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Hall MT, Simms KT, Murray JM, Keane A, Nguyen DTN, Caruana M, Lui G, Kelly H, Eckert LO, Santesso N, de Sanjose S, Swai EE, Rangaraj A, Owiredu MN, Gauvreau C, Demke O, Basu P, Arbyn M, Dalal S, Broutet N, Canfell K. Benefits and harms of cervical screening, triage and treatment strategies in women living with HIV. Nat Med 2023; 29:3059-3066. [PMID: 38087116 PMCID: PMC10719091 DOI: 10.1038/s41591-023-02601-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 09/20/2023] [Indexed: 12/17/2023]
Abstract
To support a strategy to eliminate cervical cancer as a public health problem, the World Health Organisation (WHO) reviewed its guidelines for screening and treatment of cervical pre-cancerous lesions in 2021. Women living with HIV have 6-times the risk of cervical cancer compared to women in the general population, and we harnessed a model platform ('Policy1-Cervix-HIV') to evaluate the benefits and harms of a range of screening strategies for women living with HIV in Tanzania, a country with endemic HIV. Assuming 70% coverage, we found that 3-yearly primary HPV screening without triage would reduce age-standardised cervical cancer mortality rates by 72%, with a number needed to treat (NNT) of 38.7, to prevent a cervical cancer death. Triaging HPV positive women before treatment resulted in minimal loss of effectiveness and had more favorable NNTs (19.7-33.0). Screening using visual inspection with acetic acid (VIA) or cytology was less effective than primary HPV and, in the case of VIA, generated a far higher NNT of 107.5. These findings support the WHO 2021 recommendation that women living with HIV are screened with primary HPV testing in a screen-triage-and-treat approach starting at 25 years, with regular screening every 3-5 years.
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Affiliation(s)
- Michaela T Hall
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia.
| | - Kate T Simms
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - John M Murray
- School of Mathematics and Statistics, University of New South Wales, Sydney, NSW, Australia
| | - Adam Keane
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Diep T N Nguyen
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Michael Caruana
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Gigi Lui
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Helen Kelly
- London School of Hygiene and Tropical Medicine, University of London, London, UK
| | - Linda O Eckert
- Department of Global Health and the Department of Obstetrics & Gynecology, University of Washington, Seattle, WA, USA
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Silvia de Sanjose
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA
- ISGlobal, Barcelona, Spain
| | - Edwin E Swai
- Universal Health Coverage and Life Course Cluster, World Health Organization, Dar es Salaam, Tanzania
| | - Ajay Rangaraj
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Morkor Newman Owiredu
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Cindy Gauvreau
- Child Health Evaluative Sciences, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
- SUCCESS Project, Expertise France, Paris, France
| | - Owen Demke
- Global Diagnostics, Clinton Health Access Initiative, Kigali, Rwanda
| | - Partha Basu
- Early Detection Prevention and Infections, International Agency for Research on Cancer, Lyon, France
| | - Marc Arbyn
- Cancer Epidemiology Unit, Belgian Cancer Centre, Sciensano, Brussels, Belgium
- Department of Human Structure and Repair, Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
| | - Shona Dalal
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Nathalie Broutet
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Karen Canfell
- Daffodil Centre, University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
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Burke RM, Feasey N, Rangaraj A, Camps MR, Meintjes G, El-Sadr WM, Ford N. Ending AIDS deaths requires improvements in clinical care for people with advanced HIV disease who are seriously ill. Lancet HIV 2023; 10:e482-e484. [PMID: 37301220 PMCID: PMC7614731 DOI: 10.1016/s2352-3018(23)00109-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/12/2023] [Accepted: 05/04/2023] [Indexed: 06/12/2023]
Abstract
Over 4 million adults are living with advanced HIV disease with approximately 650 000 fatalities from HIV reported in 2021. People with advanced HIV disease have low immunity and can present to health services in two ways: those who are well but at high risk of developing severe disease, and those who are severely ill. These two groups require specific management approaches that place different demands on the health system. The first group can generally be supported in primary care settings but require differentiated care to meet their needs. The second group are at high risk of death and need focused diagnostics and clinical care, and possibly hospitalisation. Investments in high-quality clinical management of patients with advanced HIV disease who are seriously ill at primary care or hospital level (often only for a brief period of time during their acute illness) improves the likelihood that their condition will stabilise and that they will recover. Providing high-quality and safe clinical care that is accessible to these groups of people living with HIV who are at risk of severe illness and death is a key priority for reaching the global target of zero AIDS deaths.
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Affiliation(s)
- Rachael M Burke
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Nicholas Feasey
- Malawi Liverpool Wellcome Research Programme, Blantyre, Malawi; Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ajay Rangaraj
- Global HIV, STIs and Hepatitis Programme, WHO, Geneva, Switzerland
| | | | - Graeme Meintjes
- Department of Medicine, Wellcome Centre for Infectious Diseases Research in Africa and Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Wafaa M El-Sadr
- ICAP, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Nathan Ford
- Global HIV, STIs and Hepatitis Programme, WHO, Geneva, Switzerland; Centre for Infectious Disease and Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
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Frigati LJ, Gibb D, Harwell J, Kose J, Musiime V, Rabie H, Rangaraj A, Rojo P, Turkova A, Penazzato M. The hard part we often forget: providing care to children and adolescents with advanced HIV disease. J Int AIDS Soc 2023; 26:e26041. [PMID: 36943761 PMCID: PMC10029994 DOI: 10.1002/jia2.26041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 11/10/2022] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Many children and adolescents living with HIV still present with severe immunosuppression with morbidity and mortality remaining high in those starting antiretroviral therapy (ART) when hospitalized. DISCUSSION The major causes of morbidity and mortality in children living with HIV are pneumonia, tuberculosis, bloodstream infections, diarrhoeal disease and severe acute malnutrition. In contrast to adults, cryptococcal meningitis is rare in children under 5 years of age but increases in adolescence. In 2021, the World Health Organizations (WHO) consolidated guidelines for managing HIV disease and rapid ART included recommendations for children and adolescents. In addition, a WHO technical brief released in 2020 highlighted the various interventions that are specifically related to children and adolescents with advanced HIV disease (AHD). We discuss the common clinical presentations of children and adolescents with AHD with a focus on diagnosis, prevention and treatment, highlight some of the challenges in the implementation of the existing package of care, and emphasize the importance of additional research to address the needs of children and adolescents with AHD. CONCLUSIONS There are limited data informing these recommendations and an urgent need for further research on how to implement optimal strategies to ensure tailored approaches to prevent and treat AHD in children and adolescents. Holistic care that goes beyond a simple choice of ART regimen should be provided to all children and adolescents with AHD.
