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Millard T, Elliott JH, Green S, McGloughlin S, Turner T. Exploring the use and impact of the Australian living guidelines for the clinical care of people with COVID-19: where to from here? J Clin Epidemiol 2024; 166:111234. [PMID: 38072175 DOI: 10.1016/j.jclinepi.2023.111234] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVES The Australian National COVID-19 Clinical Evidence Taskforce has been developing, maintaining, and disseminating living guidelines and decision support tools (clinical flowcharts) for the care of people with suspected or confirmed COVID-19 since 2020. Living guidelines, a form of living evidence, are a relatively new approach; hence, more work is required to determine how to optimize their use to inform practice, policy, and decision-making and to explore implementation, uptake, and impact implications. An update of an earlier impact evaluation was conducted to understand sustained awareness and use of the guidelines; the factors that facilitate the widespread adoption of the guidelines and to explore the perceived strengths and opportunities for improvement of the guidelines. STUDY DESIGN AND SETTING A mixed-methods impact evaluation was conducted. Surveys collected both quantitative and qualitative data and were supplemented with qualitative interviews. Participants included Australian healthcare practitioners providing care to individuals with suspected or confirmed COVID-19 and people involved in policy-making. Data were collected on awareness, use, impact, strengths, and opportunities for improvement of the guidelines and flow charts. RESULTS A total of 148 participants completed the survey and 21 people were interviewed between January and March 2022. Awareness of the work of the Taskforce was high and more than 75% of participants reported that the guidelines were used within their workplace. Participants described the Taskforce website and guidelines as trustworthy, valuable, and reliable sources of up-to-date evidence-based information. The evaluation highlighted the varied ways the guidelines were being used across a range of settings and the diverse impacts they have from those at a clinical level to impacts at a policy level. Barriers to and enablers of impact and uptake of the guideline were explored. CONCLUSION This evaluation highlights the value of living guidelines during a pandemic when the evidence base is rapidly changing and expanding. It presents useful understanding of the ways clinicians and others use living evidence to inform their clinical practice and decision-making and the diverse impacts the guidelines are having around Australia.
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Affiliation(s)
- Tanya Millard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Julian H Elliott
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sally Green
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Steve McGloughlin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tari Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Siafis S, McCutcheon R, Chiocchia V, Ostinelli EG, Wright S, Stansfield C, Juma DO, Mantas I, Howes OD, Rutigliano G, Ramage F, Tinsdeall F, Friedrich C, Milligan L, Moreno C, Elliott JH, Thomas J, Macleod MR, Sena ES, Seedat S, Salanti G, Potts J, Cipriani A, Leucht S. Trace amine-associated receptor 1 (TAAR1) agonists for psychosis: protocol for a living systematic review and meta-analysis of human and non-human studies. Wellcome Open Res 2023; 8:365. [PMID: 38634067 PMCID: PMC11021884 DOI: 10.12688/wellcomeopenres.19866.1] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2023] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND There is an urgent need to develop more effective and safer antipsychotics beyond dopamine 2 receptor antagonists. An emerging and promising approach is TAAR1 agonism. Therefore, we will conduct a living systematic review and meta-analysis to synthesize and triangulate the evidence from preclinical animal experiments and clinical studies on the efficacy, safety, and underlying mechanism of action of TAAR1 agonism for psychosis. METHODS Independent searches will be conducted in multiple electronic databases to identify clinical and animal experimental studies comparing TAAR1 agonists with licensed antipsychotics or other control conditions in individuals with psychosis or animal models for psychosis, respectively. The primary outcomes will be overall psychotic symptoms and their behavioural proxies in animals. Secondary outcomes will include side effects and neurobiological measures. Two independent reviewers will conduct study selection, data extraction using predefined forms, and risk of bias assessment using suitable tools based on the study design. Ontologies will be developed to facilitate study identification and data extraction. Data from clinical and animal studies will be synthesized separately using random-effects meta-analysis if appropriate, or synthesis without meta-analysis. Study characteristics will be investigated as potential sources of heterogeneity. Confidence in the evidence for each outcome and source of evidence will be evaluated, considering the summary of the association, potential concerns regarding internal and external validity, and reporting biases. When multiple sources of evidence are available for an outcome, an overall conclusion will be drawn in a triangulation meeting involving a multidisciplinary team of experts. We plan trimonthly updates of the review, and any modifications in the protocol will be documented. The review will be co-produced by multiple stakeholders aiming to produce impactful and relevant results and bridge the gap between preclinical and clinical research on psychosis. PROTOCOL REGISTRATION PROSPERO-ID: CRD42023451628.
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Affiliation(s)
- Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Robert McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
| | - Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Canton of Bern, Switzerland
| | - Edoardo G. Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | - Simonne Wright
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Claire Stansfield
- EPPI Centre, Social Research Institute, University College London, London, England, UK
| | | | - Ioannis Mantas
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Oliver D. Howes
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
| | - Grazia Rutigliano
- Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, England, UK
| | - Fiona Ramage
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Francesca Tinsdeall
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Claire Friedrich
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | | | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense de Madrid, Madrid, Community of Madrid, Spain
| | - Julian H. Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Future Evidence Foundation, Melbourne, Australia
| | - James Thomas
- EPPI Centre, Social Research Institute, University College London, London, England, UK
| | - Malcolm R. Macleod
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Emily S. Sena
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Canton of Bern, Switzerland
| | - Jennifer Potts
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | - Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - the GALENOS team
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
- Department of Psychiatry, University of Oxford, Oxford, England, UK
- Oxford Health NHS Foundation Trust, Oxford, England, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, England, UK
- Institute of Social and Preventive Medicine, University of Bern, Bern, Canton of Bern, Switzerland
- Oxford Precision Psychiatry Lab, University of Oxford, Oxford, England, UK
- Department of Psychiatry, Stellenbosch University, Stellenbosch, Western Cape, South Africa
- EPPI Centre, Social Research Institute, University College London, London, England, UK
- My Mind Our Humanity, Mombasa, Kenya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Institute of Clinical Sciences, Faculty of Medicine, Imperial College London, London, England, UK
- Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, Scotland, UK
- MQ Mental Health Research, London, UK
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense de Madrid, Madrid, Community of Madrid, Spain
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Future Evidence Foundation, Melbourne, Australia
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3
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Cipriani A, Seedat S, Milligan L, Salanti G, Macleod M, Hastings J, Thomas J, Michie S, Furukawa TA, Gilbert D, Soares-Weiser K, Moreno C, Leucht S, Egger M, Mansoori P, Barker JM, Siafis S, Ostinelli EG, McCutcheon R, Wright S, Simpson M, Elugbadebo O, Chiocchia V, Tonia T, Elgarf R, Kurtulmus A, Sena E, Simple O, Boyce N, Chung S, Sharma A, Wolpert M, Potts J, Elliott JH. New living evidence resource of human and non-human studies for early intervention and research prioritisation in anxiety, depression and psychosis. BMJ Ment Health 2023; 26:e300759. [PMID: 37290906 PMCID: PMC10255027 DOI: 10.1136/bmjment-2023-300759] [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] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 05/04/2023] [Indexed: 06/10/2023]
Abstract
In anxiety, depression and psychosis, there has been frustratingly slow progress in developing novel therapies that make a substantial difference in practice, as well as in predicting which treatments will work for whom and in what contexts. To intervene early in the process and deliver optimal care to patients, we need to understand the underlying mechanisms of mental health conditions, develop safe and effective interventions that target these mechanisms, and improve our capabilities in timely diagnosis and reliable prediction of symptom trajectories. Better synthesis of existing evidence is one way to reduce waste and improve efficiency in research towards these ends. Living systematic reviews produce rigorous, up-to-date and informative evidence summaries that are particularly important where research is emerging rapidly, current evidence is uncertain and new findings might change policy or practice. Global Alliance for Living Evidence on aNxiety, depressiOn and pSychosis (GALENOS) aims to tackle the challenges of mental health science research by cataloguing and evaluating the full spectrum of relevant scientific research including both human and preclinical studies. GALENOS will also allow the mental health community-including patients, carers, clinicians, researchers and funders-to better identify the research questions that most urgently need to be answered. By creating open-access datasets and outputs in a state-of-the-art online resource, GALENOS will help identify promising signals early in the research process. This will accelerate translation from discovery science into effective new interventions for anxiety, depression and psychosis, ready to be translated in clinical practice across the world.
