potential solutions to these barriers, including educational interventions for healthcare workers, the introduction of a tiered system for headache care provision, creation of locally contextualized diagnostic and management algorithms, and implementation of a stepped approach to headache treatment.
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12
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Ravishankar M, Dallah I, Mathews M, Bositis CM, Mwenechanya M, Kalungwana‐Mambwe L, Bearden D, Navis A, Elafros MA, Gelbard H, Theodore WH, Koralnik IJ, Okulicz JF, Johnson BA, Belessiotis C, Ciccone O, Thornton N, Tsuboyama M, Siddiqi OK, Potchen MJ, Sikazwe I, Birbeck GL. Clinical characteristics and outcomes after new-onset seizure among Zambian children with HIV during the antiretroviral therapy era. Epilepsia Open 2022; 7:315-324. [PMID: 35305291 PMCID: PMC9159241 DOI: 10.1002/epi4.12595] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 03/10/2022] [Accepted: 03/12/2022] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE This study describes clinical profiles including human immunodeficiency virus (HIV) disease history and seizure etiology among children living with HIV presenting with new-onset seizure during the era of antiretroviral therapy (ART) in Zambia. 30-day mortality and cause of death are also reported. METHODS Children living with HIV (CLWHIV) with new-onset seizures were prospectively evaluated at one large urban teaching hospital and two non-urban healthcare facilities. Interviews with family members, review of medical records, and where needed, verbal autopsies were undertaken. Two clinicians who were not responsible for the patients' care independently reviewed all records and assigned seizure etiology and cause of death with adjudication as needed. RESULTS From April 2016 to June 2019, 73 children (49 urban, 24 rural) were identified. Median age was 6 years (IQR 2.2-10.0) and 39 (53%) were male children. Seizures were focal in 36 (49%) and were often severe, with 37% presenting with multiple recurrent seizures in the 24 hours before admission or in status epilepticus. Although 36 (49%) were on ART at enrollment, only 7 of 36 (19%) were virally suppressed. Seizure etiologies were infectious in over half (54%), with HIV encephalitis, bacterial meningitis, and tuberculous meningitis being the most common. Metabolic causes (19%) included renal failure and hypoglycemia. Structural lesions identified on imaging accounted for 10% of etiologies and included stroke and non-accidental trauma. No etiology could be identified in 12 (16%) children, most of whom died before the completion of clinical investigations. Twenty-two (30%) children died within 30 days of the index seizure. SIGNIFICANCE Despite widespread ART roll out in Zambia, new-onset seizure in CLWHIV occurs in the setting of advanced, active HIV disease. Seizure severity/burden is high as is early mortality. Enhanced programs to assure early ART initiation, improve adherence, and address ART failure are needed to reduce the burden of neurological injury and premature death in CLWHIV.
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Affiliation(s)
| | - Ifunanya Dallah
- Center for Health + TechnologyUniversity of Rochester Medical CenterRochesterNew YorkUSA
| | - Manoj Mathews
- University Teaching Hospitals Children's HospitalLusakaZambia
| | | | | | | | - David Bearden
- University of Rochester Medical CenterRochesterNew YorkUSA
| | | | | | - Harris Gelbard
- University of Rochester Medical CenterRochesterNew YorkUSA
| | | | - Igor J. Koralnik
- Northwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | | | | | | | - Ornella Ciccone
- University Teaching Hospitals Children's HospitalLusakaZambia
- University of ZambiaLusakaZambia
| | | | | | | | - Michael J. Potchen
- University of Rochester Medical CenterRochesterNew YorkUSA
- Zambian College of Medicine & SurgeryLusakaZambia
| | | | - Gretchen L. Birbeck
- University Teaching Hospitals Children's HospitalLusakaZambia
- Epilepsy DivisionDepartment of NeurologyUniversity of RochesterRochesterNew YorkUSA
- Epilepsy Care TeamChikankata HospitalMazabukaZambia
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13
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MAKADZANGE TA, HLUPENI A, MACHEKANO R, BOYD K, MTISI T, NYAMAYARO P, ROSS C, VALLABHANENI S, BALACHANDRA S, CHONZI P, NDHLOVU CE. Survival following screening and preemptive antifungal therapy for subclinical cryptococcal disease in advanced HIV infection. AIDS 2021; 35:1929-1938. [PMID: 34101629 PMCID: PMC8416705 DOI: 10.1097/qad.0000000000002971] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Our study's primary objective was to compare 1-year survival rates between serum cryptococcal antigen (sCrAg)-positive and sCrAg-negative HIV-positive individuals with CD4+ cell counts less than 100 cells/μl without symptoms of meningitis in Zimbabwe. DESIGN This was a prospective cohort study. METHODS Participants were enrolled as either sCrAg-positive or sCrAg-negative and followed up for 52 weeks or less, with death as the outcome. Lumbar punctures were recommended to all sCrAg-positives and inpatient management with intravenous amphotericin B and high-dose fluconazole was recommended to those with disseminated Cryptococcus. Antiretroviral therapy was initiated immediately in sCrAg-negatives and after at least 4 weeks following initiation of antifungals in sCrAg-positives. Multivariable logistic regression models were used to determine risk factors for mortality. RESULTS We enrolled 1320 participants and 130 (9.8%) were sCrAg positive, with a median sCrAg titre of 1 : 20. Sixty-six (50.8%) sCrAg-positives had lumbar punctures and 16.7% (11/66) had central nervous system (CNS) dissemination. Cryptococcal blood cultures were performed in 129 sCrAg-positives, with 10 (7.8%) being positive. One-year (48-52 weeks) survival rates were 83.9 and 76.1% in sCrAg-negatives and sCrAg-positives, respectively, P = 0.011. Factors associated with increased mortality were a positive sCrAg, CD4+ cell count less than 50 cells/μl and having presumptive tuberculosis (TB) symptoms. CONCLUSION Our study reports a high prevalence of subclinical cryptococcal antigenemia and reiterates the importance of TB and a positive sCrAg as risk factors for mortality in advanced HIV disease (AHD). Therefore, TB and sCrAg screening remains a crucial component of AHD package, hence it should always be part of the comprehensive clinical evaluation in AHD patients.
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Affiliation(s)
| | - Admire HLUPENI
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Rhoderick MACHEKANO
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Kathryn BOYD
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Takudzwa MTISI
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Primrose NYAMAYARO
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Christine ROSS
- US Centers for Disease Control and Prevention, Atlanta, GA, United States
| | | | | | - Prosper CHONZI
- Health Services Department, City of Harare, Harare, Zimbabwe
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14
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Elafros MA, Belessiotis-Richards C, Birbeck GL, Bond V, Sikazwe I, Kvalsund MP. A qualitative study of patient, caregiver, doctor and nurse views of factors influencing lumbar puncture uptake in Zambia. Trans R Soc Trop Med Hyg 2021; 116:322-327. [PMID: 34352890 PMCID: PMC8978296 DOI: 10.1093/trstmh/trab124] [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] [Received: 03/14/2021] [Revised: 06/19/2021] [Accepted: 07/21/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Uptake of lumbar puncture (LP) remains low in regions with a high prevalence of central nervous system (CNS) infections like Zambia. Efforts to improve uptake are hindered by limited understanding of factors influencing LP uptake. METHODS Semistructured qualitative interviews were conducted with patients with suspected CNS infection, caregivers, doctors and nurses at the University Teaching Hospitals in 2016. Questions focused on LP experiences, knowledge, the consent process and health system barriers to LP among patients with an LP indication. Interviews were transcribed, translated to English and analysed using a thematic approach. RESULTS We recruited 24 adult patients, 36 caregivers of adult patients, 63 caregivers of paediatric patients, 20 doctors and 30 nurses (173 in total). LP barriers arose from both patients/caregivers and health providers and included community apprehension about LP, proxy (family) consensus consent practices, competing clinical demands, wariness of patient/caregiver responses, limitations in consumables and time to complete the LP. This could result in consent not being obtained correctly. LP enablers included patient/caregiver perceived LP utility, provider comfort with LP and in-person counselling. CONCLUSIONS LP uptake is a complex sociocultural process influenced by patient, healthcare and community-level factors. Interventions to improve uptake must address multiple barriers to be successful.
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Affiliation(s)
- Melissa A Elafros
- Department of Neurology, University of Michigan, Ann Arbor, MI 48105, USA
| | - Clara Belessiotis-Richards
- Department of Psychiatry, University College London, London, W1T 7BN, UK.,Camden and Islington NHS Foundation Trust, London, NW1 OPE, UK
| | - Gretchen L Birbeck
- Department of Neurology, University of Rochester, Rochester, NY 14642, USA.,Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, 10101, Zambia.,University Teaching Hospitals, Children's Hospital, Lusaka, 10101, Zambia
| | - Virginia Bond
- Zambart, School of Public Health, University of Zambia, Lusaka, 10101, Zambia.,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, 10101, Zambia
| | - Michelle P Kvalsund
- Department of Neurology, University of Rochester, Rochester, NY 14642, USA.,Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, 10101, Zambia
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15
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Blasich NP, Wake RM, Rukasha I, Prince Y, Govender NP. Association of semi-quantitative cryptococcal antigen results in plasma with subclinical cryptococcal meningitis and mortality among patients with advanced HIV disease. Med Mycol 2021; 59:1041-1047. [PMID: 34169984 DOI: 10.1093/mmy/myab038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/21/2021] [Accepted: 06/23/2021] [Indexed: 01/02/2023] Open
Abstract
Blood cryptococcal antigen (CrAg) titres > 160 are associated with concurrent subclinical cryptococcal meningitis (CM). When lumbar puncture (LP) is not immediately available in a CrAg screening programme, semi-quantitative CrAg assays may provide risk stratification for CM. Two semi-quantitative assays (SQ [Immuno-Mycologics, Norman, OK, USA] and CryptoPS [Biosynex, Strasbourg, France]) were evaluated against a qualitative lateral flow assay (LFA) using 194 plasma samples from a cohort of HIV-seropositive individuals with CD4 counts < 100 cells/µL. We compared SQ and CryptoPS results to titres for LFA-positive samples. Among patients with LP, we examined the association between semi-quantitative CrAg results and CM. We used a Cox proportional hazards model to determine the association between SQ score and mortality. Of 194 participants, 60 (31%) had positive LFA results, of whom 41 (68%) had a titre of ≤ 160 and 19 (32%) a titre > 160. Fifty individuals with antigenaemia had an LP; a clinically-useful SQ score that identified all ten cases of subclinical CM was ≥ 3 (100% sensitivity, 55% specificity). Patients with an SQ score of 3 or 4 also had a 2.2-fold increased adjusted hazards of 6-month mortality (95% CI, 0.79-6.34; p = 0.13) versus those with score of < 3. Nine of ten patients with subclinical CM had a strong-positive CryptoPS result versus 10/40 without subclinical CM (p<0.001). Semi-quantitative assays offered a sensitive though not specific means of gauging the risk of concurrent CM in this patient population. LAY ABSTRACT We evaluated two single-step laboratory tests that can quantify the amount of cryptococcal antigen in plasma of patients with advanced HIV disease and could thus gauge the risk of concurrent cryptococcal meningitis and subsequent mortality. These tests are not a substitute for a lumbar puncture.