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Affiliation(s)
- Lisa Jane Frigati
- Department of Paediatrics and Child HealthStellenbosch University, Tygerberg Academic HospitalCape TownSouth Africa
| | - Diana Gibb
- Medical Research CouncilClinical Trials Unit at University CollegeLondonLondonUK
| | | | - Judith Kose
- Technical Strategy and InnovationThe Elizabeth Glaser Pediatric AIDS FoundationNairobiKenya
- Erasmus MCDepartment of ViroscienceErasmus UniversityRotterdamNetherlands
| | - Victor Musiime
- Department of Paediatrics and Child HealthMakerere UniversityKampalaUganda
- Research DepartmentJoint Clinical Research CentreKampalaUganda
| | - Helena Rabie
- Department of Paediatrics and Child HealthStellenbosch University, Tygerberg Academic HospitalCape TownSouth Africa
| | | | - Pablo Rojo
- Department of PediatricsHospital Universitario Doce de OctubreMadridSpain
| | - Anna Turkova
- Medical Research CouncilClinical Trials Unit at University CollegeLondonLondonUK
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Chun HM, Milligan K, Agyemang E, Ford N, Rangaraj A, Desai S, Wilder-Smith A, Vitoria M, Zulu I. A Systematic Review of COVID-19 Vaccine Antibody Responses in People With HIV. Open Forum Infect Dis 2022; 9:ofac579. [PMID: 36438620 PMCID: PMC9685180 DOI: 10.1093/ofid/ofac579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022] Open
Abstract
HIV infection is a significant independent risk factor for severe coronavirus disease 2019 (COVID-19) disease and death. We summarize COVID-19 vaccine responses in people with HIV (PWH). A systematic literature review of studies from January 1, 2020, to March 31, 2022, of COVID-19 vaccine immunogenicity in PWH from multiple databases was performed. Twenty-eight studies from 12 countries were reviewed. While 22 (73%) studies reported high COVID-19 vaccine seroconversion rates in PWH, PWH with lower baseline CD4 counts, CD4/CD8 ratios, or higher baseline viral loads had lower seroconversion rates and immunologic titers. Data on vaccine-induced seroconversion in PWH are reassuring, but more research is needed to evaluate the durability of COVID-19 vaccine responses in PWH.
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Affiliation(s)
- Helen M Chun
- Correspondence: H. M. Chun, MD, MPH, Division of Global HIV/TB, Center for Global Health, Centers for Disease Control and Prevention, 1600 Clifton Road, E04, Atlanta, GA 30329-4108 ()
| | - Kyle Milligan
- Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, USA,Peraton, Herndon, Virginia, USA
| | - Elfriede Agyemang
- Division of Global HIV/TB, Center for Global Health, Atlanta, Georgia, USA
| | - Nathan Ford
- Global HIV, Viral Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Ajay Rangaraj
- Global HIV, Viral Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Shalini Desai
- Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Annelies Wilder-Smith
- Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland
| | - Marco Vitoria
- Global HIV, Viral Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
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Kanters S, Renaud F, Rangaraj A, Zhang K, Limbrick-Oldfield E, Hughes M, Ford N, Vitoria M. Evidence synthesis evaluating body weight gain among people treating HIV with antiretroviral therapy - a systematic literature review and network meta-analysis. EClinicalMedicine 2022; 48:101412. [PMID: 35706487 PMCID: PMC9112095 DOI: 10.1016/j.eclinm.2022.101412] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 04/03/2022] [Accepted: 04/05/2022] [Indexed: 11/04/2022] Open
Abstract
Background This systematic review aimed to compare body weight gain associated outcomes over time between dolutegravir (DTG)-based antiretroviral (ART) regimens to other ART regimens, to compare tenofovir alafenamide (TAF)-based regimens, and to evaluate the associated prognostic factors. Methods Systematic searches of MEDLINE, Embase, and CENTRAL for RCTs and observational studies comparing ART regimens were conducted on 13 September 2021. Outcomes of interest included: change in body weight, body mass index (BMI), waist circumference; and risk of hyperglycaemia and diabetes. Network meta-analyses were conducted at 12, 24, 48, 96 and 144 weeks using two networks differentiated by 3rd agents and backbone agents. Findings The review identified 113 publications reporting on 73 studies. DTG-based regimens led to statistically higher weight gains than efavirenz-based regimens at all time points (mean difference: 1·99 kg at 96 weeks; 95% credible interval: 0·85-3·09) and was higher over time than low-dose efavirenz-, elvitegravir-, and rilpivirine-based regimens. They were comparable to raltegravir-, bictegravir- and atazanavir-based regimens. For backbones, TAF led to higher weight gain relative to tenofovir disoproxil fumarate (TDF), abacavir, and zidovudine. Prognostic factor analysis showed both low CD4 cell count and high HIV RNA viral load at baseline were consistently associated with higher weight gain, while sex was an effect modifier to African origins. Interpretation DTG-based regimens lead to larger average weight gains than some other ART regimens and TAF leads to larger average weight gains than all other backbone antiretrovirals. Further research is needed to better understand long-term outcomes and their relationship to other metabolic outcomes. Funding The WHO Global HIV, Hepatitis and Sexually Transmitted Infections Programmes.