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Affiliation(s)
- Andrea Cipriani
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Soraya Seedat
- South African Medical Research Council/Stellenbosch University Extramural Genomics of Brain Disorders Unit, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Malcolm Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Janna Hastings
- Institute for Implementation Science in Health Care, Faculty of Medicine, University of Zurich, Zurich, Switzerland
- School of Medicine, University of St. Gallen, St. Gallen, Switzerland
| | - James Thomas
- EPPI Centre, Social Research Institute, University College London, London, UK
| | - Susan Michie
- UCL Centre for Behaviour Change, University College London, London, UK
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine / School of Public Health, Kyoto, Japan
| | - David Gilbert
- Chair, GALENOS Global Experiential Advisory Board, InHealth Associates, London, UK
| | | | - Carmen Moreno
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, IiSGM, CIBERSAM, ISCIII, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Stefan Leucht
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Spyridon Siafis
- Department of Psychiatry and Psychotherapy, School of Medicine, Technical University of Munich, Munich, Germany
| | - Edoardo Giuseppe Ostinelli
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Robert McCutcheon
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, UK
| | - Simonne Wright
- South African Medical Research Council/Stellenbosch University Extramural Genomics of Brain Disorders Unit, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Olufisayo Elugbadebo
- South African Medical Research Council/Stellenbosch University Extramural Genomics of Brain Disorders Unit, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- Department of Psychiatry, University of Ibadan, Ibadan, Nigeria
| | - Virginia Chiocchia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Rania Elgarf
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Ayse Kurtulmus
- Department of Psychiatry, Istanbul Medeniyet University, Turkey, Turkey
| | - Emily Sena
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Ouma Simple
- South African Medical Research Council/Stellenbosch University Extramural Genomics of Brain Disorders Unit, Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | | | - Jennifer Potts
- Department of Psychiatry, University of Oxford, Oxford, UK
- Oxford Precision Psychiatry Lab, NIHR Oxford Health Biomedical Research Centre, Oxford, UK
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Future Evidence Foundation, Melbourne, Victoria, Australia
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4
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Arno A, Thomas J, Wallace B, Marshall IJ, McKenzie JE, Elliott JH. Accuracy and Efficiency of Machine Learning-Assisted Risk-of-Bias Assessments in "Real-World" Systematic Reviews : A Noninferiority Randomized Controlled Trial. Ann Intern Med 2022; 175:1001-1009. [PMID: 35635850 DOI: 10.7326/m22-0092] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Automation is a proposed solution for the increasing difficulty of maintaining up-to-date, high-quality health evidence. Evidence assessing the effectiveness of semiautomated data synthesis, such as risk-of-bias (RoB) assessments, is lacking. OBJECTIVE To determine whether RobotReviewer-assisted RoB assessments are noninferior in accuracy and efficiency to assessments conducted with human effort only. DESIGN Two-group, parallel, noninferiority, randomized trial. (Monash Research Office Project 11256). SETTING Health-focused systematic reviews using Covidence. PARTICIPANTS Systematic reviewers, who had not previously used RobotReviewer, completing Cochrane RoB assessments between February 2018 and May 2020. INTERVENTION In the intervention group, reviewers received an RoB form prepopulated by RobotReviewer; in the comparison group, reviewers received a blank form. Studies were assigned in a 1:1 ratio via simple randomization to receive RobotReviewer assistance for either Reviewer 1 or Reviewer 2. Participants were blinded to study allocation before starting work on each RoB form. MEASUREMENTS Co-primary outcomes were the accuracy of individual reviewer RoB assessments and the person-time required to complete individual assessments. Domain-level RoB accuracy was a secondary outcome. RESULTS Of the 15 recruited review teams, 7 completed the trial (145 included studies). Integration of RobotReviewer resulted in noninferior overall RoB assessment accuracy (risk difference, -0.014 [95% CI, -0.093 to 0.065]; intervention group: 88.8% accurate assessments; control group: 90.2% accurate assessments). Data were inconclusive for the person-time outcome (RobotReviewer saved 1.40 minutes [CI, -5.20 to 2.41 minutes]). LIMITATION Variability in user behavior and a limited number of assessable reviews led to an imprecise estimate of the time outcome. CONCLUSION In health-related systematic reviews, RoB assessments conducted with RobotReviewer assistance are noninferior in accuracy to those conducted without RobotReviewer assistance. PRIMARY FUNDING SOURCE University College London and Monash University.
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Affiliation(s)
- Anneliese Arno
- EPPI-Centre, University College London, London, United Kingdom, and School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (A.A.)
| | - James Thomas
- EPPI-Centre, University College London, London, United Kingdom (J.T.)
| | - Byron Wallace
- College of Computer and Information Science, Northeastern University, Boston, Massachusetts (B.W.)
| | - Iain J Marshall
- School of Population Health and Environmental Sciences, King's College London, London, United Kingdom (I.J.M.)
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (J.E.M., J.H.E.)
| | - Julian H Elliott
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia (J.E.M., J.H.E.)