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Affiliation(s)
- Nozuko P Blasich
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Department of Biomedical Sciences, Faculty of Health and Wellness, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Rachel M Wake
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,Institute of Infection & Immunity, St George's, University of London, United Kingdom
| | - Ivy Rukasha
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa
| | - Yvonne Prince
- Department of Biomedical Sciences, Faculty of Health and Wellness, Cape Peninsula University of Technology, Cape Town, South Africa
| | - Nelesh P Govender
- National Institute for Communicable Diseases (Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses), a Division of the National Health Laboratory Service, Johannesburg, South Africa.,School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Tenforde MW, Milton T, Rulaganyang I, Muthoga C, Tawe L, Chiller T, Greene G, Jordan A, Williams CG, Owen L, Leeme TB, Boose A, Ngidi J, Mine M, Jarvis JN. Outcomes of Reflex Cryptococcal Antigen (CrAg) Screening in Human Immunodeficiency Virus (HIV)-Positive Patients With CD4 Counts of 100-200 Cells/µL in Botswana. Clin Infect Dis 2021; 72:1635-1638. [PMID: 32604411 DOI: 10.1093/cid/ciaa899] [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: 04/20/2020] [Accepted: 06/24/2020] [Indexed: 01/20/2023] Open
Abstract
Increasing the CD4-count threshold for cryptococcal antigen (CrAg) screening from ≤100 to ≤200 cells/µL resulted in a 3-fold increase in numbers screened. CrAg-prevalence was 3.5% at CD4 101-200 and 6.2% ≤100 cells/µL. Six-month mortality was 21.4% (9/42) in CrAg-positive CD4 ≤100 cells/µL and 3.2% (1/31) in CrAg-positive CD4 101-200 cells/µL.
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Affiliation(s)
- Mark W Tenforde
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.,Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA.,Botswana-UPenn Partnership, Gaborone, Botswana
| | | | | | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | - Tom Chiller
- Mycotics Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Gregory Greene
- Mycotics Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Alexander Jordan
- Mycotics Division, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | | | - Leah Owen
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Tshepo B Leeme
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Amber Boose
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Madisa Mine
- Botswana National Health Laboratory, Gaborone, Botswana
| | - Joseph N Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
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17
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Elafros MA, Belessiotis-Richards C, Birbeck GL, Bond V, Sikazwe I, Kvalsund MP. Lumbar Puncture-Related Knowledge, Attitudes, and Practices among Patients, Caregivers, Doctors, and Nurses in Zambia. Am J Trop Med Hyg 2021; 104:1925-1931. [PMID: 33755588 PMCID: PMC8103467 DOI: 10.4269/ajtmh.20-0509] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 01/18/2021] [Indexed: 11/07/2022] Open
Abstract
Lumbar puncture (LP) is underused for neuroinfectious disease diagnosis in Zambia, but reasons for poor uptake remain speculative. This cross-sectional study assessed LP knowledge, attitudes, and practices among patients/caregivers and healthcare workers (HCWs) and predictors of LP completion. Patients with suspected central nervous system infection, caregivers, and HCWs at the University Teaching Hospitals in 2016 were eligible. Questions adapted from the existing literature were used for a LP knowledge score. Predictors of knowledge scores were assessed independently for patients/caregivers and HCWs. Predictors of LP completion were assessed using multivariable logistic regression. Among 123 patients/caregivers, LP knowledge was poor. Pediatric caregivers were more likely than adult patients/caregivers to report LP could be replaced by neuroimaging (90% versus 78%, P < 0.001) and cause paralysis (57% versus 39%, P = 0.01). There were no significant predictors of the knowledge score among patients/caregivers. Among HCWs, 28% said LP makes patients clinically worse, and 60% reported it could cause paralysis. The increased knowledge score was associated with greater wealth (P = 0.03) and personally knowing someone who underwent LP (P < 0.001). Lumbar puncture was completed on 67/112 (57%) patients and was associated with an increased knowledge score (OR: 1.62 [95% CI: 1.19-2.23]). Pediatric patients (OR: 0.18 [95% CI: 0.07-0.47]) and those with a fear of paralysis (OR 0.29 [95% CI: 0.11-0.77]) were less likely to undergo LP. Improving LP-related knowledge may improve uptake. Healthcare workers sense of LP risk may also play a role in encouraging/discouraging use.
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Affiliation(s)
- Melissa A. Elafros
- Department of Neurology, University of Michigan, Ann Arbor, Michigan;,Address correspondence to Melissa A. Elafros, Department of Neurology, University of Michigan, F2647 UH South SPC 5223, 1500 E Medical Center Dr., Ann Arbor, MI 48109. E-mail:
| | - Clara Belessiotis-Richards
- Department of Psychiatry, University College London, London, United Kingdom;,Camden and Islington NHS Foundation Trust, London, United Kingdom
| | - Gretchen L. Birbeck
- Department of Neurology, University of Rochester, Rochester, New York;,Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia;,University Teaching Hospitals, Children’s Hospital, Lusaka, Zambia
| | - Virginia Bond
- ZAMBART, University of Zambia, Lusaka, Zambia;,Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Izukanji Sikazwe
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia
| | - Michelle P. Kvalsund
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia;,Department of Neurology, Michigan State University, East Lansing, Michigan
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18
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Temfack E, Rim JJB, Spijker R, Loyse A, Chiller T, Pappas PG, Perfect J, Sorell TC, Harrison TS, Cohen JF, Lortholary O. Cryptococcal Antigen in Serum and Cerebrospinal Fluid for Detecting Cryptococcal Meningitis in Adults Living With Human Immunodeficiency Virus: Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies. Clin Infect Dis 2021; 72:1268-1278. [PMID: 32829406 PMCID: PMC8522332 DOI: 10.1093/cid/ciaa1243] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Indexed: 02/01/2023] Open
Abstract
Cryptococcal antigen (CrAg) detection could direct the timely initiation of antifungal therapy. We searched MEDLINE and Embase for studies where CrAg detection in serum/cerebrospinal fluid (CSF) and CSF fungal culture were done on adults living with human immunodeficiency virus (HIV) who had suspected cryptococcal meningitis (CM). With Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2), we evaluated the risk of bias in 11 included studies with 3600 participants, and used a random-effects meta-analysis to obtain summary sensitivity and specificity of serum and CSF CrAg, as well as agreement between CSF CrAg and CSF culture. Summary sensitivity and specificity of serum CrAg were 99.7% (97.4-100) and 94.1% (88.3-98.1), respectively, and summary sensitivity and specificity of CSF CrAg were 98.8% (96.2-99.6) and 99.3% (96.7-99.9), respectively. Agreement between CSF CrAg and CSF culture was 98% (97-99). In adults living with HIV who have CM symptoms, serum CrAg negativity may rule out CM, while positivity should prompt induction antifungal therapy if lumbar puncture is not feasible. In a first episode of CM, CSF CrAg positivity is diagnostic.
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Affiliation(s)
- Elvis Temfack
- Institut Pasteur, Centre National de la Recherche Scientifique,
Molecular Mycology Unit Unite Mixte de Recherche 2000,
Paris, France
- Internal Medicine Unit, Douala General Hospital,
Douala, Cameroon
| | | | - Rene Spijker
- Cochrane Netherlands, Julius Centre for Health Sciences and Primary
Care, University Medical Centre Utrecht,
Utrecht, The
Netherlands
| | - Angela Loyse
- Institute of Infection and Immunity, St. George’s University of
London, London, United Kingdom
- Department of Infection, St George’s University Hospitals
National Health Service Trust, London,
United Kingdom
- Institute of Infectious Disease and Molecular Medicine, University of
Cape Town, Cape Town, South Africa
| | - Tom Chiller
- Tulane School of Public Health and Tropical Medicine,
Atlanta, Georgia, USA
| | - Peter G Pappas
- Division of Infectious Diseases, University of Alabama at
Birmingham, Birmingham, Alabama, USA
| | - John Perfect
- Division of Infectious Diseases, Department of Medicine, Duke
University Medical Centre, Durham, North
Carolina, USA
| | - Tania C Sorell
- University of Sydney Faculty of Medicine and Health, Westmead Clinical
School and Centre for Infectious Diseases and Microbiology, The Westmead
Institute of Medical Research, Westmead,
Australia
| | - Thomas S Harrison
- Institute of Infection and Immunity, St. George’s University of
London, London, United Kingdom
- Department of Infection, St George’s University Hospitals
National Health Service Trust, London,
United Kingdom
- Institute of Infectious Disease and Molecular Medicine, University of
Cape Town, Cape Town, South Africa
| | - Jérémie F Cohen
- Institut National de la Sante et de la Recherche Medicale UMR 1153
Hospital, Assistance Publique-Hopitaux de Paris, Paris Descartes
University, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases,
Necker Hospital, Assistance Publique-Hopitaux de Paris. Paris Descartes
University, Paris, France
| | - Olivier Lortholary
- Institut Pasteur, Centre National de la Recherche Scientifique,
Molecular Mycology Unit Unite Mixte de Recherche 2000,
Paris, France
- University Paris Descartes, Necker Pasteur Center for Infectious
Diseases and Tropical Medicine, Hôpital Necker - Enfants malades,
Assistance Publique-Hopitaux de Paris, Institut Hospitalo-Universitaire
Imagine, Paris, France
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19
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Lawrence DS, Tsholo K, Ssali A, Mupambireyi Z, Hoddinott G, Nyirenda D, Meya DB, Ndhlovu C, Harrison TS, Jarvis JN, Seeley J. The Lived Experience Of Participants in an African RandomiseD trial (LEOPARD): protocol for an in-depth qualitative study within a multisite randomised controlled trial for HIV-associated cryptococcal meningitis. BMJ Open 2021; 11:e039191. [PMID: 33820784 PMCID: PMC8030472 DOI: 10.1136/bmjopen-2020-039191] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Individuals recruited into clinical trials for life-threatening illnesses are particularly vulnerable. This is especially true in low-income settings. The decision to enrol may be influenced by existing inequalities, poor healthcare infrastructure and fear of death. Where patients are confused or unconscious the responsibility for this decision falls to relatives. This qualitative study is nested in the ongoing AMBIsome Therapy Induction OptimisatioN (AMBITION) Trial. AMBITION is recruiting participants from five countries in sub-Saharan Africa and is trialling a novel treatment approach for HIV-associated cryptococcal meningitis, an infection known to affect brain function. We aim to learn from the experiences of participants, relatives and researchers involved in AMBITION. METHODS AND ANALYSIS We will collect data through in-depth interviews with trial participants and the next of kin of participants who were confused at enrolment and therefore provided surrogate consent. Data will be collected in Gaborone, Botswana; Kampala, Uganda and Harare, Zimbabwe. Interviews will follow a narrative approach including participatory drawing of participation timelines. This will be supplemented by direct observation of the research process at each of the three recruiting hospitals. Interviews will also take place with researchers from the African and European institutions that form the partnership through which the trial is administered. Interviews will be transcribed verbatim, translated (if necessary) and organised thematically for narrative analysis. ETHICS AND DISSEMINATION This study has been approved by the Health Research Development Committee, Gaborone (Reference: HPDME:13/18/1); Makerere School of Health Sciences Institutional Review Board, Kampala (Reference: 2019-061); University of Zimbabwe Joint Research Ethics Committee, Harare (Reference: 219/19), and the London School of Hygiene and Tropical Medicine (Reference: 17957). Study findings will be shared with research participants from the sites, key stakeholders at each research institution and ministries of health to help inform the development and implementation of future trials. The findings of this study will be published in journals and presented at academic meetings. TRIAL REGISTRATION Registered at www.clinicaltrials.gov:NCT04296292.