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Affiliation(s)
- Steve Kanters
- School of Population and Public Health, University of British Columbia, 2206 E Mall, Vancouver, British Columbia, Canada
- RainCity Analytics, Vancouver, Canada
| | - Francoise Renaud
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Ajay Rangaraj
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | | | | | - Monica Hughes
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Nathan Ford
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Marco Vitoria
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
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Salomon A, Law S, Johnson C, Baddeley A, Rangaraj A, Singh S, Daftary A. Interventions to improve linkage along the HIV-tuberculosis care cascades in low- and middle-income countries: A systematic review and meta-analysis. PLoS One 2022; 17:e0267511. [PMID: 35552547 PMCID: PMC9098064 DOI: 10.1371/journal.pone.0267511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 04/09/2022] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION In support of global targets to end HIV/AIDS and tuberculosis (TB) by 2030, we reviewed interventions aiming to improve TB case-detection and anti-TB treatment among people living with HIV (PLHIV) and HIV testing and antiretroviral treatment initiation among people with TB disease in low- and middle-income countries (LMICs). METHODS We conducted a systematic review of comparative (quasi-)experimental interventional studies published in Medline or EMBASE between January 2003-July 2021. We performed random-effects effect meta-analyses (DerSimonian and Laird method) for interventions that were homogenous (based on intervention descriptions); for others we narratively synthesized the intervention effect. Studies were assessed using ROBINS-I, Cochrane Risk-of-Bias, and GRADE. (PROSPERO #CRD42018109629). RESULTS Of 21,516 retrieved studies, 23 were included, contributing 53 arms and 84,884 participants from 4 continents. Five interventions were analyzed: co-location of test and/or treatment services; patient education and counselling; dedicated personnel; peer support; and financial support. A majority were implemented in primary health facilities (n = 22) and reported on HIV outcomes in people with TB (n = 18). Service co-location had the most consistent positive effect on HIV testing and treatment initiation among people with TB, and TB case-detection among PLHIV. Other interventions were heterogenous, implemented concurrent with standard-of-care strategies and/or diverse facility-level improvements, and produced mixed effects. Operational system, human resource, and/or laboratory strengthening were common within successful interventions. Most studies had a moderate to serious risk of bias. CONCLUSIONS This review provides operational clarity on intervention models that can support early linkages between the TB and HIV care cascades. The findings have supported the World Health Organization 2020 HIV Service Delivery Guidelines update. Further research is needed to evaluate the distinct effect of education and counselling, financial support, and dedicated personnel interventions, and to explore the role of community-based, virtual, and differentiated service delivery models in addressing TB-HIV co-morbidity.
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Affiliation(s)
- Angela Salomon
- School of Medicine, Queen’s University, Kingston, Canada
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
| | - Stephanie Law
- McGill International TB Centre, Research Institute of the McGill University Health Centre, Montréal, Canada
| | - Cheryl Johnson
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Annabel Baddeley
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Ajay Rangaraj
- Global HIV, Hepatitis and STI Programmes, World Health Organization, Geneva, Switzerland
| | - Satvinder Singh
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland
| | - Amrita Daftary
- School of Global Health and Dahdaleh Institute of Global Health Research, York University, Toronto, Canada
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- * E-mail:
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Ford N, Patten G, Rangaraj A, Davies MA, Meintjes G, Ellman T. Outcomes of people living with HIV after hospital discharge: a systematic review and meta-analysis. The Lancet HIV 2022; 9:e150-e159. [PMID: 35245507 PMCID: PMC8905089 DOI: 10.1016/s2352-3018(21)00329-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 12/03/2021] [Accepted: 12/13/2021] [Indexed: 12/19/2022]
Abstract
Background The identification and appropriate management of people with advanced HIV disease is a key component in the HIV response. People with HIV who are hospitalised are at a higher risk of death, a risk that might persist after discharge. The aims of this study were to estimate the frequency of negative post-discharge outcomes, and to determine risk factors for such outcomes in people with HIV. Methods Using a broad search strategy combining terms for hospital discharge and HIV infection, we searched MEDLINE via PubMed and Embase from Jan 1, 2003 to Nov 30, 2021 to identify studies reporting outcomes among people with HIV following discharge from hospital. We estimated pooled proportions of readmissions and deaths after hospital discharge using random-effects models. We also did subgroup analyses by setting, region, duration of follow-up, and advanced HIV status at admission, and sensitivity analyses to assess heterogeneity. Findings We obtained data from 29 cohorts, which reported outcomes of people living with HIV after hospital discharge in 92 781 patients. The pooled proportion of patients readmitted to hospital after discharge was 18·8% (95% CI 15·3–22·3) and 14·1% (10·8–17·3) died post-discharge. In sensitivity analyses, no differences were identified in the proportion of patients who were readmitted or died when comparing studies published before 2016 with those published after 2016. Post-discharge mortality was higher in studies from Africa (23·1% [16·5–29·7]) compared with the USA (7·5% [4·4–10·6]). For studies that reported both post-discharge mortality and readmission, the pooled proportion of patients who had this composite adverse outcome was 31·7% (23·9–39·5). Heterogeneity was moderate, and largely explained by patient status and linkage to care. Reported risk factors for readmission included low CD4 cell count at admission, longer length of stay, discharge against medical advice, and not linking to care following discharge; inpatient treatment with antiretroviral therapy (ART) during hospitalisation was protective of post-discharge mortality. Interpretation More than a quarter of patients with HIV had an adverse outcome after hospital discharge with no evidence of improvement in the past 15 years. This systematic review highlights the importance of ensuring post-discharge referral and appropriate management, including ART, to reduce mortality and readmission to hospital among this group of high-risk patients. Funding Bill & Melinda Gates Foundation. Translations For the French and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Nathan Ford