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5
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Schaffer AL, Henry D, Zoega H, Elliott JH, Pearson SA. Changes in dispensing of medicines proposed for re-purposing in the first year of the COVID-19 pandemic in Australia. PLoS One 2022; 17:e0269482. [PMID: 35704621 PMCID: PMC9200317 DOI: 10.1371/journal.pone.0269482] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 12/07/2021] [Accepted: 05/20/2022] [Indexed: 12/15/2022] Open
Abstract
Background Since COVID-19 was first recognised, there has been ever-changing evidence and misinformation around effective use of medicines. Understanding how pandemics impact on medicine use can help policymakers act quickly to prevent harm. We quantified changes in dispensing of common medicines proposed for “re-purposing” due to their perceived benefits as therapeutic or preventive for COVID-19 in Australia. Methods We performed an interrupted time series analysis and cross-sectional study using nationwide dispensing claims data (January 2017-November 2020). We focused on six subsidized medicines proposed for re-purposing: hydroxychloroquine, azithromycin, ivermectin, colchicine, corticosteroids, and calcitriol (Vitamin D analog). We quantified changes in monthly dispensing and initiation trends during COVID-19 (March-November 2020) using autoregressive integrated moving average models and compared characteristics of initiators in 2020 and 2019. Results In March 2020, we observed a 99% (95%CI: 96%-103%) increase in hydroxychloroquine dispensing (approximately 22% attributable to new users), and a 199% increase (95%CI: 184%-213%) in initiation, with an increase in prescribing by general practitioners (42% in 2020 vs 25% in 2019) rather than specialists. These increases subsided following regulatory restrictions on prescribing. There was a small but sustained increase in ivermectin dispensing over multiple months, with an 80% (95%CI 42%-118%) increase in initiation in May 2020 following its first identification as potentially disease-modifying in April. Other than increases in March related to stockpiling, we observed no change in the initiation of calcitriol or colchicine during COVID-19. Dispensing of corticosteroids and azithromycin was lower than expected from April through November 2020. Conclusions While most increases in dispensing observed early on during COVID-19 were temporary and appear to be related to stockpiling among existing users, we observed increases in the initiation of hydroxychloroquine and ivermectin and a shift in prescribing patterns which may be related to the media hype around these medicines. A quick response by regulators can help limit inappropriate repurposing to lessen the impact on medicine supply and patient harm.
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Affiliation(s)
- Andrea L. Schaffer
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
- * E-mail:
| | - David Henry
- Institute for Evidence-Based Healthcare, Bond University, Gold Coast, Australia
| | - Helga Zoega
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
- Centre of Public Health Services, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Julian H. Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Monash, Australia
| | - Sallie-Anne Pearson
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, Australia
- Menzies Centre for Health Policy, The University of Sydney, Sydney, Australia
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6
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Gardiner E, Baumgart A, Tong A, Elliott JH, Azevedo LC, Bersten A, Cervantes L, Chew DP, Cho Y, Crowe S, Douglas IS, Evangelidis N, Flemyng E, Horby P, Howell M, Lee J, Lorca E, Lynch D, Marshall JC, Gonzalez AM, McKenzie A, Manera K, Mehta S, Mer M, Morris AC, Nseir S, Povoa P, Reid M, Sakr Y, Shen N, Smyth AR, Snelling T, Strippoli GFM, Teixeira-Pinto A, Torres A, Viecelli AK, Webb S, Williamson PR, Woc-Colburn L, Zhang J, Craig JC. Perspectives of patients, family members, health professionals and the public on the impact of COVID-19 on mental health. J Ment Health 2022; 31:524-533. [PMID: 34983279 DOI: 10.1080/09638237.2021.2022637] [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] [Indexed: 10/19/2022]
Abstract
BACKGROUND The coronavirus (COVID-19) pandemic has seen a global surge in anxiety, depression, post-traumatic stress disorder (PTSD), and stress. AIMS This study aimed to describe the perspectives of patients with COVID-19, their family, health professionals, and the general public on the impact of COVID-19 on mental health. METHODS A secondary thematic analysis was conducted using data from the COVID-19 COS project. We extracted data on the perceived causes and impact of COVID-19 on mental health from an international survey and seven online consensus workshops. RESULTS We identified four themes (with subthemes in parenthesis): anxiety amidst uncertainty (always on high alert, ebb and flow of recovery); anguish of a threatened future (intense frustration of a changed normality, facing loss of livelihood, trauma of ventilation, a troubling prognosis, confronting death); bearing responsibility for transmission (fear of spreading COVID-19 in public; overwhelming guilt of infecting a loved one); and suffering in isolation (severe solitude of quarantine, sick and alone, separation exacerbating grief). CONCLUSION We found that the unpredictability of COVID-19, the fear of long-term health consequences, burden of guilt, and suffering in isolation profoundly impacted mental health. Clinical and public health interventions are needed to manage the psychological consequences arising from this pandemic.
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Affiliation(s)
| | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Andrew Bersten
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Lilia Cervantes
- Department of Medicine, Denver Health, Denver, United States
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Yeoungjee Cho
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | | | - Ivor S Douglas
- Department of Medicine, Pulmonary Sciences and Critical Care, School of Medicine Denver, Denver Health and University of Colorado Anschutz, United States
| | - Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Ella Flemyng
- Editorial and Methods Department, Cochrane, London, UK
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Eduardo Lorca
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | | | - Karine Manera
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Saad Nseir
- Critical Care Centre, CHU Lille, and Lille University, Lille, France
| | - Pedro Povoa
- Nova Medical School, CHRC, Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
| | - Mark Reid
- Department of Medicine, Denver Health, Denver, United States
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China
| | - Alan R Smyth
- Evidence Based Child Health Group, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Giovanni F M Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, Australia
| | - Antoni Torres
- Department of Pulmonology, Respiratory Intitute, Hospital Clinic of Barcelona, University of Barcelona (UB), CIBERES, IDIBAPS, Barcelona, Spain
| | - Andrea K Viecelli
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Steve Webb
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Laila Woc-Colburn
- Department of Infectious Diseases, Emory University Hospital, Atlanta, Georgia, USA
| | - Junhua Zhang
- Evidence-based Medicine center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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7
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Abstract
Systematic reviews are difficult to keep up to date, but failure to do so leads to poor review currency and accuracy. "Living systematic review" (LSR) is an approach that aims to continually update a review, incorporating relevant new evidence as it becomes available. LSRs may be particularly important in fields where research evidence is emerging rapidly, current evidence is uncertain, and new research may change policy or practice decisions.This chapter describes the concept and processes of living systematic reviews. It describes the general principles of LSRs, when they might be of particular value, and how their procedures differ from conventional systematic reviews. The chapter focuses particularly on two methods of sequential meta-analysis that may be particularly useful for LSRs: Trial Sequential Analysis and Sequential Meta-Analysis, which both control for Type I error, Type II error (failing to detect a genuine effect) and take account of heterogeneity.
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Affiliation(s)
- Mark Simmonds
- Centre for Reviews and Dissemination, University of York, York, UK.
| | - Julian H Elliott
- Cochrane Australia, Monash University, Melbourne, VIC, Australia
| | - Anneliese Synnot
- Cochrane Australia, Monash University, Melbourne, VIC, Australia
| | - Tari Turner
- Cochrane Australia, Monash University, Melbourne, VIC, Australia
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8
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Abstract
In their article, Qaseem and colleagues reported how the American College of Physicians responded to the urgent need for guidance during the COVID-19 pandemic by producing living, rapid practice points. The editorialists discuss the challenges of developing high-quality, up-to-date evidence-based recommendations and how rapid and living reviews and guidelines are important additions to the tools we have available to translate research evidence into improved health outcomes.