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Affiliation(s)
- David S Lawrence
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Katlego Tsholo
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Agnes Ssali
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Graeme Hoddinott
- Desmond Tutu TB Centre, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, Western Cape, South Africa
| | - Deborah Nyirenda
- Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - David B Meya
- Infectious Diseases Institute, Makerere University, Kampala, Uganda
| | - Chiratidzo Ndhlovu
- Department of Medicine, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George's University of London, London, UK
| | - Joseph N Jarvis
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
- Social Aspects of Health Programme, MRC/UVRI & LSHTM Uganda Research Unit, Entebbe, Uganda
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20
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2020 update on the clinical validity of cerebrospinal fluid amyloid, tau, and phospho-tau as biomarkers for Alzheimer's disease in the context of a structured 5-phase development framework. Eur J Nucl Med Mol Imaging 2021; 48:2121-2139. [PMID: 33674895 PMCID: PMC8175301 DOI: 10.1007/s00259-021-05258-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 02/11/2021] [Indexed: 12/15/2022]
Abstract
Purpose In the last decade, the research community has focused on defining reliable biomarkers for the early detection of Alzheimer’s disease (AD) pathology. In 2017, the Geneva AD Biomarker Roadmap Initiative adapted a framework for the systematic validation of oncological biomarkers to cerebrospinal fluid (CSF) AD biomarkers—encompassing the 42 amino-acid isoform of amyloid-β (Aβ42), phosphorylated-tau (P-tau), and Total-tau (T-tau)—with the aim to accelerate their development and clinical implementation. The aim of this work is to update the current validation status of CSF AD biomarkers based on the Biomarker Roadmap methodology. Methods A panel of experts in AD biomarkers convened in November 2019 at a 2-day workshop in Geneva. The level of maturity (fully achieved, partly achieved, preliminary evidence, not achieved, unsuccessful) of CSF AD biomarkers was assessed based on the Biomarker Roadmap methodology before the meeting and presented and discussed during the workshop. Results By comparison to the previous 2017 Geneva Roadmap meeting, the primary advances in CSF AD biomarkers have been in the area of a unified protocol for CSF sampling, handling and storage, the introduction of certified reference methods and materials for Aβ42, and the introduction of fully automated assays. Additional advances have occurred in the form of defining thresholds for biomarker positivity and assessing the impact of covariates on their discriminatory ability. Conclusions Though much has been achieved for phases one through three, much work remains in phases four (real world performance) and five (assessment of impact/cost). To a large degree, this will depend on the availability of disease-modifying treatments for AD, given these will make accurate and generally available diagnostic tools key to initiate therapy. Supplementary Information The online version contains supplementary material available at 10.1007/s00259-021-05258-7.
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21
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Alshaibari KS, Hasan ER, Dammaj MZ, Sharaf Adeen IA. Mothers' Views About Lumbar Puncture for Their Children in a Maternity and Children's Hospital in Najran, Saudi Arabia. Pediatric Health Med Ther 2021; 12:91-99. [PMID: 33658883 PMCID: PMC7920614 DOI: 10.2147/phmt.s292671] [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] [Received: 11/18/2020] [Accepted: 01/21/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Refusal rates for offered pediatric lumbar puncture (LP) are high in many parts of the world, potentially hindering diagnosis and treatment for thousands of children. There is relatively little research about why such rates are so high. Understanding the formation and development of mothers' opinions about LP could help identify barriers to accessing this modality to improve diagnostic and treatment outcomes in children with neurological and systemic diseases. METHODS We surveyed mothers of hospitalized children in the Maternity and Children's Hospital in Najran in November and December 2018. We queried their familiarity with LP and their decision to accept or refuse LP when it was offered. The team recorded demographic data on survey respondents, as well as their stated reasons for their LP decisions, and used chi-square tests to evaluate the correlation between patient or parent characteristics and the decision to accept or refuse LP. RESULTS A total of 202 mothers responded to the survey, with a mean age of 30.7 (± 6.9); nearly all women were stay-at-home mothers (93.1%). Most (61.4%) lived in urban settings. Four in 10 respondents (40.6%) were not familiar with LP. A sizable minority of 89 mothers (44.0%) refused LP for their children when offered, most commonly citing fear of paralysis (39.3%) as the reason for refusal. Those who accepted LP were more likely to do so following physician advice than for any other reason (p <0.001). CONCLUSION Lumbar puncture refusal rates may be even higher than previously reported, and there is a pressing need to educate women on the diagnostic and therapeutic benefits of LP for their children. Maternal education from physicians may help improve acceptance rates for the procedure.
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Affiliation(s)
| | | | - Mayasa Zaid Dammaj
- Department of Pediatrics, College of Medicine, Najran University, Najran, Saudi Arabia
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22
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Reynolds RA, Bhebhe A, Garcia RM, Zhao S, Lam S, Sichizya K, Shannon CN. Pediatric hydrocephalus outcomes in Lusaka, Zambia. J Neurosurg Pediatr 2020; 26:624-635. [PMID: 32916646 PMCID: PMC7947024 DOI: 10.3171/2020.5.peds20193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus is a global disease that disproportionally impacts low- and middle-income countries. Limited data are available from sub-Saharan Africa. This study aims to be the first to describe pediatric hydrocephalus epidemiology and outcomes in Lusaka, Zambia. METHODS This retrospective cohort study included patients < 18 years of age who underwent surgical treatment for hydrocephalus at Beit-CURE Hospital and the University Teaching Hospital in Lusaka, Zambia, from August 2017 to May 2019. Surgeries included ventriculoperitoneal shunt insertions, revisions, and endoscopic third ventriculostomies (ETVs) with or without choroid plexus cauterization (CPC). A descriptive analysis of patient demographics, clinical presentation, and etiologies was summarized, followed by a multivariable analysis of mortality and 90-day complications. RESULTS A total of 378 patients met the inclusion criteria. The median age at first surgery was 5.5 (IQR 3.1, 12.7) months, and 51% of patients were female (n = 193). The most common presenting symptom was irritability (65%, n = 247), followed by oculomotor abnormalities (54%, n = 204). Postinfectious hydrocephalus was the predominant etiology (65%, n = 226/347), and 9% had a myelomeningocele (n = 32/347). It was the first hydrocephalus surgery for 87% (n = 309) and, of that group, 15% underwent ETV/CPC (n = 45). Severe hydrocephalus was common, with 42% of head circumferences more than 6 cm above the 97th percentile (n = 111). The median follow-up duration was 33 (IQR 4, 117) days. The complication rate was 20% (n = 76), with infection being most common (n = 29). Overall, 7% of the patients died (n = 26). Postoperative complication was significantly associated with mortality (χ2 = 81.2, p < 0.001) with infections and CSF leaks showing the strongest association (χ2 = 14.6 and 15.2, respectively, p < 0.001). On adjusted multivariable analysis, shunt revisions were more likely to have a complication than ETV/CPC or primary shunt insertions (OR 2.45 [95% CI 1.26-4.76], p = 0.008), and the presence of any postoperative complication was the only significant predictor of mortality (OR 42.9 [95% CI 12.3-149.1], p < 0.001). CONCLUSIONS Pediatric postinfectious hydrocephalus is the most common etiology of hydrocephalus in Lusaka, Zambia, which is similar to other countries in sub-Saharan Africa. Most children present late with neglected hydrocephalus. Shunt revision procedures are more prone to complication than ETV/CPC or primary shunt insertion, and postoperative complications represent a significant predictor of mortality in this population.
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Affiliation(s)
- Rebecca A. Reynolds
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
| | - Arnold Bhebhe
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Roxanna M. Garcia
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Shilin Zhao
- Vanderbilt Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandi Lam
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Kachinga Sichizya
- Department of Neurological Surgery, University Teaching Hospital, Lusaka, Zambia
| | - Chevis N. Shannon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital, Nashville, Tennessee
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23
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Gaudenzi G, Kumbakumba E, Rasti R, Nanjebe D, Réu P, Nyehangane D, Mårtensson A, Nassejje M, Karlsson J, Mzee J, Nilsson P, Businge S, Loh E, Boum Ii Y, Andersson-Svahn H, Gantelius J, Mwanga-Amumpaire J, Alfvén T. Point-of-Care Approaches for Meningitis Diagnosis in a Low-Resource Setting (Southwestern Uganda): Observational Cohort Study Protocol of the "PI-POC" Trial. JMIR Res Protoc 2020; 9:e21430. [PMID: 33146628 PMCID: PMC7690656 DOI: 10.2196/21430] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND A timely differential diagnostic is essential to identify the etiology of central nervous system (CNS) infections in children, in order to facilitate targeted treatment, manage patients, and improve clinical outcome. OBJECTIVE The Pediatric Infection-Point-of-Care (PI-POC) trial is investigating novel methods to improve and strengthen the differential diagnostics of suspected childhood CNS infections in low-income health systems such as those in Southwestern Uganda. This will be achieved by evaluating (1) a novel DNA-based diagnostic assay for CNS infections, (2) a commercially available multiplex PCR-based meningitis/encephalitis (ME) panel for clinical use in a facility-limited laboratory setting, (3) proteomics profiling of blood from children with severe CNS infection as compared to outpatient controls with fever yet not severely ill, and (4) Myxovirus resistance protein A (MxA) as a biomarker in blood for viral CNS infection. Further changes in the etiology of childhood CNS infections after the introduction of the pneumococcal conjugate vaccine against Streptococcus pneumoniae will be investigated. In addition, the carriage and invasive rate of Neisseria meningitidis will be recorded and serotyped, and the expression of its major virulence factor (polysaccharide capsule) will be investigated. METHODS The PI-POC trial is a prospective observational study of children including newborns up to 12 years of age with clinical features of CNS infection, and age-/sex-matched outpatient controls with fever yet not severely ill. Participants are recruited at 2 Pediatric clinics in Mbarara, Uganda. Cerebrospinal fluid (for cases only), blood, and nasopharyngeal (NP) swabs (for both cases and controls) sampled at both clinics are analyzed at the Epicentre Research Laboratory through gold-standard methods for CNS infection diagnosis (microscopy, biochemistry, and culture) and a commercially available ME panel for multiplex PCR analyses of the cerebrospinal fluid. An additional blood sample from cases is collected on day 3 after admission. After initial clinical analyses in Mbarara, samples will be transported to Stockholm, Sweden for (1) validation analyses of a novel nucleic acid-based POC test, (2) biomarker research, and (3) serotyping and molecular characterization of S. pneumoniae and N. meningitidis. RESULTS A pilot study was performed from January to April 2019. The PI-POC trial enrollment of patients begun in April 2019 and will continue until September 2020, to include up to 300 cases and controls. Preliminary results from the PI-POC study are expected by the end of 2020. CONCLUSIONS The findings from the PI-POC study can potentially facilitate rapid etiological diagnosis of CNS infections in low-resource settings and allow for novel methods for determination of the severity of CNS infection in such environment. TRIAL REGISTRATION ClinicalTrials.gov NCT03900091; https://clinicaltrials.gov/ct2/show/NCT03900091. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/21430.