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland; Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
| | - Gabriela Patten
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Ajay Rangaraj
- Department of Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, Geneva, Switzerland
| | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Tom Ellman
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
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Broutet N, Jeronimo J, Kumar S, Almonte M, Murillo R, Huy NVQ, Denny L, Kapambwe S, Bhatla N, Sebitloane M, Zhao F, Gravitt P, Adsul P, Rangaraj A, Dalal S, Newman M, Chowdhury R, Church K, Nakisige C, Diop M, Parham G, Thomson KA, Basu P, Steyn P. Implementation research to accelerate scale-up of national screen and treat strategies towards the elimination of cervical cancer. Prev Med 2022; 155:106906. [PMID: 34896155 DOI: 10.1016/j.ypmed.2021.106906] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 11/24/2021] [Accepted: 11/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cervical cancer is a significant public health problem, with 570,000 new cases and 300,000 deaths of women per year globally, mostly in low- and middle-income countries. In 2018 the WHO Director General made a call to action for the elimination of cervical cancer as a public health problem. MAIN BODY New thinking on programmatic approaches to introduce emerging technologies and screening and treatment interventions of cervical precancer at scale is needed to achieve elimination goals. Implementation research (IR) is an important yet underused tool for facilitating scale-up of evidence-based screening and treatment interventions, as most research has focused on developing and evaluating new interventions. It is time for countries to define their specific IR needs to understand acceptability, feasibility, and cost-effectiveness of interventions as to design and ensure effective implementation, scale-up, and sustainability of evidence-based screening and treatment interventions. WHO convened an expert advisory group to identify priority IR questions for HPV-based screening and treatment interventions in population-based programmes. Several international organizations are supporting large scale introduction of screen-and-treat approaches in many countries, providing ideal platforms to evaluate different approaches and strategies in diverse national contexts. CONCLUSION For reducing cervical cancer incidence and mortality, the readiness of health systems, the reach and effectiveness of new technologies and algorithms for increasing screening and treatment coverage, and the factors that support sustainability of these programmes need to be better understood. Answering these key IR questions could provide actionable guidance for countries seeking to implement the WHO Global Strategy towards cervical cancer elimination.
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Affiliation(s)
| | - Jose Jeronimo
- Consultant for the US National Cancer Institute, MD, USA
| | | | - Maribel Almonte
- International Agency for Research in Cancer (IARC), Lyon, France
| | | | | | | | | | - Neerja Bhatla
- All India Institute of Medical Sciences, New Delhi, India
| | | | - Fanghui Zhao
- Chinese Academy of Medical Sciences, Beijing, China
| | - Patti Gravitt
- University of Maryland Baltimore, Baltimore, MD, USA
| | - Prajakta Adsul
- University of New Mexico Comprehensive Cancer Center, USA
| | | | - Shona Dalal
- World Health Organization, Geneva, Switzerland
| | | | | | | | | | - Mamadou Diop
- Cancer Institute, Le Dantec Hospital, Cheikh Anta Diop University, Senegal
| | - Groesbeck Parham
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Kerry A Thomson
- PATH, Sexual & Reproductive Health Program, Seattle, WA, USA
| | - Partha Basu
- International Agency for Research in Cancer (IARC), Lyon, France
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Kanters S, Vitoria M, Zoratti M, Doherty M, Penazzato M, Rangaraj A, Ford N, Thorlund K, Anis PAH, Karim ME, Mofenson L, Zash R, Calmy A, Kredo T, Bansback N. Comparative efficacy, tolerability and safety of dolutegravir and efavirenz 400mg among antiretroviral therapies for first-line HIV treatment: A systematic literature review and network meta-analysis. EClinicalMedicine 2020; 28:100573. [PMID: 33294805 PMCID: PMC7700905 DOI: 10.1016/j.eclinm.2020.100573] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/17/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To inform World Health Organization (WHO) global guidelines, we updated and expanded the evidence base to assess the comparative efficacy, tolerability, and safety of first-line antiretroviral therapy (ART) regimens. METHODS We searched Embase, Medline and CENTRAL on 28 February 2020 to update the systematic literature review of clinical trials comparing recommended first-line ART that informed previous WHO guidelines. Outcomes included viral suppression, change in CD4 cell counts, mortality, serious and overall adverse events (AEs), discontinuation, discontinuations due to AEs (DAEs); and new outcomes: drug-resistance, neuropsychiatric AEs, early viral suppression, weight gain and birth outcomes. Comparative effects were assessed through network meta-analyses and certainty in the evidence was assessed using the GRADE framework. FINDINGS We identified 156 publications pertaining to 68 trials for the primary population. Relative to efavirenz, dolutegravir had improved odds of viral suppression across all time points (odds ratio [OR]: 1·94; 95% credible interval [CrI]: 1·48-2·56 at 96 weeks); was protective of drug-resistance (OR: 0·13; 95%CrI: 0·04-0·48); and led to fewer discontinuations (OR: 0·58; 95%CrI: 0·48-0·70). Evidence supported dolutegravir use among TB-HIV co-infected persons and pregnant women. Adverse birth outcomes were observed in 33.2% of dolutegravir-managed pregnancies and 35.0% of efavirenz-managed pregnancies. Low-dose efavirenz had comparable efficacy and safety to standard-dose efavirenz, but led to fewer DAEs (OR: 0·70; 95%CrI: 0·50-0·92). INTERPRETATION The evidence supports choosing dolutegravir in combination with lamivudine/emtricitabine and tenofovir disoproxil fumarate as the preferred first-line regimen and low-dose efavirenz-based regimens as an alternative. Dolutegravir can be considered to be effective, safe and tolerable. FUNDING WHO.