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Affiliation(s)
- Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University Melbourne, Australia
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9
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Synnot A, Gruen RL, Menon D, Steyerberg EW, Buki A, Peul WC, Elliott JH, Maas A. A New Approach to Evidence Synthesis in Traumatic Brain Injury: A Living Systematic Review. J Neurotrauma 2021; 38:1069-1071. [PMID: 26414062 PMCID: PMC8054513 DOI: 10.1089/neu.2015.4124] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Living systematic reviews (LSRs) are online summaries of health care research that are updated as new research becomes available. This new development in evidence synthesis is being trialled as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) project. We will develop and sustain an international TBI knowledge community that maintains up-to-date, high quality LSRs of the current state of knowledge in the most important questions in TBI. Automatic search updates will be run three-monthly, and newly identified studies incorporated into the review. Review teams will seek to publish journal updates at regular intervals, with abridged updates available more frequently online. Future project stages include the integration of LSR and other study findings into "living" clinical practice guidance. It is hoped these efforts will go some way to bridging current temporal disconnects between evidence, guidelines, and practice in TBI.
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Affiliation(s)
- Anneliese Synnot
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Cochrane Consumers and Communication Review Group, Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
- National Trauma Research Institute, Alfred Hospital, Melbourne, Australia
| | - Russell L. Gruen
- Central Clinical School, Monash University, Melbourne, Australia
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - David Menon
- University of Cambridge, Cambridge, United Kingdom
| | - Ewout W. Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Andras Buki
- Department of Neurosurgery, University of Pécs and Clinical Neuroscience Image Center of Hungarian Academy of Sciences (HAS), Pécs, Hungary
| | - Wilco C. Peul
- Department of Neurosurgery, Leiden University Medical Centre and Medical Centre The Hague, The Hague and Leiden, the Netherlands
| | - Julian H. Elliott
- Department of Infectious Diseases and Australasian Cochrane Centre, Monash University, Melbourne, Australia
| | - Andrew Maas
- Department of Neurosurgery, University Hospital Antwerp and University of Antwerp, Antwerp, Belgium
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10
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Evangelidis N, Tong A, Howell M, Teixeira-Pinto A, Elliott JH, Azevedo LC, Bersten A, Cervantes L, Chew DP, Crowe S, Douglas IS, Flemyng E, Horby P, Lee J, Lorca E, Lynch D, Marshall JC, McKenzie A, Mehta S, Mer M, Morris AC, Nseir S, Povoa P, Reid M, Sakr Y, Shen N, Smyth AR, Snelling T, Strippoli GFM, Torres A, Turner T, Webb S, Williamson PR, Woc-Colburn L, Zhang J, Baumgart A, Cabrera S, Cho Y, Cooper T, Guha C, Liu E, Gonzalez AM, McLeod C, Natale P, Saglimbene V, Viecelli AK, Craig JC. International Survey to Establish Prioritized Outcomes for Trials in People With Coronavirus Disease 2019. Crit Care Med 2020; 48:1612-1621. [PMID: 32804789 PMCID: PMC7448718 DOI: 10.1097/ccm.0000000000004584] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES There are over 4,000 trials conducted in people with coronavirus disease 2019. However, the variability of outcomes and the omission of patient-centered outcomes may diminish the impact of these trials on decision-making. The aim of this study was to generate a consensus-based, prioritized list of outcomes for coronavirus disease 2019 trials. DESIGN In an online survey conducted in English, Chinese, Italian, Portuguese, and Spanish languages, adults with coronavirus disease 2019, their family members, health professionals, and the general public rated the importance of outcomes using a 9-point Likert scale (7-9, critical importance) and completed a Best-Worst Scale to estimate relative importance. Participant comments were analyzed thematically. SETTING International. SUBJECTS Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public, and health professionals (including clinicians, policy makers, regulators, funders, and researchers). INTERVENTIONS None. MEASUREMENTS None. MAIN RESULTS In total, 9,289 participants from 111 countries (776 people with coronavirus disease 2019 or family members, 4,882 health professionals, and 3,631 members of the public) completed the survey. The four outcomes of highest priority for all three groups were: mortality, respiratory failure, pneumonia, and organ failure. Lung function, lung scarring, sepsis, shortness of breath, and oxygen level in the blood were common to the top 10 outcomes across all three groups (mean > 7.5, median ≥ 8, and > 70% of respondents rated the outcome as critically important). Patients/family members rated fatigue, anxiety, chest pain, muscle pain, gastrointestinal problems, and cardiovascular disease higher than health professionals. Four themes underpinned prioritization: fear of life-threatening, debilitating, and permanent consequences; addressing knowledge gaps; enabling preparedness and planning; and tolerable or infrequent outcomes. CONCLUSIONS Life-threatening respiratory and other organ outcomes were consistently highly prioritized by all stakeholder groups. Patients/family members gave higher priority to many patient-reported outcomes compared with health professionals.