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Affiliation(s)
- Giulia Gaudenzi
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Division of Nanobiotechnology, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, Stockholm, Sweden
| | - Elias Kumbakumba
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Reza Rasti
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | | | - Pedro Réu
- Division of Affinity Proteomics, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, Stockholm, Sweden
| | | | - Andreas Mårtensson
- Department of Women's and Children's Health, International Maternal and Child Health, Uppsala University, Uppsala, Sweden
| | - Milly Nassejje
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jens Karlsson
- Department of Microbiology, Tumor, and Cell Biology, BioClinicum, Karolinska University Hospital, Stockholm, Sweden
| | - John Mzee
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Holy Innocents Children's Hospital, Mbarara, Uganda
| | - Peter Nilsson
- Division of Affinity Proteomics, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, Stockholm, Sweden
| | - Stephen Businge
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- Holy Innocents Children's Hospital, Mbarara, Uganda
| | - Edmund Loh
- Department of Microbiology, Tumor, and Cell Biology, BioClinicum, Karolinska University Hospital, Stockholm, Sweden
- SCELSE, Nanyang Technological University, Singapore, Singapore
| | - Yap Boum Ii
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- MSF Epicentre Mbarara Research Centre, Mbarara, Uganda
| | - Helene Andersson-Svahn
- Division of Nanobiotechnology, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, Stockholm, Sweden
| | - Jesper Gantelius
- Division of Nanobiotechnology, Department of Protein Science, KTH Royal Institute of Technology, SciLifeLab, Stockholm, Sweden
| | - Juliet Mwanga-Amumpaire
- Department of Paediatrics and Child Health, Faculty of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
- MSF Epicentre Mbarara Research Centre, Mbarara, Uganda
| | - Tobias Alfvén
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Greene G, Lawrence DS, Jordan A, Chiller T, Jarvis JN. Cryptococcal meningitis: a review of cryptococcal antigen screening programs in Africa. Expert Rev Anti Infect Ther 2020; 19:233-244. [PMID: 32567406 DOI: 10.1080/14787210.2020.1785871] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cryptococcal meningitis remains a significant contributor to AIDS-related mortality despite widened access to antiretroviral therapy. Cryptococcal antigen (CrAg) can be detected in the blood prior to development of meningitis. Development of highly sensitive and specific rapid diagnostic CrAg tests has helped facilitate the adoption of CrAg screening programs in 19 African countries. AREAS COVERED The biological rationale for CrAg screening and the programmatic strategies for its implementation are reviewed. We describe the approach to the investigation of patients with cryptococcal antigenemia and the importance of lumbar puncture to identify individuals who may have cryptococcal meningitis in the absence of symptoms. The limitations of current treatment recommendations and the potential role of newly defined combination antifungal therapies are discussed. A literature review was conducted using a broad database search for cryptococcal antigen screening and related terms in published journal articles dating up to December 2019. Conference abstracts, publicly available guidelines, and project descriptions were also incorporated. EXPERT OPINION As we learn more about the risks of cryptococcal antigenemia, it has become clear that the current management paradigm is inadequate. More intensive investigation and management are required to prevent the development of cryptococcal meningitis and reduce mortality associated with cryptococcal antigenemia.
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Affiliation(s)
- Greg Greene
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases, a Division of the NHLS , Johannesburg, South Africa.,Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK
| | - David S Lawrence
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
| | - Alex Jordan
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Tom Chiller
- Mycotic Diseases Branch, Centers for Disease Control and Prevention , Atlanta, USA
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine , London, UK.,Botswana Harvard AIDS Institute Partnership , Gaborone, Botswana
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25
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Mulholland K. Management of childhood pneumonia in Nigeria. Pediatr Pulmonol 2020; 55 Suppl 1:S34-S36. [PMID: 32203644 PMCID: PMC7318196 DOI: 10.1002/ppul.24717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 02/24/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Kim Mulholland
- Infection and Immunity, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Ahmed M, Ejaz M, Nasir S, Mainosh S, Jahangeer A, Bhatty M, Razi Z. Parental Refusal to Lumbar Puncture: Effects on Treatment, Hospital Stay and Leave Against Medical Advice. Cureus 2020; 12:e7781. [PMID: 32461854 PMCID: PMC7243628 DOI: 10.7759/cureus.7781] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Introduction Lumbar puncture (LP) is an effective method in the diagnosis and management of central nervous system infections. Refusal to LP is associated with severe consequences. This study aims to examine the impact of parental LP refusal on treatment, the length of hospital stay, and the frequency of patients leaving against medical advice (LAMA). Method A cross-sectional study was conducted at the pediatric department of Civil Hospital, Karachi, from June 2018 to November 2019. All hospitalized patients suspected to have a central nervous system disease, which requires LP, were enrolled. Patients were followed for the duration of antibiotic and antiviral therapy, length of hospital stay, and LAMA. Results A total of 220 patients participated in the study, with the median age of nine (2-47) months. There were 113 (51.1%) males. The median length of hospital stay was 10 (4-14) days. The comparison of parental LP refusal with the length of hospital stay showed a significant difference (p-value <0.001) in the number of days of treatment among patients who received vancomycin (p-value =0.008) and meropenem (p-value =0.012). A significant association of parental LP refusal was also observed with meningoencephalitis and meningitis as provisional diagnosis (p-value =0.006). In particular, LAMA and death were found significantly higher among parents who refused LP (p-value <0.001). Conclusion LP refusal has a significant effect on the treatment, hospital stay, and disposition outcomes. A large number of parents who declined the procedure left against medical advice or suffered grave medical consequences. Parental education addressing their concerns and beliefs, while explaining the indications, and need for performing LP can help effectively overcome this issue.
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Affiliation(s)
- Mushtaq Ahmed
- Pediatrics, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Muzamil Ejaz
- Pediatrics, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Saad Nasir
- Internal Medicine, United Medical and Dental College, Creek General Hospital, Karachi, PAK
| | - Salma Mainosh
- Pediatrics, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | - Ashraf Jahangeer
- Epidemiology, Civil Hospital Karachi, Dow University of Health Sciences, Karachi, PAK
| | | | - Zobia Razi
- Pediatrics, Dow Medical College, Karachi, PAK
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Tenforde MW, Muthoga C, Callaghan A, Ponatshego P, Ngidi J, Mine M, Jordan A, Chiller T, Larson BA, Jarvis JN. Cost-effectiveness of reflex laboratory-based cryptococcal antigen screening for the prevention and treatment of cryptococcal meningitis in Botswana. Wellcome Open Res 2020; 4:144. [PMID: 31803848 PMCID: PMC6871359 DOI: 10.12688/wellcomeopenres.15464.2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2020] [Indexed: 01/26/2023] Open
Abstract
Background: Cryptococcal antigen (CrAg) screening for antiretroviral therapy (ART)-naïve adults with advanced HIV/AIDS can reduce the incidence of cryptococcal meningitis (CM) and all-cause mortality. We modeled the cost-effectiveness of laboratory-based "reflex" CrAg screening for ART-naïve CrAg-positive patients with CD4<100 cells/µL (those currently targeted in guidelines) and ART-experienced CrAg-positive patients with CD4<100 cells/µL (who make up an increasingly large proportion of individuals with advanced HIV/AIDS). Methods: A decision analytic model was developed to evaluate CrAg screening and treatment based on local CD4 count and CrAg prevalence data, and realistic assumptions regarding programmatic implementation of the CrAg screening intervention. We modeled the number of CrAg tests performed, the number of CrAg positives stratified by prior ART experience, the proportion of patients started on pre-emptive antifungal treatment, and the number of incident CM cases and CM-related deaths. Screening and treatment costs were evaluated, and cost per death or disability-adjusted life year (DALY) averted estimated. Results: We estimated that of 650,000 samples undergoing CD4 testing annually in Botswana, 16,364 would have a CD4<100 cells/µL and receive a CrAg test, with 70% of patients ART-experienced at the time of screening. Under base model assumptions, CrAg screening and pre-emptive treatment restricted to ART-naïve patients with a CD4<100 cells/µL prevented 20% (39/196) of CM-related deaths in patients undergoing CD4 testing at a cost of US$2 per DALY averted. Expansion of preemptive treatment to include ART-experienced patients with a CD4<100 cells/µL resulted in 55 additional deaths averted (a total of 48% [94/196]) and was cost-saving compared to no screening. Findings were robust across a range of model assumptions. Conclusions: Reflex laboratory-based CrAg screening for patients with CD4<100 cells/µL is a cost-effective strategy in Botswana, even in the context of a relatively low proportion of advanced HIV/AIDS in the overall HIV-infected population, the majority of whom are ART-experienced.
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Affiliation(s)
- Mark W. Tenforde
- University of Washington School of Medicine, Seattle, Washington, 98195, USA
- University of Washington School of Public Health, Seattle, WA, 98195, USA
| | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Gaborone, Botswana
| | - Alexander Jordan
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Tom Chiller
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Bruce A. Larson
- Boston University School of Public Health, Boston, MA, 02118, USA
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene & Tropical Medicine, London, UK
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Waldrop G, Goetz TG, Siddiqi OK, Koralnik IJ, Shah H, Thakur KT. The World Health Organization's Essential Diagnostics List: Diagnostics for neurologic disorders. Neurology 2020; 93:680-683. [PMID: 31591174 DOI: 10.1212/wnl.0000000000008247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Greer Waldrop
- From the Department of Neurology (G.W., H.S., K.T.T.), Community and Global Neurology Program, Columbia University Irving Medical Center; Vagelos College of Physicians and Surgeons (L.G.G.), Columbia University, New York; Department of Neurology, Global Neurology Program (O.K.S.) and Department of Internal Medicine, Center for Vaccines and Virology Research (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Internal Medicine (O.K.S.), University of Zambia School of Medicine, Lusaka; and Department of Neurological Sciences (I.J.K.), Rush University Medical Center, Chicago, IL
| | - Teddy G Goetz
- From the Department of Neurology (G.W., H.S., K.T.T.), Community and Global Neurology Program, Columbia University Irving Medical Center; Vagelos College of Physicians and Surgeons (L.G.G.), Columbia University, New York; Department of Neurology, Global Neurology Program (O.K.S.) and Department of Internal Medicine, Center for Vaccines and Virology Research (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Internal Medicine (O.K.S.), University of Zambia School of Medicine, Lusaka; and Department of Neurological Sciences (I.J.K.), Rush University Medical Center, Chicago, IL
| | - Omar K Siddiqi
- From the Department of Neurology (G.W., H.S., K.T.T.), Community and Global Neurology Program, Columbia University Irving Medical Center; Vagelos College of Physicians and Surgeons (L.G.G.), Columbia University, New York; Department of Neurology, Global Neurology Program (O.K.S.) and Department of Internal Medicine, Center for Vaccines and Virology Research (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Internal Medicine (O.K.S.), University of Zambia School of Medicine, Lusaka; and Department of Neurological Sciences (I.J.K.), Rush University Medical Center, Chicago, IL
| | - Igor J Koralnik
- From the Department of Neurology (G.W., H.S., K.T.T.), Community and Global Neurology Program, Columbia University Irving Medical Center; Vagelos College of Physicians and Surgeons (L.G.G.), Columbia University, New York; Department of Neurology, Global Neurology Program (O.K.S.) and Department of Internal Medicine, Center for Vaccines and Virology Research (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Internal Medicine (O.K.S.), University of Zambia School of Medicine, Lusaka; and Department of Neurological Sciences (I.J.K.), Rush University Medical Center, Chicago, IL
| | - Hiral Shah
- From the Department of Neurology (G.W., H.S., K.T.T.), Community and Global Neurology Program, Columbia University Irving Medical Center; Vagelos College of Physicians and Surgeons (L.G.G.), Columbia University, New York; Department of Neurology, Global Neurology Program (O.K.S.) and Department of Internal Medicine, Center for Vaccines and Virology Research (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Internal Medicine (O.K.S.), University of Zambia School of Medicine, Lusaka; and Department of Neurological Sciences (I.J.K.), Rush University Medical Center, Chicago, IL
| | - Kiran T Thakur
- From the Department of Neurology (G.W., H.S., K.T.T.), Community and Global Neurology Program, Columbia University Irving Medical Center; Vagelos College of Physicians and Surgeons (L.G.G.), Columbia University, New York; Department of Neurology, Global Neurology Program (O.K.S.) and Department of Internal Medicine, Center for Vaccines and Virology Research (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Internal Medicine (O.K.S.), University of Zambia School of Medicine, Lusaka; and Department of Neurological Sciences (I.J.K.), Rush University Medical Center, Chicago, IL.