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Affiliation(s)
- Steve Kanters
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Corresponding author.
| | | | - Michael Zoratti
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Meg Doherty
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | | | | | - Nathan Ford
- Department of HIV/AIDS, WHO, Geneva, Switzerland
| | - Kristian Thorlund
- Departments of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Prof. Aslam H. Anis
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
| | - Mohammad Ehsanul Karim
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, USA
| | - Rebecca Zash
- Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, USA
- Botswana–Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Alexandra Calmy
- HIV/AIDS Unit, Division of Infectious Diseases, Geneva University Hospital, Geneva, Switzerland
| | - Tamara Kredo
- South African Medical Research Council, Cape Town, South Africa
| | - Nick Bansback
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation and Outcome Science, University of British Columbia, Vancouver, Canada
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Jesani H, Jesani L, Rangaraj A, Rasheed A. Splenic trauma, the way forward in reducing splenectomy: our 15-year experience. Ann R Coll Surg Engl 2020; 102:263-270. [PMID: 31909638 PMCID: PMC7099152 DOI: 10.1308/rcsann.2019.0164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2019] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The aim of this study was to study radiological assessment, management and outcome of traumatic splenic injury over 15 years in a UK district general hospital. METHOD A retrospective database was established including all splenic injury cases from June 2002 to June 2017 by searching the clinical electronic database. We searched the radiological database for computed tomography reported phrases 'spleen injury', 'laceration', 'haematoma', 'trauma'. We interrogated theatre records for operations coded as splenectomy and cross-referenced this with pathology. Records were reviewed for demographics, vital observations, documentation of American Association for the Surgery of Trauma (AAST) grading of splenic injury, subsequent management and outcomes. RESULTS There were 126 patients identified with traumatic splenic injury, with male to female ratio three to one. Operative management was undertaken in 54/126 (43%) patients and selective non-operative management in the remaining. Splenic artery embolisation was undertaken in 5/126 (4%) and 2/126 underwent splenorrhaphy. Computed tomography was undertaken in 109/126 (87%) patients and AAST grading was reported in 18 (17%) patients. AAST grade reporting did not improve significantly when comparing the first 7.5 years with the latter (2/30, 7%; 16/79, 20%), respectively; p = 0.09). Selective non-operative management increased significantly over the studied period (14/34, 42%; 58/93, 62%; p = 0.04). The overall hospital mortality was 10.3%. DISCUSSION AND CONCLUSION AAST grade reporting of splenic injury has remained sub-optimal over 15 years. Despite progression towards selective non-operative management, operative intervention remained unacceptably high, with splenectomy being the main therapeutic modality. Standardisation through an integrated multidisciplinary diagnostic and management pathway offers the optimal strategy to reduce trauma-induced splenectomy.
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Affiliation(s)
- H Jesani
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
| | - L Jesani
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
| | - A Rangaraj
- Department of Radiology, Royal Gwent Hospital, Newport, UK
| | - A Rasheed
- Department of General Surgery, Royal Gwent Hospital, Newport, UK
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Ford N, Vitoria M, Rangaraj A, Norris SL, Calmy A, Doherty M. Systematic review of the efficacy and safety of antiretroviral drugs against SARS, MERS or COVID-19: initial assessment. J Int AIDS Soc 2020; 23:e25489. [PMID: 32293807 PMCID: PMC7158851 DOI: 10.1002/jia2.25489] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 03/17/2020] [Accepted: 03/20/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Several antiretroviral drugs are being considered for the treatment of COVID-19, the disease caused by a newly identified coronavirus, (SARS-CoV-2). We systematically reviewed the clinical outcomes of using antiretroviral drugs for the prevention and treatment of coronaviruses and planned clinical trials. METHODS Three databases were screened from inception to 30 March 2020 for studies reporting clinical outcomes of patients with SARS, MERS or COVID-19 treated with antiretrovirals. RESULTS From an initial screen of 433 titles, two randomized trials and 24 observational studies provided clinical outcome data on the use of antiretroviral drugs; most studies reported outcomes using LPV/r as treatment. Of the 21 observational studies reporting treatment outcomes, there were three studies among patients with SARS, six studies among patients with MERS and 12 studies among patients with COVID-19. In one randomized trial 99 patients with severe COVID-19 illness were randomized to receive LPV/r (400/100 mg twice a day) and 100 patients to standard of care for 14 days: LPV/r was not associated with a statistically significant difference in time to clinical improvement, although LPV/r given within 12 days of symptoms was associated with shorter time to clinical improvement; 28 day mortality was numerically lower in the LPV/r group (14/99) compared to the control group (25/100), but this difference was not statistically significant. The second trial found no benefit. The certainty of the evidence for the randomized trials was low. In the observational studies 3 out of 361 patients who received LPV/r died; the certainty of evidence was very low. Three studies reported a possible protective effect of LPV/r as post-exposure prophylaxis. Again, the certainty of the evidence was very low due to uncertainty due to limited sample size. CONCLUSIONS On the basis of the available evidence it is uncertain whether LPV/r and other antiretrovirals improve clinical outcomes or prevent infection among patients at high risk of acquiring COVID-19.