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Affiliation(s)
- Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Andrew Bersten
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Ivor S Douglas
- Department of Medicine, Pulmonary Sciences and Critical Care, Denver Health and University of Colorado Anschutz, School of Medicine, Denver, CO
| | - Ella Flemyng
- Editorial and Methods Department, Cochrane, London, United Kingdom
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Eduardo Lorca
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mervyn Mer
- Divisions of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Saad Nseir
- Critical Care Centre, CHU Lille, and Lille University, F-59000 Lille, France
| | - Pedro Povoa
- Nova Medical School, CHRC, New University of Lisbon, Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal. Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Denmark
| | - Mark Reid
- Department of Medicine, Denver Health, Denver, CO
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Giovanni F M Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Antoni Torres
- Department of Pulmonology Hospital Clinic. University of Barcelona, CIBERES, IDIBAPS, ICREA, Barcelona, Spain
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Steve Webb
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Laila Woc-Colburn
- Section of Infectious Diseases Department of Medicine, National School of Tropical Medicine Baylor College of Medicine, Houston, TX
| | - Junhua Zhang
- Evidence-based Medicine center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Sebastian Cabrera
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Yeoungjee Cho
- Faculty of Medicine, University of Queensland, Brisbane, Old, Australia
| | - Tess Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Chandana Guha
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Emma Liu
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, NSW, Australia
| | - Charlie McLeod
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Patrizia Natale
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Valeria Saglimbene
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Andrea K Viecelli
- Faculty of Medicine, University of Queensland, Brisbane, Old, Australia
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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11
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Tong A, Elliott JH, Azevedo LC, Baumgart A, Bersten A, Cervantes L, Chew DP, Cho Y, Cooper T, Crowe S, Douglas IS, Evangelidis N, Flemyng E, Hannan E, Horby P, Howell M, Lee J, Liu E, Lorca E, Lynch D, Marshall JC, Gonzalez AM, McKenzie A, Manera KE, McLeod C, Mehta S, Mer M, Morris AC, Nseir S, Povoa P, Reid M, Sakr Y, Shen N, Smyth AR, Snelling T, Strippoli GF, Teixeira-Pinto A, Torres A, Turner T, Viecelli AK, Webb S, Williamson PR, Woc-Colburn L, Zhang J, Craig JC. Core Outcomes Set for Trials in People With Coronavirus Disease 2019. Crit Care Med 2020; 48:1622-1635. [PMID: 32804792 PMCID: PMC7448717 DOI: 10.1097/ccm.0000000000004585] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The outcomes reported in trials in coronavirus disease 2019 are extremely heterogeneous and of uncertain patient relevance, limiting their applicability for clinical decision-making. The aim of this workshop was to establish a core outcomes set for trials in people with suspected or confirmed coronavirus disease 2019. DESIGN Four international online multistakeholder consensus workshops were convened to discuss proposed core outcomes for trials in people with suspected or confirmed coronavirus disease 2019, informed by a survey involving 9,289 respondents from 111 countries. The transcripts were analyzed thematically. The workshop recommendations were used to finalize the core outcomes set. SETTING International. SUBJECTS Adults 18 years old and over with confirmed or suspected coronavirus disease 2019, their family members, members of the general public and health professionals (including clinicians, policy makers, regulators, funders, researchers). INTERVENTIONS None. MEASUREMENTS None. MAIN RESULTS Six themes were identified. "Responding to the critical and acute health crisis" reflected the immediate focus on saving lives and preventing life-threatening complications that underpinned the high prioritization of mortality, respiratory failure, and multiple organ failure. "Capturing different settings of care" highlighted the need to minimize the burden on hospitals and to acknowledge outcomes in community settings. "Encompassing the full trajectory and severity of disease" was addressing longer term impacts and the full spectrum of illness (e.g. shortness of breath and recovery). "Distinguishing overlap, correlation and collinearity" meant recognizing that symptoms such as shortness of breath had distinct value and minimizing overlap (e.g. lung function and pneumonia were on the continuum toward respiratory failure). "Recognizing adverse events" refers to the potential harms of new and evolving interventions. "Being cognizant of family and psychosocial wellbeing" reflected the pervasive impacts of coronavirus disease 2019. CONCLUSIONS Mortality, respiratory failure, multiple organ failure, shortness of breath, and recovery are critically important outcomes to be consistently reported in coronavirus disease 2019 trials.
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Affiliation(s)
- Allison Tong
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Amanda Baumgart
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Andrew Bersten
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | | | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Yeoungjee Cho
- Faculty of Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Tess Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | - Ivor S Douglas
- Department of Medicine, Pulmonary Sciences and Critical Care, Denver Health and University of Colorado Anschutz, School of Medicine Denver, Aurora, CO
| | - Nicole Evangelidis
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Ella Flemyng
- Department of Editorial and Methods, Cochrane, London, United Kingdom
| | - Elyssa Hannan
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Peter Horby
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Martin Howell
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Jaehee Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Emma Liu
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Eduardo Lorca
- Department of Internal Medicine, Faculty of Medicine, University of Chile, Santiago, Chile
| | | | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Andrea Matus Gonzalez
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | | | - Karine E Manera
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Charlie McLeod
- Department of Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Mervyn Mer
- Department of Medicine, Divisions of Critical Care and Pulmonology, Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Saad Nseir
- Critical Care Centre, CHU Lille, and Lille University, F-59000 Lille, France
| | - Pedro Povoa
- Nova Medical School, CHRC, New University of Lisbon, Polyvalent Intensive Care Unit, Sao Francisco Xavier Hospital, CHLO, Lisbon, Portugal
- Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark
| | - Mark Reid
- Department of Medicine, Denver Health, Denver, CO
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Jena University Hospital, Jena, Germany
| | - Ning Shen
- Department of Respiratory Medicine, Peking University Third Hospital, Beijing, China
| | - Alan R Smyth
- Evidence Based Child Health Group, University of Nottingham, Nottingham, United Kingdom
| | - Tom Snelling
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Armando Teixeira-Pinto
- Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
- Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Antoni Torres
- Department of Pulmonology Hospital Clinic. University of Barcelona, CIBERES, IDIBAPS, Barcelona, Spain
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrea K Viecelli
- Faculty of Medicine, University of Queensland at Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Steve Webb
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paula R Williamson
- Department of Biostatistics, University of Liverpool, Liverpool, United Kingdom
| | - Laila Woc-Colburn
- Section of Infectious Diseases Department of Medicine, National School of Tropical Medicine, Baylor College of Medicine, Houston, TX
| | - Junhua Zhang
- Evidence-based Medicine center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Jonathan C Craig
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
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12
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Klassen KM, Millard T, Stout J, McDonald K, Dodson S, Osborne RH, Battersby MW, Fairley CK, Kidd MR, McMahon J, Baker D, Elliott JH. Recruiting people with HIV to an online self-management support randomised controlled trial: barriers and facilitators. Sex Health 2020; 16:340-347. [PMID: 31234962 DOI: 10.1071/sh18130] [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] [Received: 07/17/2018] [Accepted: 03/08/2019] [Indexed: 11/23/2022]
Abstract
Background Recruitment of people to randomised trials of online interventions presents particular challenges and opportunities. The aim of this study was to evaluate factors associated with the recruitment of people with HIV (PWHIV) and their doctors to the HealthMap trial, a cluster randomised trial of an online self-management program. METHODS Recruitment involved a three-step process. Study sites were recruited, followed by doctors caring for PWHIV at study sites and finally PWHIV. Data were collected from study sites, doctors and patient participants. Factors associated with site enrolment and patient participant recruitment were investigated using regression models. RESULTS Thirteen study sites, 63 doctor participants and 728 patient participants were recruited to the study. Doctors having a prior relationship with the study investigators (odds ratio (OR) 13.3; 95% confidence interval (CI) 3.0, 58.7; P = 0.001) was positively associated with becoming a HealthMap site. Most patient participants successfully recruited to HealthMap (80%) had heard about the study from their HIV doctor. Patient enrolment was associated with the number of people with HIV receiving care at the site (β coefficient 0.10; 95% CI 0.04, 0.16; P = 0.004), but not with employing a clinic or research nurse to help recruit patients (β coefficient 55.9; 95% CI -2.55, 114.25; P = 0.06). CONCLUSION Despite substantial investment in online promotion, a previous relationship with doctors was important for doctor recruitment, and doctors themselves were the most important source of patient recruitment to the HealthMap trial. Clinic-based recruitment strategies remain a critical component of trial recruitment, despite expanding opportunities to engage with online communities.