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Abstract
PURPOSE OF REVIEW HIV-associated cryptococcal meningitis remains a significant contributor to AIDS-related mortality despite widened access to antiretroviral therapy. Even in clinical trial settings 10-week mortality is roughly 40%. A number of important clinical trials have either recently concluded or are actively recruiting. RECENT FINDINGS Global burden of disease estimates suggest cryptococcal meningitis causes 181 100 deaths annually. Screening blood for cryptococcal antigen in HIV-infected individuals with CD4 cell counts less than 100 cells/μl and preemptive antifungal treatment for those with detectable cryptococcal antigen reduces the incidence of cryptococcal meningitis and is likely to reduce mortality. Cryptococcal meningitis treatment with conventional 14-day courses of amphotericin are associated with high toxicity and mortality and can be reduced to 7 days if given alongside flucytosine. Flucytosine is a significantly superior adjunct to amphotericin treatment compared with fluconazole. In settings without amphotericin B dual oral antifungal combinations of flucytosine and fluconazole offer an effective alternative treatment. A single, high-dose of liposomal amphotericin is effective at reducing fungal burden and is being tested in a phase III trial. SUMMARY Recently completed and ongoing clinical trials are increasing our understanding of how to optimize induction therapy for cryptococcal meningitis. Advocacy efforts are needed to broaden access to amphotericin formulations and flucytosine.
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Frances Ndyetukira J, Kwizera R, Kugonza F, Ahimbisibwe C, Namujju C, Sadiq A, Namudde A. The conundrum of clinical trials and standard of care in sub-Saharan Africa - the research nurse perspective. J Res Nurs 2019; 24:649-660. [PMID: 34394589 PMCID: PMC7932327 DOI: 10.1177/1744987118824625] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Nurses form a very important part of the health workforce in sub-Saharan Africa. Research nurses are critical to the implementation of clinical trials. The duties and responsibilities of a research nurse are complex and continue to evolve as new practices and guidelines are formulated. AIMS In this paper, we have highlighted the major contributions of research nurses in HIV clinical trials in sub-Saharan Africa from the unique perspective of Ugandan nurses. METHODS The requirements and challenges of two multi-site, randomised cryptococcal meningitis clinical trials in Uganda were assessed from the perspective of research nurses conducting complex research in resource-limited settings. RESULTS Over the course of 8 years, approximately 1739 participants were screened and 934 people were enrolled into the two trials. The nurses found that patient education and engagement were among the most important predictors of success in minimising loss to follow-up. CONCLUSIONS Research nurses played a key role in communicating clinical research goals to patients, obtaining informed consent, minimising loss to follow-up, and ensuring that research practices are translated and implemented into standard of care. However, there remains a need to integrate the same level of care provided in clinical research studies to non-study patients.
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Affiliation(s)
| | - Richard Kwizera
- Richard Kwizera, Department of Research, Infectious Diseases Institute College of Health Sciences, Makerere University P.O. BOX 22418, Kampala, Uganda.
| | | | | | | | | | - Alice Namudde
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
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31
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Imran D, Hill PC, McKnight J, van Crevel R. Establishing the cascade of care for patients with tuberculous meningitis. Wellcome Open Res 2019; 4:177. [PMID: 32118119 PMCID: PMC7008603 DOI: 10.12688/wellcomeopenres.15515.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 10/13/2023] Open
Abstract
Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.
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Affiliation(s)
- Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia
| | - Philip C. Hill
- Center for International Health, University of Otago, Dunedin, New Zealand
| | - Jacob McKnight
- Oxford Health System Collaboration, Oxford University, Oxford, UK
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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32
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Imran D, Hill PC, McKnight J, van Crevel R. Establishing the cascade of care for patients with tuberculous meningitis. Wellcome Open Res 2019; 4:177. [PMID: 32118119 PMCID: PMC7008603 DOI: 10.12688/wellcomeopenres.15515.2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 12/03/2022] Open
Abstract
Meningitis is a relatively rare form of tuberculosis, but it carries a high mortality rate, reaching 50% in some settings, with higher rates among patients with HIV co-infection and those with drug-resistant disease. Most studies of tuberculosis meningitis (TBM) tend to focus on better diagnosis, drug treatment and supportive care for patients in hospital. However, there is significant variability in mortality between settings, which may be due to specific variation in the availability and quality of health care services, both prior to, during, and after hospitalization. Such variations have not been studied thoroughly, and we therefore present a theoretical framework that may help to identify where efforts should be focused in providing optimal services for TBM patients. As a first step, we propose an adjusted cascade of care for TBM and patient pathway studies that might help identify factors that account for losses and delays across the cascade. Many of the possible gaps in the TBM cascade are related to health systems factors; we have selected nine domains and provide relevant examples of systems factors for TBM for each of these domains that could be the basis for a health needs assessment to address such gaps. Finally, we suggest some immediate action that could be taken to help make improvements in services. Our theoretical framework will hopefully lead to more health system research and improved care for patients suffering from this most dangerous form of tuberculosis.
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Affiliation(s)
- Darma Imran
- Department of Neurology, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia
| | - Philip C Hill
- Center for International Health, University of Otago, Dunedin, New Zealand
| | - Jacob McKnight
- Oxford Health System Collaboration, Oxford University, Oxford, UK
| | - Reinout van Crevel
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Abstract
PURPOSE OF REVIEW Defective cell-mediated immunity is a major risk factor for cryptococcosis, a fatal disease if untreated. Cryptococcal meningitis (CM), the main presentation of disseminated disease, occurs through hematogenous spread to the brain from primary pulmonary foci, facilitated by yeast virulence factors. We revisit remarkable recent improvements in the prevention, diagnosis and management of CM. RECENT FINDINGS Cryptococcal antigen (CrAg), main capsular polysaccharide of Cryptococcus spp. is detectable in blood and cerebrospinal fluid of infected patients with point of care lateral flow assays. Recent World Health Organization guidelines recommend 7-day amphotericin B plus flucytosine, then 7-day high dose (1200 mg/day) fluconazole for induction treatment of HIV-associated CM. Management of raised intracranial pressure, a consequence of CM, should rely mainly on daily therapeutic lumbar punctures until normalisation. In HIV-associated CM, following introduction of antifungal therapy, (re)initiation of antiretroviral therapy should be delayed by 4-6 weeks to prevent immune reconstitution inflammatory syndrome, common in CM. CM is a fatal disease whose diagnosis has recently been simplified. Treatment should always include antifungal combination therapy and management of raised intracranial pressure. Screening for immune deficiency should be mandatory in all patients with cryptococcosis.
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Imran D, Satiti S, Sugianto P, Estiasari R, Maharani K, Pangeran D, Andini PW, Munir B, Mawuntu AHP, Susilawathi NM, Ritarwan K, Hartanto OS, Frida M, Ganiem AR, Gunawan D, Dian S, Sudewi AAR, van Crevel R. Barriers to diagnosis and management of CNS infections in Indonesia. Neurology 2019; 92:104-106. [PMID: 30617169 DOI: 10.1212/wnl.0000000000006732] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Darma Imran
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK.
| | - Sekar Satiti
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Paulus Sugianto
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Riwanti Estiasari
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Kartika Maharani
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - David Pangeran
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Putri Widya Andini
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Badrul Munir
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Arthur H P Mawuntu
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Ni Made Susilawathi
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Kiking Ritarwan
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - O S Hartanto
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Meity Frida
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Ahmad Rizal Ganiem
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Dede Gunawan
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Sofiati Dian
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - A A R Sudewi
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
| | - Reinout van Crevel
- From the Faculty of Medicine (D.I., R.E., K.M., D.P., P.W.A.), Universitas Indonesia, Jakarta; Faculty of Medicine (S.S.), Universitas Gadjah Mada, Yogyakarta; Faculty of Medicine (P.S.), Universitas Airlangga, Surabaya; Faculty of Medicine (B.M.), Universitas Brawijaya, Malang; Faculty of Medicine (A.H.P.M.), Universitas Sam Ratulangi, Manado; Faculty of Medicine (N.M.S., A.A.R.S.), Universitas Udayana, Denpasar; Faculty of Medicine (K.R.), Universitas Sumatera Utara, Medan; Faculty of Medicine (O.S.H.), Universitas Negeri Sebelas Maret, Solo; Faculty of Medicine (M.F.), Universitas Andalas, Padang; Faculty of Medicine (A.R.G., D.G., S.D.), Universitas Padjadjaran, Bandung, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (R.v.C.), Radboud University Medical Center, Nijmegen, the Netherlands; and Centre for Tropical Medicine and Global Health (R.v.C.), Nuffield Department of Medicine, University of Oxford, UK
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35
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Tenforde MW, Muthoga C, Callaghan A, Ponatshego P, Ngidi J, Mine M, Jordan A, Chiller T, Larson BA, Jarvis JN. Cost-effectiveness of reflex laboratory-based cryptococcal antigen screening for the prevention and treatment of cryptococcal meningitis in Botswana. Wellcome Open Res 2019; 4:144. [PMID: 31803848 PMCID: PMC6871359 DOI: 10.12688/wellcomeopenres.15464.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2019] [Indexed: 01/06/2023] Open
Abstract
Background: Cryptococcal antigen (CrAg) screening for antiretroviral therapy (ART)-naïve adults with advanced HIV/AIDS can reduce the incidence of cryptococcal meningitis (CM) and all-cause mortality. We modeled the cost-effectiveness of laboratory-based "reflex" CrAg screening for ART-naïve CrAg-positive patients with CD4<100 cells/µL (those currently targeted in guidelines) and ART-experienced CrAg-positive patients with CD4<100 cells/µL (who make up an increasingly large proportion of individuals with advanced HIV/AIDS). Methods: A decision analytic model was developed to evaluate CrAg screening and treatment based on local CD4 count and CrAg prevalence data, and realistic assumptions regarding programmatic implementation of the CrAg screening intervention. We modeled the number of CrAg tests performed, the number of CrAg positives stratified by prior ART experience, the proportion of patients started on pre-emptive antifungal treatment, and the number of incident CM cases and CM-related deaths. Screening and treatment costs were evaluated, and cost per death or disability-adjusted life year (DALY) averted estimated. Results: We estimated that of 650,000 samples undergoing CD4 testing annually in Botswana, 16,364 would have a CD4<100 cells/µL and receive a CrAg test, with 70% of patients ART-experienced at the time of screening. Under base model assumptions, CrAg screening and pre-emptive treatment restricted to ART-naïve patients with a CD4<100 cells/µL prevented 20% (39/196) of CM-related deaths in patients undergoing CD4 testing at a cost of US$2 per DALY averted. Expansion of preemptive treatment to include ART-experienced patients with a CD4<100 cells/µL resulted in 55 additional deaths averted (a total of 48% [94/196]) and was cost-saving compared to no screening. Findings were robust across a range of model assumptions. Conclusions: Reflex laboratory-based CrAg screening for patients with CD4<100 cells/µL is a cost-effective strategy in Botswana, even in the context of a relatively low proportion of advanced HIV/AIDS in the overall HIV-infected population, the majority of whom are ART-experienced.