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Affiliation(s)
- Nathan Ford
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
| | - Marco Vitoria
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
| | - Ajay Rangaraj
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
| | - Susan L Norris
- Science DivisionQuality of Norms and Standards DepartmentWorld Health OrganizationGenevaSwitzerland
| | - Alexandra Calmy
- HIV/AIDS UnitDivision of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Meg Doherty
- Department of HIV, Hepatitis and Sexually Transmitted InfectionsWorld Health OrganizationGenevaSwitzerland
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Abdullah AAN, Rangaraj A, Rashid M, Puw-Jones R, Rasheed A. Gallbladder polypoid lesions are inaccurately reported and undermanaged: a retrospective study of the management of gallbladder polypoid lesions detected at ultrasound in symptomatic patients during a 36-month period. Clin Radiol 2019; 74:489.e17-489.e23. [PMID: 30910171 DOI: 10.1016/j.crad.2019.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 02/06/2019] [Indexed: 01/11/2023]
Abstract
AIM To investigate whether gallbladder polypoid lesions (GPL) are accurately reported and managed by radiologists, sonographers, general practitioners (GPs) and surgeons. MATERIALS AND METHODS Consecutive abdominal ultrasound examinations indicating GPL in symptomatic patients performed during 2011-2013 were captured and analysed. The study comprised 244 patients who satisfied the inclusion criteria. RESULTS Of the ultrasound reports retrieved, 238/244 reports (98%) erroneously described the polypoid lesions as polyps. One hundred and thirty-two of the 244 (54%) reports recommended follow-up, 5/244 (2%) recommended no follow-up, 35/244 (14%) deemed the findings insignificant, and 72/244 (30%) did not comment. Regarding GP referral, 57/184 (31%) patients were correctly referred to general surgeons, 20/184 (11%) to gastroenterologists, and 107/184 (58%) were not referred to secondary care. Forty-three of the 244 patients (18%) underwent cholecystectomy. Regarding subsequent biliary presentations, 63/244 patients (26%) presented at a later date with biliary symptoms; 13/63 (21%) of these eventually had cholecystectomies with 2/13 (15%) experiencing potentially life-threatening pancreatitis episodes. Regarding the surgical approach, differences were observed in the way individual surgeons managed polypoid lesions, with some veering towards cholecystectomy, others towards follow-up ultrasound, and some towards discharge. CONCLUSION GPL tend to be misreported by radiologists and sonographers, unappreciated by GPs, and variably managed by surgeons. These factors delay definitive therapy and seem to contribute to future biliary presentations. A fresh educational approach is required to raise awareness among radiologists, sonographers, and GPs regarding the clinical relevance and possible representations of GPL, and a uniform strategy is needed for managing GPL.
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Affiliation(s)
- A A N Abdullah
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK.
| | - A Rangaraj
- Department of Radiology, Royal Gwent Hospital, Newport, NP20 2UB, UK
| | - M Rashid
- Department of Histopathology, Royal Gwent Hospital, Newport, NP20 2UB, UK
| | - R Puw-Jones
- Department of Histopathology, Royal Gwent Hospital, Newport, NP20 2UB, UK
| | - A Rasheed
- Gwent Centre for Digestive Diseases, Royal Gwent Hospital, Newport, NP20 2UB, UK
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Abhilash KPP, Jeevan JA, Mitra S, Paul N, Murugan TP, Rangaraj A, David S, Hansdak SG, Prakash JAJ, Abraham AM, Ramasami P, Sathyendra S, Sudarsanam TD, Varghese GM. Acute Undifferentiated Febrile Illness in Patients Presenting to a Tertiary Care Hospital in South India: Clinical Spectrum and Outcome. J Glob Infect Dis 2016; 8:147-154. [PMID: 27942194 PMCID: PMC5126753 DOI: 10.4103/0974-777x.192966] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background: Acute undifferentiated febrile illness (AUFI) may have similar clinical presentation, and the etiology is varied and region specific. Materials and Methods: This prospective observational study was conducted in a tertiary hospital in South India. All adult patients presenting with AUFI of 3–14 days duration were evaluated for etiology, and the differences in presentation and outcome were analyzed. Results: The study cohort included 1258 patients. A microbiological cause was identified in 82.5% of our patients. Scrub typhus was the most common cause of AUFI (35.9%) followed by dengue (30.6%), malaria (10.4%), enteric fever (3.7%), and leptospirosis (0.6%). Both scrub typhus and dengue fever peaked during the monsoon season and the cooler months, whereas no seasonality was observed with enteric fever and malaria. The mean time to presentation was longer in enteric fever (9.9 [4.7] days) and scrub typhus (8.2 [3.2] days). Bleeding manifestations were seen in 7.7% of patients, mostly associated with dengue (14%), scrub typhus (4.2%), and malaria (4.6%). The requirement of supplemental oxygen, invasive ventilation, and inotropes was higher in scrub typhus, leptospirosis, and malaria. The overall mortality rate was 3.3% and was highest with scrub typhus (4.6%) followed by dengue fever (2.3%). Significant clinical predictors of scrub typhus were breathlessness (odds ratio [OR]: 4.96; 95% confidence interval [CI]: 3.38–7.3), total whole blood cell count >10,000 cells/mm3 (OR: 2.31; 95% CI: 1.64–3.24), serum albumin <3.5 g % (OR: 2.32; 95% CI: 1.68–3.2). Overt bleeding manifestations (OR: 2.98; 95% CI: 1.84–4.84), and a platelet count of <150,000 cells/mm3 (OR: 2.09; 95% CI: 1.47–2.98) were independent predictors of dengue fever. Conclusion: The similarity in clinical presentation and diversity of etiological agents demonstrates the complexity of diagnosis and treatment of AUFI in South India. The etiological profile will be of use in the development of rational guidelines for control and treatment of AUFI.