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Affiliation(s)
- Karen M Klassen
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 3004, Australia; and Corresponding author.
| | - Tanya Millard
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 3004, Australia
| | - Julia Stout
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 3004, Australia
| | - Karalyn McDonald
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 3004, Australia
| | - Sarity Dodson
- Health Systems Improvement Unit, Centre for Population Health Research, School of Health and Social Development, Deakin University, Geelong, Vic. 3125, Australia
| | - Richard H Osborne
- Health Systems Improvement Unit, Centre for Population Health Research, School of Health and Social Development, Deakin University, Geelong, Vic. 3125, Australia
| | - Malcolm W Battersby
- Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, SA 5001, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre and Department of Medicine, Central Clinical School, Monash University, Melbourne, Vic. 3000, Australia
| | - Michael R Kidd
- Department of Family and Community Medicine, University of Toronto, Toronto M5G 1V7, Canada
| | - James McMahon
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 3004, Australia
| | - David Baker
- East Sydney Doctors, 102 Burton Street, Darlinghurst, NSW 2010, Australia
| | - Julian H Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Vic. 3004, Australia; and Cochrane Australia, School of Public Health and Preventative Medicine, Monash University, Melbourne, Vic. 3004, Australia
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13
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Pollack TM, Duong HT, Pham TT, Nguyen TD, Libman H, Ngo L, McMahon JH, Elliott JH, Do CD, Colby DJ. Routine versus Targeted Viral Load Strategy among Patients Starting Antiretroviral in Hanoi, Vietnam. J Int AIDS Soc 2020; 22:e25258. [PMID: 30897303 PMCID: PMC6428502 DOI: 10.1002/jia2.25258] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 02/04/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION HIV viral load (VL) testing is recommended by the WHO as the preferred method for monitoring patients on antiretroviral therapy (ART). However, evidence that routine VL (RVL) monitoring improves clinical outcomes is lacking. METHODS We conducted a prospective, randomized controlled trial of RVL monitoring every six months versus a targeted VL (TVL) strategy (routine CD4 plus VL testing if clinical or immunological failure) in patients starting ART between April 2011 and April 2014 at Bach Mai Hospital in Hanoi. Six hundred and forty-seven subjects were randomized to RVL (n = 305) or TVL monitoring (n = 342) and followed up for three years. Primary endpoints were death or WHO clinical Stage 4 events between six and thirty-six months of ART and rate of virological suppression at three years. RESULTS Overall, 37.1% of subjects were female, median age was 33.4 years (IQR: 29.5 to 38.6), and 47% had a CD4 count ≤100 cells/mm3 at time of ART initiation. Approximately 44% of study events (death, LTFU, withdrawal, or Stage 4 event) and 68% of deaths occurred within the first six months of ART. Among patients on ART at six months, death or Stage 4 event occurred in 3.6% of RVL and 3.9% of TVL (p = 0.823). Survival analysis showed no significant difference between the groups (p = 0.825). Viral suppression at 36 months of ART was 97.2% in RVL and 98.9% in TVL (p = 0.206) at a threshold of 400 copies/mL and was 98.0% in RVL and 98.9% in TVL (p = 0.488) at 1000 copies/mL. In ITT analysis, 20.7% in RVL and 21.9% in TVL (p = 0.693) were unsuppressed at 1000 copies/mL. CONCLUSIONS We found no significant difference in rates of death or Stage 4 events and virological failure in patients with RVL monitoring compared to those monitored with a TVL strategy after three years of follow-up. Viral suppression rates were high overall and there were few study events among patients alive and on ART after six months, limiting the study's power to detect a difference among study arms. Nonetheless, these data suggest that the choice of VL monitoring strategy may have less impact on patient outcomes compared to efforts to reduce early mortality and improve ART retention.
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Affiliation(s)
- Todd M Pollack
- The Partnership for Health Advancement in Vietnam (HAIVN), Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Hao T Duong
- The Partnership for Health Advancement in Vietnam (HAIVN), Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Thuy T Pham
- The Partnership for Health Advancement in Vietnam (HAIVN), Hanoi, Vietnam.,Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA.,Department of Infectious Diseases, Bach Mai Hospital (BMH), Hanoi, Vietnam
| | - Thang D Nguyen
- Department of Infectious Diseases, Bach Mai Hospital (BMH), Hanoi, Vietnam
| | - Howard Libman
- Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - Long Ngo
- Department of Medicine, Beth Israel Deaconess Medical Center (BIDMC), Boston, MA, USA
| | - James H McMahon
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Vic., Australia
| | - Julian H Elliott
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, Vic., Australia
| | - Cuong D Do
- Department of Infectious Diseases, Bach Mai Hospital (BMH), Hanoi, Vietnam
| | - Donn J Colby
- Center for Applied Research on Men and Community Health (CARMAH), Ho Chi Minh City, Vietnam.,SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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McDonald S, Elliott JH, Green S, Turner T. Towards a new model for producing evidence-based guidelines: a qualitative study of current approaches and opportunities for innovation among Australian guideline developers. F1000Res 2019; 8:956. [PMID: 31543956 PMCID: PMC6738187 DOI: 10.12688/f1000research.19661.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2019] [Indexed: 01/24/2023] Open
Abstract
Background: Many organisations in Australia undertake systematic reviews to inform development of evidence-based guidelines or would like to do so. However, the substantial resources required to produce systematic reviews limit the feasibility of evidence-based approaches to guideline development. We are working with Australian guideline developers to design, build and test systems that make creating evidence-based guidelines easier and more efficient. Methods: To understand the evidence needs of guideline developers and to inform the development of potential tools and services, we conducted 16 semi-structured interviews with Australian guideline developers. Developers were involved in different types of guidelines, represented both new and established guideline groups, and had access to widely different levels of resources. Results: All guideline developers recognised the importance of having access to timely evidence to support their processes, but were frequently overwhelmed by the scale of this task. Groups developing new guidelines often underestimated the time, expertise and work involved in completing searching and screening. Many were grappling with the challenge of updating and were keen to explore alternatives to the blanket updating of the full guideline. Horizon-scanning and evidence signalling were seen as providing more pragmatic approaches to updating, although some were wary of challenges posed by receiving evidence on a too-frequent basis. Respondents were aware that new technologies, such as machine learning, offered potentially large time and resource savings. Conclusions: As well as the constant challenge of managing financial constraints, Australian guideline developers seeking to develop clinical guidelines face several critical challenges. These include acquiring appropriate methodological expertise, investing in information technology, coping with the proliferation of research output, feasible publication and dissemination options, and keeping guidance up to date.