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Affiliation(s)
- Mark W. Tenforde
- University of Washington School of Medicine, Seattle, Washington, 98195, USA
- University of Washington School of Public Health, Seattle, WA, 98195, USA
| | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | | | | | - Julia Ngidi
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- National Health Laboratory, Gaborone, Botswana
| | - Madisa Mine
- National Health Laboratory, Gaborone, Botswana
| | - Alexander Jordan
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Tom Chiller
- Centers for Disease Controls and Prevention, Atlanta, Georgia, 30329-4018, USA
| | - Bruce A. Larson
- Boston University School of Public Health, Boston, MA, 02118, USA
| | - Joseph N. Jarvis
- Botswana-UPenn Partnership, Gaborone, Botswana
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
- London School of Hygiene & Tropical Medicine, London, UK
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36
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Aldayel AY, Alharbi MM, Almasri MS, Alkhonezan SM. Public knowledge and attitude toward lumbar puncture among adults in Riyadh, Saudi Arabia: A cross-sectional study. SAGE Open Med 2019; 7:2050312119871066. [PMID: 31452886 PMCID: PMC6700881 DOI: 10.1177/2050312119871066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 07/29/2019] [Indexed: 12/01/2022] Open
Abstract
Objective: The aim of this study is to evaluate knowledge of and attitudes toward the
lumbar puncture procedure among adults in Riyadh region, Saudi Arabia,
2018. Methods: This study used a quantitative cross-sectional evaluation of the responses of
adults aged ⩾18 years from the Saudi Telecom Company database in the Riyadh
region of Saudi Arabia to an online survey between October and December
2018. The questionnaire included questions on knowledge, attitudes, and
demography. The questionnaire was pretested and validated (Cronbach’s
alpha = 0.701). Results: Of 1500 questionnaires, 1223 (81.5%) were returned and included in the
analysis. In the study, 57.7% of the participants were aged 18–25 years, and
58.5% of the participants were females. Only 235 (19.2%) participants had an
accepted knowledge level of lumbar puncture. The attitudes of the majority
of the participants (n = 1151, 94%) to lumbar puncture were
acceptable. A multivariate logistic regression test revealed a significant
association between an acceptable knowledge level and acceptable attitude
level (odds ratio = 2.30, 95% confidence interval = 1.06–5.66). A
significant association was also found with ages over 46 years old (odds
ratio = 12.99, 95% confidence interval = 4.45–37.9). The attitudes level
toward lumbar puncture had a significant negative association among the
participants who had a fear of injections in the lumbar region (odds
ratio = 0.46, 95% confidence interval = 0.3–0.68). Conclusion: There is a lack of appropriate knowledge of the lumbar puncture procedure
among the public which predict an unacceptable attitude toward lumbar
puncture. Improvements in public education could improve public awareness of
the clinical importance/value and complications of lumbar puncture.
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Affiliation(s)
- Abdulrahman Yousef Aldayel
- Abdulrahman Yousef Aldayel, College of
Medicine, Al-Imam Mohammad Ibn Saud Islamic University (IMSIU), Othman Ibn Afan
Road, Exit 5, PO Box 7544, Riyadh 13317, Saudi Arabia.
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37
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Prabhu S, Harwell JI, Kumarasamy N. Advanced HIV: diagnosis, treatment, and prevention. Lancet HIV 2019; 6:e540-e551. [PMID: 31285181 DOI: 10.1016/s2352-3018(19)30189-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 05/06/2019] [Accepted: 05/17/2019] [Indexed: 11/25/2022]
Abstract
Substantial progress has been made this century in bringing millions of people living with HIV into care, but progress for early HIV diagnosis has stalled. Individuals first diagnosed with advanced HIV have higher rates of mortality than those diagnosed at an earlier stage even after starting antiretroviral therapy (ART), resulting in substantial costs to health systems. Diagnosis of these individuals is hindered because many patients are asymptomatic, despite being severely immunosuppressed. Baseline CD4 counts and screening for opportunistic infections, such as tuberculosis and cryptococcus, is crucial because of the high mortality associated with these co-infections. Individuals with advanced HIV should have rapid ART initiation (except when found to have symptoms, signs, or a diagnosis of cryptococcal meningitis) and those in treatment failure should switch treatment. Overcoming barriers to testing and adherence through the development of differentiated care models and providing psychosocial support will be key in reaching populations at high risk of presenting with advanced HIV.
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Affiliation(s)
- Sandeep Prabhu
- University of California, San Diego School of Medicine, La Jolla, CA, USA
| | | | - Nagalingeswaran Kumarasamy
- Chennai Antiviral Research and Treatment Clinical Research Site, Voluntary Health Services, Chennai, India.
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Abstract
: Neurological conditions associated with HIV remain major contributors to morbidity and mortality and are increasingly recognized in the aging population on long-standing combination antiretroviral therapy (cART). Importantly, growing evidence shows that the central nervous system (CNS) may serve as a reservoir for viral replication, which has major implications for HIV eradication strategies. Although there has been major progress in the last decade in our understanding of the pathogenesis, burden, and impact of neurological conditions associated with HIV infection, significant scientific gaps remain. In many resource-limited settings, antiretrovirals considered second or third line in the United States, which carry substantial neurotoxicity, remain mainstays of treatment, and patients continue to present with severe immunosuppression and CNS opportunistic infections. Despite this, increased global access to cART has coincided with an aging HIV-positive population with cognitive sequelae, cerebrovascular disease, and peripheral neuropathy. Further neurological research in low-income and middle-income countries (LMICs) is needed to address the burden of neurological complications in HIV-positive patients, particularly regarding CNS viral reservoirs and their effects on eradication.
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Elafros MA, Johnson BA, Siddiqi OK, Okulicz JF, Sikazwe I, Bositis CM, Potchen MJ, Koralnik IJ, Theodore WH, Kalungwana L, Birbeck GL. Mortality & recurrent seizure risk after new-onset seizure in HIV-positive Zambian adults. BMC Neurol 2018; 18:201. [PMID: 30522451 PMCID: PMC6284303 DOI: 10.1186/s12883-018-1205-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 11/27/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Recurrent seizure risks in HIV-positive people with new-onset seizure are largely unknown, making it challenging to offer optimal recommendations regarding antiepileptic drug (AED) initiation. Existing outcomes data is limited, and risk factor identification requires a diagnostic assessment, which is often unavailable in regions heavily effected by HIV, like sub-Saharan Africa. METHODS HIV-positive Zambian adults with new-onset seizure were enrolled in a prospective cohort study to determine seizure recurrence and risk factors for recurrence. Seizure etiology was evaluated, and recurrent seizures and medication usage were assessed during clinic visits. Due to unexpectedly high mortality rates, predictors of death were evaluated using proportional hazards with Gray's test to compare cumulative incidence functions for recurrent seizure across groups adjusting for the competing outcome of death. RESULTS 95 patients were enrolled (mean age 37 years, 43% female, 83% with Karnofsky > 50) and followed for a mean of 293 days (median 241 (IQR: 29-532)). At presentation, 50 (53%) were in status epilepticus. The majority (91, 85%) had advanced HIV disease and 65 (68%) were not on combined antiretroviral therapy (cART). After extensive workup, seizure etiology remained unknown in 16 (17%). Average time to cART initiation after enrollment was 61 days. During follow up, 37 (39%) died and 23 (24%) had recurrent seizure. Most deaths (25/37, 68%) occurred in the first 60 days post-index seizure. Individuals with advanced HIV were more likely to die (HR: 19.1 [95% CI: 1.1-333.4]) as were those whose seizure etiology remained unknown (HR: 2.2 [95% CI: 1.1-4.4]). Among participants that survived from enrolment to the end of data collection on 10 May 2013 (n = 58), 20 (34%) experienced recurrent seizures. CONCLUSIONS New-onset seizure among HIV-positive Zambian adults is associated with high mortality despite good functional status prior to presentation. Advanced HIV infection and failure to identify an underlying seizure etiology are associated with greater mortality. Recurrent seizures occur in over a third of survivors within only 2 years of follow-up. This provides evidence to support AED initiation after first seizure in HIV-positive individuals with advanced HIV disease at the time of presentation though the risks of AED-cART interactions remain a concern and warrant further study.
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Affiliation(s)
- Melissa A. Elafros
- Department of Neurology, Johns Hopkins Hospital, Sheik Zayed Tower, Room 6005, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Brent A. Johnson
- Department of Biostatistics and Computational Biology, University of Rochester, 265 Crittenden Boulevard, CU 420-630, Rochester, NY 14642-0630 USA
| | - Omar K. Siddiqi
- Global Neurology Program, Division of Neuroimmunology, Department of Neurology, E/CLS 1017B Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215 USA
- Department of Internal Medicine, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jason F. Okulicz
- Infectious Disease Service, Brooke Army Medical Center, 3851 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX 78234 USA
| | - Izukanji Sikazwe
- Center for Infectious Disease Research in Zambia, 5032 Great North Road, P.O. Box 34681, Lusaka, Zambia
| | | | - Michael J. Potchen
- Neuroradiology Division, Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642 USA
| | - Igor J. Koralnik
- Department of Neurological Sciences, Rush University Medical Center, 1725 W. Harrison Street, Suite 1106, Chicago, IL 60612 USA
| | - William H. Theodore
- Clinical Epilepsy Section, National Institute of Neurological Disorders and Stroke, NINDS NIH Building 10 Room 7D-43, Bethesda, MD 20892 USA
| | - Lisa Kalungwana
- Department of Psychology, University of Zambia, P.O. BOX 32379, 10101 Lusaka, Zambia
| | - Gretchen L. Birbeck
- Epilepsy Division, Department of Neurology, University of Rochester School of Medicine & Dentistry, 265 Crittenden Blvd, CU420694, Rochester, NY 14642–0694 USA
- Epilepsy Care Team, Chikankata Hospital, Private Bag S2, Mazabuka, Zambia
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40
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Howlett WP. The role of LP in NDs where there is no neuroimaging. J Neurol Sci 2018; 393:110-112. [PMID: 30153570 DOI: 10.1016/j.jns.2018.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 08/02/2018] [Indexed: 11/17/2022]
Affiliation(s)
- William P Howlett
- Department of Internal Medicine, Kilimanjaro Christian Medical Centre, Box 3010, Moshi, United Republic of Tanzania.
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41
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Chen J, Zhang R, Shen Y, Liu L, Qi T, Wang Z, Mehraj V, Routy JP, Lu H. Serum cryptococcal antigen titre as a diagnostic tool and a predictor of mortality in HIV-infected patients with cryptococcal meningitis. HIV Med 2018; 20:69-73. [PMID: 30311440 DOI: 10.1111/hiv.12679] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim was to determine the effectiveness of the serum cryptococcal antigen (CrAg) test in the diagnosis of concurrent cryptococcal meningitis (CM) and as a predictor of mortality in HIV-infected patients. METHODS In this retrospective study, all HIV-infected patients admitted to Shanghai Public Health Clinical Center from 1 January 2014 to 31 August 2016 were screened for serum CrAg using the latex agglutination test. Serum CrAg-positive patients underwent lumbar puncture to confirm CM prior to the initiation of appropriate antifungal therapy and were followed up for at least 6 months. RESULTS One hundred and four (7.1%) of the total of 1474 HIV-infected patients screened were serum CrAg-positive. CM was diagnosed in the majority of serum CrAg-positive patients (71.3%; 67 of 94) and was confirmed in all (46 of 46) of the patients with headache or coma and in 43.8% (21 of 48) of patients without neurological symptoms. CrAg titres ≥ 1:1024 showed a sensitivity of 82.5% and a specificity of 86.7% for the diagnosis of concurrent CM (P < 0.001). The positive predictive value for CM in this population was 94.3%. A total of 13 serum CrAg-positive patients [13.8%; 95% confidence interval (CI) 7.5-22.4%] died (11 as a result of CM and two others as a result of bacterial pneumonia) despite early antifungal treatment initiation. Serum CrAg titres ≥ 1:1024 predicted all-cause mortality (hazard ratio 3.69; P = 0.03). CONCLUSIONS Serum CrAg titres ≥ 1:1024 not only were associated with concurrent CM but also predicted mortality. HIV-infected patients with a positive serum CrAg test during screening should receive lumbar punctures regardless of symptoms to rule out CM and patients with serum CrAg titres ≥ 1:1024 should be offered immediate care.