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Affiliation(s)
| | - Jonathan Arul Jeevan
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shubhanker Mitra
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Nirvin Paul
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Ajay Rangaraj
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sandeep David
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Samuel George Hansdak
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Asha Mary Abraham
- Department of Clinical Virology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Prakash Ramasami
- Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sowmya Sathyendra
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - George M Varghese
- Department of General Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Hall T, Stephenson J, Rangaraj A, Mulcahy K, Rajesh A. Imaging protocol for suspected ureteric calculi in patients presenting to the emergency department. Clin Radiol 2015; 70:243-7. [DOI: 10.1016/j.crad.2014.10.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 09/29/2014] [Accepted: 10/22/2014] [Indexed: 10/24/2022]
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Bosanquet DC, Rangaraj A, Richards AJ, Riddell A, Saravolac VM, Harding KG. Authors' response. Ann R Coll Surg Engl 2013. [PMID: 24151661 DOI: 10.1308/003588413x13629960047236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bosanquet DC, Rangaraj A, Richards AJ, Riddell A, Saravolac VM, Harding KG. Authors’ response. Ann R Coll Surg Engl 2013; 95:448-9. [DOI: 10.1308/rcsann.2013.95.6.448a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - A Rangaraj
- Cardiff University School of Medicine, UK
| | | | - A Riddell
- Cardiff University School of Medicine, UK
| | | | - KG Harding
- Cardiff University School of Medicine, UK
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Nikkhah D, Dheansa B, Bosanquet DC, Rangaraj A, Richards AJ. Topical steroids for chronic wounds displaying abnormal inflammation. Ann R Coll Surg Engl 2013; 95:448. [DOI: 10.1308/rcsann.2013.95.6.448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- D Nikkhah
- Queen Victoria Hospital NHS Foundation Trust, UK
| | - B Dheansa
- Queen Victoria Hospital NHS Foundation Trust, UK
| | - DC Bosanquet
- Queen Victoria Hospital NHS Foundation Trust, UK
| | - A Rangaraj
- Queen Victoria Hospital NHS Foundation Trust, UK
| | - AJ Richards
- Queen Victoria Hospital NHS Foundation Trust, UK
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Bosanquet DC, Rangaraj A, Richards AJ, Riddell A, Saravolac VM, Harding KG. Topical steroids for chronic wounds displaying abnormal inflammation. Ann R Coll Surg Engl 2013; 95:291-6. [PMID: 23676816 DOI: 10.1308/003588413x13629960045634] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Chronic, non-healing wounds are often characterised by an excessive, and detrimental, inflammatory response. We review our experience of using a combined topical steroid, antibiotic and antifungal preparation in the treatment of chronic wounds displaying abnormal and excessive inflammation. METHODS A retrospective review was undertaken of all patients being treated with a topical preparation containing a steroid (clobetasone butyrate 0.05%), antibiotic and antifungal at a tertiary wound healing centre over a ten-year period. Patients were selected as the primary treating physician felt the wounds were displaying excessive inflammation. Healing rates were calculated for before and during this treatment period for each patient. Changes in symptom burden (pain, odour and exudate levels) following topical application were also calculated. RESULTS Overall, 34 ulcers were identified from 25 individual patients (mean age: 65 years, range: 37-97 years) and 331 clinic visits were analysed, spanning a total time of 14,670 days (7,721 days 'before treatment' time, 6,949 days 'during treatment' time). Following treatment, 24 ulcers demonstrated faster rates of healing, 3 ulcers showed no significant change in healing rates and 7 were healing more slowly (p=0.0006). Treatment generally reduced the burden of pain and exudate, without affecting odour. CONCLUSIONS In normal wound healing, inflammation represents a transient but essential phase of tissue repair. In selected cases, direct application of a steroid containing agent has been shown to improve healing rates, presumably by curtailing this phase. Further evaluation is required to establish the role of preparations containing topical steroids without antimicrobials in the management of chronic wounds.
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Rangaraj A, Ye L, Harding KG, Mansel RE, Jiang WG. Abstract P1-04-02: The Role of BIK (BCL-2 Interaction Killer) Pro-Apoptotic Gene in Breast Cancer. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p1-04-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The human BIK (BCL-2 interaction killer) gene is a pro-apoptotic member in the Bcl-2 gene family. The BIK gene encodes a Mr 18,000 protein product, which contains a BH3 domain critical for its pro-apoptotic activities. Bik forms heterodimers with various anti-apoptotic proteins, including Bcl-2 and Bcl-XL, the association of which hinders the function of the anti-apoptotic proteins. Fluorescent in-situ hybridization has established the chromosomal localization of the BIK gene to 22q13.3. Recent evidence also reveals that oestrogen starvation-induced apoptosis of breast cancer cells requires BIK.