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Affiliation(s)
- Steve McDonald
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Julian H. Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Sally Green
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, 3004, Australia
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Millard T, Dodson S, McDonald K, Klassen KM, Osborne RH, Battersby MW, Fairley CK, Elliott JH. The systematic development of a complex intervention: HealthMap, an online self-management support program for people with HIV. BMC Infect Dis 2018; 18:615. [PMID: 30509195 PMCID: PMC6278155 DOI: 10.1186/s12879-018-3518-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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] [Received: 12/18/2017] [Accepted: 11/15/2018] [Indexed: 12/25/2022] Open
Abstract
Background Despite persistent calls for HIV care to adopt a chronic care approach, few HIV treatment services have been able to establish service arrangements that prioritise self-management. To prevent cardiovascular and other chronic disease outcomes, the HealthMap program aims to enhance routine HIV care with opportunities for self-management support. This paper outlines the systematic process that was used to design and develop the HealthMap program, prior to its evaluation in a cluster-randomised trial. Methods Program development, planning and evaluation was informed by the PRECEDE-PROCOEDE Model and an Intervention Mapping approach and involved four steps: (1) a multifaceted needs assessment; (2) the identification of intervention priorities; (3) exploration and identification of the antecedents and reinforcing factors required to initiate and sustain desired change of risk behaviours; and finally (4) the development of intervention goals, strategies and methods and integrating them into a comprehensive description of the intervention components. Results The logic model incorporated the program’s guiding principles, program elements, hypothesised causal processes, and intended program outcomes. Grounding the development of HealthMap on a clear conceptual base, informed by the research literature and stakeholder’s perspectives, has ensured that the HealthMap program is targeted, relevant, provides transparency, and enables effective program evaluation. Conclusions The use of a systematic process for intervention development facilitated the development of an intervention that is patient centred, accessible, and focuses on the key determinants of health-related outcomes for people with HIV in Australia. The techniques used here may offer a useful methodology for those involved in the development and implementation of complex interventions.
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Affiliation(s)
- Tanya Millard
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia. .,Cochrane Australia, School of Public Health and Preventative Medicine, Melbourne, Australia.
| | | | - Karalyn McDonald
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Karen M Klassen
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Richard H Osborne
- Public Health Innovation, Population Health Strategic Research Centre, School of Health and Social Development, Deakin University, Melbourne, Australia
| | - Malcolm W Battersby
- Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia
| | - Christopher K Fairley
- Melbourne Sexual Health Centre and Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Julian H Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.,Cochrane Australia, School of Public Health and Preventative Medicine, Melbourne, Australia
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16
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Lee SA, Elliott JH, McMahon J, Hartogenesis W, Bumpus NN, Lifson JD, Gorelick RJ, Bacchetti P, Deeks SG, Lewin SR, Savic RM. Population Pharmacokinetics and Pharmacodynamics of Disulfiram on Inducing Latent HIV-1 Transcription in a Phase IIb Trial. Clin Pharmacol Ther 2018; 105:692-702. [PMID: 30137649 DOI: 10.1002/cpt.1220] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/23/2018] [Accepted: 07/30/2018] [Indexed: 11/09/2022]
Abstract
Disulfiram (DSF) was well tolerated and activated viral transcription (cell-associated unspliced (CA-US) and plasma human immunodeficiency virus (HIV) RNA) in a phase II dose-escalation trial in HIV+ antiretroviral therapy (ART)-suppressed participants. Here, we investigated whether exposure to DSF and its metabolites predicted these changes in HIV transcription. Participants were administered 500 (N = 10), 1,000 (N = 10), or 2,000 (N = 10) mg of DSF for 3 consecutive days. DSF and four metabolites were measured by ultraperformance liquid chromatography-tandem mass spectrometry. Changes in CA-US and plasma HIV RNA were quantified by polymerase chain reaction (PCR) and analyzed in NONMEM. A seven-compartment pharmacokinetic (PK) model demonstrated nonlinear elimination kinetics. The fitted median area under the curve values for 72 hours (AUC0-72 ) were 3,816, 8,386, and 22,331 mg*hour/L, respectively. Higher exposure predicted greater increases in CA-US (maximum effect (Emax ) = 78%, AUC50 = 1,600 μg*hour/L, P = 0.013) but not plasma HIV RNA. These results provide support for further development of DSF as an important drug for future HIV cure strategies.
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Affiliation(s)
- Sulggi A Lee
- Department of Medicine, Division of HIV/AIDS, University of California, San Francisco, San Francisco, California, USA
| | - Julian H Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - James McMahon
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Wendy Hartogenesis
- Department of Medicine, Division of HIV/AIDS, University of California, San Francisco, San Francisco, California, USA
| | - Namandje N Bumpus
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jeffrey D Lifson
- Frederick National Laboratory for Cancer Research, AIDS and Cancer Virus Program, Frederick, Maryland, USA
| | - Robert J Gorelick
- Frederick National Laboratory for Cancer Research, AIDS and Cancer Virus Program, Frederick, Maryland, USA
| | - Peter Bacchetti
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Steven G Deeks
- Department of Medicine, Division of HIV/AIDS, University of California, San Francisco, San Francisco, California, USA
| | - Sharon R Lewin
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Victoria, Australia.,The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, San Francisco, California, USA
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Elliott JH, Synnot A, Turner T, Simmonds M, Akl EA, McDonald S, Salanti G, Meerpohl J, MacLehose H, Hilton J, Tovey D, Shemilt I, Thomas J. Living systematic review: 1. Introduction-the why, what, when, and how. J Clin Epidemiol 2017; 91:23-30. [PMID: 28912002 DOI: 10.1016/j.jclinepi.2017.08.010] [Citation(s) in RCA: 300] [Impact Index Per Article: 42.9] [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: 06/28/2017] [Revised: 08/17/2017] [Accepted: 08/17/2017] [Indexed: 11/26/2022]
Abstract
Systematic reviews are difficult to keep up to date, but failure to do so leads to a decay in review currency, accuracy, and utility. We are developing a novel approach to systematic review updating termed "Living systematic review" (LSR): systematic reviews that are continually updated, incorporating relevant new evidence as it becomes available. LSRs may be particularly important in fields where research evidence is emerging rapidly, current evidence is uncertain, and new research may change policy or practice decisions. We hypothesize that a continual approach to updating will achieve greater currency and validity, and increase the benefits to end users, with feasible resource requirements over time.
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Affiliation(s)
- Julian H Elliott
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 4th Floor, 553 St Kilda Road, Melbourne, Victoria 3004, Australia; Department of Infectious Diseases, Monash University and Alfred Hospital, 53 Commercial Road, Melbourne, Victoria 3004, Australia.