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Affiliation(s)
- J Chen
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China.,Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - R Zhang
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - Y Shen
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - L Liu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - T Qi
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - Z Wang
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China
| | - V Mehraj
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,CR-CHUM, Université de Montréal, Montreal, QC, Canada
| | - J P Routy
- Chronic Viral Illness Service, McGill University Health Centre, Montreal, QC, Canada.,Research Institute of the McGill University Health Centre, Montreal, QC, Canada.,Division of Hematology, McGill University Health Centre, Montreal, QC, Canada
| | - H Lu
- Department of Infectious Diseases, Shanghai Public Health Clinical Center, Shanghai, China.,Department of Internal Medicine, Shanghai Medical College, Fudan University, Shanghai, China.,Department of Infectious Diseases, Huashan Hospital Affiliated to Fudan University, Shanghai, China
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Imran D, Estiasari R, Maharani K, Sucipto, Lestari DC, Yunus RE, Yunihastuti E, Karyadi TH, Oei D, Timan IS, Wulandari D, Wahyuningsih R, Adawiyah R, Kurniawan A, Mulyadi R, Karuniawati A, Jaya UA, Safari D, van Laarhoven A, Alisjahbana B, Dian S, Chaidir L, Ganiem AR, Lastri DN, Aye Myint KS, van Crevel R. Presentation, etiology, and outcome of brain infections in an Indonesian hospital: A cohort study. Neurol Clin Pract 2018; 8:379-388. [PMID: 30564491 DOI: 10.1212/cpj.0000000000000517] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/08/2018] [Indexed: 11/15/2022]
Abstract
Background Little detailed knowledge is available regarding the etiology and outcome of CNS infection, particularly in HIV-infected individuals, in low-resource settings. Methods From January 2015 to April 2016, we prospectively included all adults with suspected CNS infection in a referral hospital in Jakarta, Indonesia. Systematic screening included HIV testing, CSF examination, and neuroimaging. Results A total of 274 patients with suspected CNS infection (median age 26 years) presented after a median of 14 days with headache (77%), fever (78%), seizures (27%), or loss of consciousness (71%). HIV coinfection was common (54%), mostly newly diagnosed (30%) and advanced (median CD4 cell count 30/µL). Diagnosis was established in 167 participants (65%), including definite tuberculous meningitis (TBM) (n = 44), probable TBM (n = 48), cerebral toxoplasmosis (n = 48), cryptococcal meningitis (n = 14), herpes simplex virus/varicella-zoster virus/cytomegalovirus encephalitis (n = 10), cerebral lymphoma (n = 1), neurosyphilis (n = 1), and mucormycosis (n = 1). In-hospital mortality was 32%; 6-month mortality was 57%. The remaining survivors had either moderate or severe disability (36%) according to Glasgow Outcome Scale. Conclusion In this setting, patients with CNS infections present late with severe disease and often associated with advanced HIV infection. Tuberculosis, toxoplasmosis, and cryptococcosis are common. High mortality and long-term morbidity underline the need for service improvements and further study.
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Affiliation(s)
- Darma Imran
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Riwanti Estiasari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Kartika Maharani
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Sucipto
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Delly Chipta Lestari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Reyhan Eddy Yunus
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Evy Yunihastuti
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Teguh Haryono Karyadi
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Diana Oei
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Ina S Timan
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Dewi Wulandari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Retno Wahyuningsih
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Robiatul Adawiyah
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Agnes Kurniawan
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Rahmad Mulyadi
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Anis Karuniawati
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Ungke Anton Jaya
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Dodi Safari
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Arjan van Laarhoven
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Bachti Alisjahbana
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Sofiati Dian
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Lidya Chaidir
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Ahmad Rizal Ganiem
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Diatri Nari Lastri
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Khin Saw Aye Myint
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
| | - Reinout van Crevel
- Departments of Neurology (DI, RE, KM, Sucipto, DO, DNL), Microbiology (DCL, A. Karuniawati), Radiology (REY, RM), Internal Medicine (EY, THK), Clinical Pathology (IST, DW), and Parasitology (RW, RA, A. Kurniawan), Cipto Mangunkusumo Hospital-Faculty of Medicine Universitas Indonesia; Eijkman Institute for Molecular Biology (UAJ, DS, KSAM); Eijkman-Oxford Clinical Research Unit (UAJ), Jakarta, Indonesia; Department of Internal Medicine and Radboud Center for Infectious Diseases (AvL, RvC), Radboud University Medical Center, Nijmegen, the Netherlands; TB/HIV Research Center (BA, SD, LC, ARG), Faculty of Medicine, Universitas Padjadjaran, Bandung, Indonesia; and Centre for Tropical Medicine and Global Health (RvC), Nuffield Department of Medicine, University of Oxford, UK
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Tembo J, Chandwe K, Kabwe M, Chilufya M, Ciccone O, Mpabalwani E, Ablashi D, Zumla A, Chen T, Bates M. Children infected by human herpesvirus 6B with febrile seizures are more likely to develop febrile status epilepticus: A case-control study in a referral hospital in Zambia. J Med Virol 2018; 90:1757-1764. [PMID: 30011348 DOI: 10.1002/jmv.25269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 06/12/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Human herpesvirus 6B (HHV-6B) is the causative agent of Roseola infantum, and has also been suggested to play a role in the pathogenesis of febrile seizures in young children, a percentage of whom go on to develop febrile status epilepticus (FSE), but the existing data is conflicting and inconclusive. HHV-6A is a distinct species, rarely detected in most parts of the world, but prior studies suggest a higher prevalence in febrile African children. We describe a case-control study comparing the frequency of HHV-6A and/or HHV-6B infections in children with febrile seizures (including FSE) and a control group of febrile children without seizures. METHODS We recruited children aged 6 to 60 months admitted with a febrile illness with (cases) or without (controls) seizures presenting within 48 hours of commencement of fever. Three milliliters of whole blood was centrifuged and plasma stored at -80°C for pooled screening for HHV-6B and HHV-6A by Taqman real-time polymerase chain reaction. RESULTS 102 cases and 95 controls were recruited. The prevalence of HHV-6B DNA detection did not differ significantly between cases (5.8% (6/102)) and controls (10.5% (10/95)) but HHV-6B infection was associated with FSE (OR, 15; 95% CI, [1.99-120]; P= 0.009). HHV-6A was not detected. CONCLUSION Prevalence of HHV-6B was similar among cases and controls. Within the FS group, HHV-6B infection was associated with FSE, suggesting HHV-6B infections could play a role in the pathogenesis of FSE.
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Affiliation(s)
- John Tembo
- Department of Clinical Immunology, Tongji Medical College, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China.,HerpeZ, University Teaching Hospital, Lusaka, Zambia
| | - Kanta Chandwe
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Mwila Kabwe
- HerpeZ, University Teaching Hospital, Lusaka, Zambia.,Depatment of Pharmacy and Applied Sciences, La Trobe University, Melbourne, Australia
| | | | - Ornella Ciccone
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Evans Mpabalwani
- Department of Paediatrics & Child Health, University Teaching Hospital, Lusaka, Zambia
| | - Dharam Ablashi
- HHV-6 Foundation, Santa Barbara, California, United States
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, United Kingdom.,NIHR Biomedical Research Centre, University College London Hospitals, London, United Kingdom
| | - Tie Chen
- Department of Clinical Immunology, Tongji Medical College, Tongji Hospital, Huazhong University of Science & Technology, Wuhan, China
| | - Matthew Bates
- HerpeZ, University Teaching Hospital, Lusaka, Zambia.,School of Life Sciences, University of Lincoln, Lincoln, United Kingdom
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Mukendi D, Kalo JRL, Kayembe T, Lutumba P, Barbé B, Gillet P, Jacobs J, Yansouni CP, Chappuis F, Verdonck K, Boelaert M, Winkler AS, Bottieau E. Where there is no brain imaging: Safety and diagnostic value of lumbar puncture in patients with neurological disorders in a rural hospital of Central Africa. J Neurol Sci 2018; 393:72-79. [PMID: 30121441 DOI: 10.1016/j.jns.2018.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/10/2018] [Accepted: 08/02/2018] [Indexed: 12/26/2022]
Abstract
Analysis of cerebrospinal fluid (CSF) obtained by lumbar puncture (LP) is an essential step for the diagnostic approach of neurological disorders, in particular neuro-infections. In low-resource settings, it is even often the only available diagnostic method. Despite its key contribution, little is known on the risks and benefits of LP in the large tropical areas where hospital-based neuroimaging is not available. The objectives of this study were to assess the safety and diagnostic yield of LP in a rural hospital of central Africa and to identify predictors of CSF pleocytosis (white blood cell count >5/μL) as surrogate marker of neuro-infections. From 2012 to 2015, 351 patients admitted for neurological disorders in the rural hospital of Mosango, Kwilu province, Democratic Republic of Congo, were evaluated using a systematic clinical and laboratory workup and a standard operating procedure for LP. An LP was successfully performed in 307 patients (87.5%). Serious post-LP adverse events (headache, backache or transient confusion) were observed in 23 (7.5%) of them but were self-limiting, and no death or long-term sequelae were attributable to LP. CSF pleocytosis was present in 54 participants (17.6%), almost always associated with neuro-infections. Presenting features strongly and independently associated with CSF pleocytosis were fever, altered consciousness, HIV infection and positive screening serology for human African trypanosomiasis. In conclusion, the established procedure for LP was safe in this hospital setting with no neuroimaging and CSF analysis brought a substantial diagnostic contribution. A set of presenting features may help accurately selecting the patients for whom LP would be most beneficial.
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Affiliation(s)
- Deby Mukendi
- Institut National de Recherche Biomédicale, Kinshasa, DR, Congo; Département de Neurologie, service de Neurologie Tropicale, Université de Kinshasa, DR, Congo.
| | | | - Tharcisse Kayembe
- Département de Neurologie, service de Neurologie Tropicale, Université de Kinshasa, DR, Congo
| | - Pascal Lutumba
- Institut National de Recherche Biomédicale, Kinshasa, DR, Congo; Département de Neurologie, service de Neurologie Tropicale, Université de Kinshasa, DR, Congo
| | - Barbara Barbé
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Philippe Gillet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
| | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Canada
| | - François Chappuis
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals and University of Geneva, Switzerland
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Marleen Boelaert
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Andrea S Winkler
- Center for Global Health, Department of Neurology, Technical University of Munich, Munich, Germany; Centre for Global Health, University of Oslo, Oslo, Norway
| | - Emmanuel Bottieau
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
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Beyene T, Zewde AG, Balcha A, Hirpo B, Yitbarik T, Gebissa T, Rajasingham R, Boulware DR. Inadequacy of High-Dose Fluconazole Monotherapy Among Cerebrospinal Fluid Cryptococcal Antigen (CrAg)-Positive Human Immunodeficiency Virus-Infected Persons in an Ethiopian CrAg Screening Program. Clin Infect Dis 2018; 65:2126-2129. [PMID: 29020172 DOI: 10.1093/cid/cix613] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/10/2017] [Indexed: 11/15/2022] Open
Abstract
A total of 817 human immunodeficiency virus-infected Ethiopians with CD4 <150 cells/mL underwent plasma cryptococcal antigen (CRAG) screening. CRAG prevalence was 6.2%. Of participants with plasma CRAG titers >1:640, 96% (27 of 28) had cryptococcal meningitis (cerebrospinal fluid CRAG-positive) whereas 50% (7 of 14) with 1:160-1:320 titers had meningitis. With fluconazole 1200 mg/d therapy, 68% of meningitis patients (23 of 34) died within 3 months. Plasma CRAG titers >1:160 predict meningitis, requiring more intensive antifungal therapy.