Methods: Breast cancer tissues (n = 122) and Normal background tissues (n = 33) were collected post surgery. Q-PCR was performed on these tissues to quantify BIK transcript levels in both tissue samples. For in vitro tests, MDA-MB-231 wild type (WT) cell was transfected with anti-BIK ribozyme transgenes, constructed based on the secondary structure of BIK and specifically targeted human BIK, in order to generate a BIK-knockdown subline. The successful knock down of the gene transcript was then verified with RT-PCR and Quantitative real time PCR (Q-PCR) alongside control MDA-MB-231 WT and MDA-MB-231 pEF cells. Cell functions; cell growth using a colorimetric growth assay and cellular motility using conventional scratch wounding assay were tested. Results: Median BIK levels on the normal background and breast cancer tissues were 0.827 and 1.23 respectively being non-significant on Mann-Whitney U test(p=0.27). Patients with higher histological grade (Grade3) (n=55, median 1.53) and TNM4 (n= 4, median= 9.75) demonstrated relatively higher levels of BIK. Tumours from patients with a poor prognosis (Nottingham prognostic index (NPI)>5.4) (n=15, median=2.54) had higher level of BIK transcripts in comparison with patients with good prognosis (NPI<3.4) (n = 65, Median = 1.010), P<0.05. Overall mean survival for patients with low levels of BIK was 139.1 months and 119.2 months for those with high levels. The disease free survival was 133.5 and 113.2 months for patients with low and high levels of BIK, respectively. In vitro, breast cancer cells MDA MB-231 expressed BIK transcript as shown by both RT-PCR and Q-PCR. The anti-BIK transgene successfully knocked down of BIK transcript in the cells. Using a scratch wounding assay and growth assays, it was shown that there was an increase in the rate of migration and growth in the BIK knockdown cells compared to control cell lines.
Conclusion: BIK is a recognized apoptosis promoting gene in breast cancer. Our cohort of breast cancer patients showed a correlation of increased levels of BIK with advancing disease, which also correlates to the estimated overall and disease free survival times. Together with the results from in vitro tests, it is postulated that BIK played a complex role in breast cancer and that the type of interactions with other apoptosis interaction regulators of BIK may be key in deciding the aggressiveness of breast cancer cells.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-04-02.
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Affiliation(s)
- A Rangaraj
- Cardiff University School of Medicine, Cardiff, United Kingdom; Cardiff Unviersity School of Medicine, Cardiff, United Kingdom
| | - L Ye
- Cardiff University School of Medicine, Cardiff, United Kingdom; Cardiff Unviersity School of Medicine, Cardiff, United Kingdom
| | - KG Harding
- Cardiff University School of Medicine, Cardiff, United Kingdom; Cardiff Unviersity School of Medicine, Cardiff, United Kingdom
| | - RE Mansel
- Cardiff University School of Medicine, Cardiff, United Kingdom; Cardiff Unviersity School of Medicine, Cardiff, United Kingdom
| | - WG. Jiang
- Cardiff University School of Medicine, Cardiff, United Kingdom; Cardiff Unviersity School of Medicine, Cardiff, United Kingdom
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George AT, Davis C, Rangaraj A, Edwards C, Chamary VL, Khan H, Javed M, Campbell PG, Allison MC, Swarnkar KJ. Cardiac ischaemia and rhythm disturbances during elective colonoscopy. Frontline Gastroenterol 2010; 1:131-137. [PMID: 28839563 PMCID: PMC5517182 DOI: 10.1136/fg.2010.001420] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2010] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The number of colonoscopic procedures continues to rise rapidly. With widespread adoption of colonoscopy based bowel screening programmes, this rising trend is set to continue. AIMS This study aimed to identify whether elective colonoscopy could provoke cardiac rhythm disturbances and/or myocardial ischaemia, as evidenced by 12 lead Holter ECG recordings and troponin I (cTnI) changes. MATERIALS AND METHODS Patients were stratified into three groups based on the presence of cardiac disease or cardiovascular risk factors. They underwent real time 12 lead Holter monitoring before, during and after colonoscopy. Bloods were taken for pre- and post-procedure cTnI estimation. RESULTS Holter ECG recordings of the three groups showed a high incidence of new but silent ischaemic and arrhythmic ECG changes during the colonoscopy in patients with documented but stable heart disease and to a lesser extent in those patients with one or more risk factors for heart disease. Three patients had high cTnI concentrations both before and after colonoscopy. Two patients with known heart disease died within 30 days of colonoscopy. CONCLUSIONS This study demonstrates for the first time the occurrence of potentially clinically significant ST-T wave changes and rhythm disturbances during elective colonoscopy in patients with known heart disease and to a lesser extent in those patients with a known cardiovascular risk profile.
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Affiliation(s)
- A T George
- Department of General Surgery, The Royal Gwent Hospital, Newport, South Wales, UK
| | - C Davis
- Department of General Surgery, The Royal Gwent Hospital, Newport, South Wales, UK
| | - A Rangaraj
- Department of General Surgery, The Royal Gwent Hospital, Newport, South Wales, UK
| | - C Edwards
- Department of Gastroenterology/General Medicine, The Royal Gwent Hospital, Newport, South Wales, UK
| | - V L Chamary
- Department of General Surgery, The Royal Gwent Hospital, Newport, South Wales, UK
| | - H Khan
- Department of Cardiology, The Royal Gwent Hospital, Newport, South Wales, UK
| | - M Javed
- Department of Cardiology, The Royal Gwent Hospital, Newport, South Wales, UK
| | - P G Campbell
- Department of Cardiology, The Royal Gwent Hospital, Newport, South Wales, UK
| | - M C Allison
- Department of Gastroenterology/General Medicine, The Royal Gwent Hospital, Newport, South Wales, UK
| | - K J Swarnkar
- Department of General Surgery, The Royal Gwent Hospital, Newport, South Wales, UK
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Roberts C, Rangaraj A, Murphy R. Oral 9, Hypocomplementaemic urticarial vasculitis: a rare but important cause of urticaria and angio-oedema. Br J Dermatol 2007. [DOI: 10.1111/j.1365-2133.2007.07876_9.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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