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Affiliation(s)
- Tafese Beyene
- Asella Teaching Hospital, College of Health Sciences, Arsi University.,Hirsch-Institute of Tropical Medicine Research Centre, Asella, Ethiopia
| | - Anteneh G Zewde
- Department of Medicine, University of Minnesota, Minneapolis
| | - Abera Balcha
- Department of Internal Medicine, College of Health Sciences, University of Gondar
| | - Belda Hirpo
- Asella Teaching Hospital, College of Health Sciences, Arsi University
| | | | - Teshome Gebissa
- Asella Teaching Hospital, College of Health Sciences, Arsi University
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Gupta KM, Harding JC, Othman MS, Merbs SL, Gower EW. Why do patients refuse trichiasis surgery? Lessons and an education initiative from Mtwara Region, Tanzania. PLoS Negl Trop Dis 2018; 12:e0006464. [PMID: 29902219 PMCID: PMC6001945 DOI: 10.1371/journal.pntd.0006464] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 04/19/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Trachomatous trichiasis is one of the leading causes of preventable blindness worldwide. A relatively simple surgery can spare vision. Although this surgery is usually performed free of charge in endemic regions, multiple studies indicate that surgical refusal is common. Prior studies have attempted to examine these reasons, although they generally rely on patient recall months to years after the surgery was offered. This study set out to determine major decision-making factors at the time of refusal. In addition, this study looked for ways to help increase surgical uptake by targeting modifiable factors. METHODOLOGY/PRINCIPAL FINDINGS We used a combination of focus groups, interviews with community health workers, and individual interviews with trichiasis patients who refused surgery to understand their decision-making. We found that several factors influenced surgical refusals, including misconception regarding recovery time, inability to find a post-surgical caregiver, and the time of year of the surgical campaign. Fear of the surgery itself played a minimal role in refusals. CONCLUSIONS/SIGNIFICANCE Trichiasis patients refuse surgery for many reasons, but a large percentage is due to lack of information and education, and is, therefore, modifiable within the structure of a surgical outreach project. To address this, we developed a "frequently asked questions" (FAQ) document aimed at community health workers, which may have helped to decrease some of the misconceptions that had led to prior refusals.
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Affiliation(s)
- Katherine M. Gupta
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, United States of America
| | | | | | - Shannath L. Merbs
- Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Emily W. Gower
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Ombelet S, Ronat JB, Walsh T, Yansouni CP, Cox J, Vlieghe E, Martiny D, Semret M, Vandenberg O, Jacobs J. Clinical bacteriology in low-resource settings: today's solutions. THE LANCET. INFECTIOUS DISEASES 2018. [PMID: 29519767 DOI: 10.1016/s1473-3099(18)30093-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Low-resource settings are disproportionately burdened by infectious diseases and antimicrobial resistance. Good quality clinical bacteriology through a well functioning reference laboratory network is necessary for effective resistance control, but low-resource settings face infrastructural, technical, and behavioural challenges in the implementation of clinical bacteriology. In this Personal View, we explore what constitutes successful implementation of clinical bacteriology in low-resource settings and describe a framework for implementation that is suitable for general referral hospitals in low-income and middle-income countries with a moderate infrastructure. Most microbiological techniques and equipment are not developed for the specific needs of such settings. Pending the arrival of a new generation diagnostics for these settings, we suggest focus on improving, adapting, and implementing conventional, culture-based techniques. Priorities in low-resource settings include harmonised, quality assured, and tropicalised equipment, consumables, and techniques, and rationalised bacterial identification and testing for antimicrobial resistance. Diagnostics should be integrated into clinical care and patient management; clinically relevant specimens must be appropriately selected and prioritised. Open-access training materials and information management tools should be developed. Also important is the need for onsite validation and field adoption of diagnostics in low-resource settings, with considerable shortening of the time between development and implementation of diagnostics. We argue that the implementation of clinical bacteriology in low-resource settings improves patient management, provides valuable surveillance for local antibiotic treatment guidelines and national policies, and supports containment of antimicrobial resistance and the prevention and control of hospital-acquired infections.
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Affiliation(s)
- Sien Ombelet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium.
| | | | | | - Cedric P Yansouni
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC, Canada
| | - Janneke Cox
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Erika Vlieghe
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of General Internal Medicine, Infectious and Tropical Diseases, Antwerp University Hospital, Antwerp, Belgium; Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Delphine Martiny
- Department of Microbiology, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Brussels, Belgium
| | - Makeda Semret
- JD MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, QC, Canada; St Mary's Hospital Centre, Montreal, QC, Canada
| | - Olivier Vandenberg
- Department of Microbiology, LHUB-ULB, Pôle Hospitalier Universitaire de Bruxelles, Brussels, Belgium; Center for Environmental Health and Occupational Health, Public Health School, Université Libre de Bruxelles, Brussels, Belgium
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; Department of Microbiology and Immunology, KU Leuven, Leuven, Belgium
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48
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Wake RM, Britz E, Sriruttan C, Rukasha I, Omar T, Spencer DC, Nel JS, Mashamaite S, Adelekan A, Chiller TM, Jarvis JN, Harrison TS, Govender NP. High Cryptococcal Antigen Titers in Blood Are Predictive of Subclinical Cryptococcal Meningitis Among Human Immunodeficiency Virus-Infected Patients. Clin Infect Dis 2018; 66:686-692. [PMID: 29028998 PMCID: PMC6220350 DOI: 10.1093/cid/cix872] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 10/03/2017] [Indexed: 01/30/2023] Open
Abstract
Background High mortality rates among asymptomatic cryptococcal antigen (CrAg)-positive patients identified through CrAg screening, despite preemptive fluconazole treatment, may be due to undiagnosed cryptococcal meningitis. Methods Symptoms were reviewed in CrAg-positive patients identified by screening 19233 individuals with human immunodeficiency virus infection and CD4 cell counts <100/µL at 17 clinics and 3 hospitals in Johannesburg from September 2012 until September 2015, and at 2 hospitals until June 2016. Cerebrospinal fluid samples from 90 of 254 asymptomatic patients (35%) and 78 of 173 (45%) with headache only were analyzed for cryptococcal meningitis, considered present if Cryptococcus was identified by means of India ink microscopy, culture, or CrAg test. CrAg titers were determined with stored blood samples from 62 of these patients. The associations between blood CrAg titer, concurrent cryptococcal meningitis, and mortality rate were assessed. Results Cryptococcal meningitis was confirmed in 34% (95% confidence interval, 25%-43%; 31 of 90) of asymptomatic CrAg-positive patients and 90% (81%-96%; 70 of 78) with headache only. Blood CrAg titer was significantly associated with concurrent cryptococcal meningitis in asymptomatic patients (P < .001) and patients with headache only (P = .003). The optimal titer for predicting cryptococcal meningitis was >160 (sensitivity, 88.2%; specificity, 82.1%); the odds ratio for concurrent cryptococcal meningitis was 34.5 (95% confidence interval, 8.3-143.1; P < .001). Conclusions About a third of asymptomatic CrAg-positive patients have concurrent cryptococcal meningitis. More effective clinical assessment strategies and antifungal regimens are required for CrAg-positive patients, including investigation for cryptococcal meningitis irrespective of symptoms. Where it is not possible to perform lumbar punctures in all CrAg-positive patients, blood CrAg titers should be used to target those most at risk of cryptococcal meningitis.
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Affiliation(s)
- Rachel M Wake
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- Institute for Infection and Immunity, St George’s University of London
| | - Erika Britz
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Charlotte Sriruttan
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand
| | - Ivy Rukasha
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
| | - Tanvier Omar
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand
| | - David C Spencer
- Helen Joseph Hospital, Johannesburg, South Africa
- Right to Care, Johannesburg, South Africa
| | - Jeremy S Nel
- Helen Joseph Hospital, Johannesburg, South Africa
| | | | | | - Tom M Chiller
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Joseph N Jarvis
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Botswana-UPenn Partnership, Gaborone, Botswana
| | - Thomas S Harrison
- Institute for Infection and Immunity, St George’s University of London
| | - Nelesh P Govender
- Centre for Healthcare-Associated Infections, Antimicrobial Resistance and Mycoses, National Institute for Communicable Diseases
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand
- Division of Medical Microbiology, Faculty of Health Sciences, University of Cape Town, South Africa
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49
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Chan P, Hellmuth J, Colby D, Kroon E, Sacdalan C, Fletcher J, Patel P, Pinyakorn S, Valcour V, Ananworanich J, Spudich S. Safety of lumbar puncture procedure in an international research setting during acute HIV infection. J Virus Erad 2018; 4:16-20. [PMID: 29568548 PMCID: PMC5851179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background: Cerebrospinal fluid (CSF) sampling at the time of acute HIV infection (AHI) is crucial in understanding NeuroAIDS pathogenesis. Here, we report on the safety of performing a lumbar puncture (LP) during untreated AHI and follow-up after initiation of combination antiretroviral therapy (cART). Methods: We reviewed clinical records of participants who took part in an AHI protocol in Bangkok, Thailand, including untreated AHI subjects (baseline), and longitudinal visits following immediate initiation of cART to assess rates and risk of post-lumbar puncture headaches (PLPH). A cerebrospinal fluid (CSF) volume of 10-20 mL was collected using standard cutting-edge or atraumatic needles. Results: From April 2009 to February 2016, 195 LPs were performed, of which 89 (46%) were at baseline. The LP procedures at baseline were not associated with an additional PLPH risk as compared to repeat LPs after cART initiation (26/89 [29%] vs 4/27 [15%], respectively; P=0.134). Higher body mass index (BMI) at baseline (P=0.070) and use of an atraumatic needle (P=0.058) had trend-level associations with reduced PLPH. A higher CSF volume collection (20 mL) was independently associated with a lower PLPH frequency (P=0.024). This association was similar in a subgroup analysis with the use of atraumatic needles. The CD4+ T lymphocyte count, blood and CSF HIV viral load, Fiebig staging, and the presence of an acute retroviral syndrome did not correlate with risk for PLPH (all P>0.05). Conclusion: The frequency of PLPH during AHI was similar to that seen in the setting of cART-treated HIV infection and not higher with a larger CSF volume collection. Our study adds to the existing evidence that atraumatic needles should be used to minimise the risk of PLPH.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Serena Spudich
- Corresponding author: Serena Spudich,
Department of Neurology,
Yale University,
15 York St,
New Haven,
CT06510,
USA
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50
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Chan P, Hellmuth J, Colby D, Kroon E, Sacdalan C, Fletcher J, Patel P, Pinyakorn S, Valcour V, Ananworanich J, Spudich S. Safety of lumbar puncture procedure in an international research setting during acute HIV infection. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30236-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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