| | - Anneliese Synnot
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 4th Floor, 553 St Kilda Road, Melbourne, Victoria 3004, Australia; Centre for Health Communication and Participation, School of Psychology and Public Health, Level 4, Health Sciences 2, Science Drive, La Trobe University, Bundoora, Victoria 3086, Australia
| | - Tari Turner
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 4th Floor, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Mark Simmonds
- Centre for Reviews and Dissemination, A/B Block, Alcuin College, University of York, York YO10 5DD, York, UK
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Office Gefinor Center Block B, Beirut, Lebanon; Department of Epidemiology and Population Health, American University of Beirut, Office Gefinor Center Block B, Beirut, Lebanon; Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main Street West, Hamilton, ON L8S 4K1, Canada
| | - Steve McDonald
- Cochrane Australia, School of Public Health and Preventive Medicine, Monash University, 4th Floor, 553 St Kilda Road, Melbourne, Victoria 3004, Australia
| | - Georgia Salanti
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, CH-3012 Bern, Switzerland
| | - Joerg Meerpohl
- Cochrane Germany, Medical Center-University of Freiburg, Breisacher Str. 153, 79110 Freiburg, Germany
| | - Harriet MacLehose
- Cochrane Editorial Unit, Cochrane, St Albans House, 57-59 Haymarket, London SW1Y 4QX, UK
| | - John Hilton
- Cochrane Editorial Unit, Cochrane, St Albans House, 57-59 Haymarket, London SW1Y 4QX, UK
| | - David Tovey
- Cochrane Editorial Unit, Cochrane, St Albans House, 57-59 Haymarket, London SW1Y 4QX, UK
| | - Ian Shemilt
- EPPI-Centre, Institute of Education, University College London, 18 Woburn Square, London WC1H 0NR, UK
| | - James Thomas
- EPPI-Centre, Institute of Education, University College London, 18 Woburn Square, London WC1H 0NR, UK
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18
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Yong MK, Cameron PU, Spelman T, Elliott JH, Fairley CK, Boyle J, Miyamasu M, Lewin SR. Quantifying Adaptive and Innate Immune Responses in HIV-Infected Participants Using a Novel High Throughput Assay. PLoS One 2016; 11:e0166549. [PMID: 27935986 PMCID: PMC5147821 DOI: 10.1371/journal.pone.0166549] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 10/31/2016] [Indexed: 11/19/2022] Open
Abstract
Objectives HIV infection is characterised by persistent immune dysfunction of both the adaptive and innate immune responses. The aim of this study was to evaluate these responses using a novel high throughput assay in healthy controls and HIV-infected individuals prior to and following anti-retroviral treatment (ART). Design Cross-sectional study. Methods Whole blood was assessed using the QuantiFERON Monitor® (QFM) assay containing adaptive and innate immunostimulants. Interferon (IFN)-γ levels (IU/mL) were measured by enzyme-linked immunosorbent assay (ELISA). Results We recruited HIV-infected participants (n = 20 off ART and viremic; n = 59 on suppressive ART) and HIV-uninfected controls (n = 229). Median IFN-γ production was significantly higher in HIV-infected participants compared to controls (IFN-γ 512 vs 223 IU/ml, p<0.0001), but within the HIV-infected participants there was no difference between those on or off ART (median IFN-γ 512 vs 593 IU/ml p = 0.94). Amongst the HIV-infected participants, IFN-γ production was higher in individuals with CD4 count>350 compared to <350 cells/μL (IFN-γ IU/ml 561 vs 259 p = 0.02) and in males compared to females (IFN-γ 542 vs 77 IU/ml p = 0.04). There were no associations between IFN-γ production and age, plasma HIV RNA, nadir CD4 count or duration of HIV infection. Using a multivariable analysis, neither CD4 nor sex were independently predictive of IFN-γ production. Conclusion Using a high throughput assay which assesses both adaptive and innate immune function, we showed elevated IFN-γ production in HIV-infected patients both on and off ART. Further research is warranted to determine if changes in QuantiFERON Monitor® are associated with clinical outcomes.
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Affiliation(s)
- Michelle K. Yong
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, Australia
- * E-mail:
| | - Paul U. Cameron
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, Australia
| | - Tim Spelman
- Centre for Population Health, Burnet Institute, Melbourne, Australia
| | - Julian H. Elliott
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, Australia
| | - Christopher K. Fairley
- Central Clinical School, Monash University and Melbourne Sexual Health Centre, Melbourne, Australia
| | - Jeffrey Boyle
- QIAGEN, Germantown, Maryland, United States of America
| | | | - Sharon R. Lewin
- The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Australia
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, Australia
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19
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Millard T, Agius PA, McDonald K, Slavin S, Girdler S, Elliott JH. The Positive Outlook Study: A Randomised Controlled Trial Evaluating Online Self-Management for HIV Positive Gay Men. AIDS Behav 2016; 20:1907-18. [PMID: 26896121 DOI: 10.1007/s10461-016-1301-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [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] [Indexed: 11/26/2022]
Abstract
The aim of this paper was to evaluate the effectiveness of an online self-management program in improving health outcomes and well-being for gay men living with HIV in Australia. The online Positive Outlook Program was based on self-efficacy theory and used a self-management approach to enhance HIV-positive gay men's skills, confidence and abilities to manage the psychosocial issues associated with HIV in daily life. The 7-week program was delivered in closed groups and comprised information modules, action-planning activities, moderated discussion boards, and weekly peer-facilitated 'live chats'. A randomised controlled trial was conducted to establish the effectiveness of the Positive Outlook program compared to a 'usual care' control. Participants were HIV-positive gay men 18 years or older living in Australia. Primary outcomes were evaluated at three time-points (baseline, post-intervention and 12-week's post-intervention follow-up) and included HIV-related quality of life (PROQOL-HIV), outcomes of health education (HeiQ) and HIV specific self-efficacy (Positive Outlook Self-Efficacy Scale). A total of 132 gay men with HIV in Australia were randomly allocated to the intervention (n = 68) or usual care control (n = 64) groups. Maximum likelihood marginal-linear modelling indicated significant improvement in the intervention group on the PROQOL-HIV subscales of body change (p = 0.036), social relationships (p = 0.035) and emotional distress (p = 0.031); the HeiQ subscales of health-directed activity (p = 0.048); constructive attitudes and approaches (p = 0.015); skill and technique acquisition (p = 0.046) and health service navigation (p = 0.008); and the Positive Outlook Self-Efficacy Scale on the subscales of relationships (p = 0.019); social participation (p = 0.006); and emotions (p = 0.041). Online delivery of self-management programs is feasible and has the potential to improve quality of life, self-management skills and domain specific self-efficacy for gay men with HIV.
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Affiliation(s)
- Tanya Millard
- Department of Infectious Diseases, Monash University, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia.
| | - Paul A Agius
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
| | - Karalyn McDonald
- Department of Infectious Diseases, Monash University, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia
- Judith Lumley Centre, La Trobe University, Melbourne, Australia
- Jean Hailes Research Unit, Monash University, Melbourne, Australia
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
| | - Sean Slavin
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Sonya Girdler
- School of Occupational Therapy and Social Work, Curtin University, Perth, Australia
| | - Julian H Elliott
- Department of Infectious Diseases, Monash University, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia
- Centre for Population Health, Burnet Institute, Melbourne, Australia
- Infectious Diseases Unit, Alfred Hospital, Melbourne, Australia
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20
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Dodson S, Batterham R, McDonald K, Elliott JH, Osborne RH. A systematic analysis of the needs of people with HIV in Australia: stakeholder views of the key elements for a healthy life. Sex Health 2016; 13:SH15026. [PMID: 27373898 DOI: 10.1071/sh15026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 04/28/2016] [Indexed: 11/23/2022]
Abstract
Background: The HealthMap project is developing an intervention to reduce cardiovascular risk in people living with HIV. As part of the formative stages of the intervention design, we sought to understand the needs of people with HIV (PWHIV). Methods: Two concept-mapping workshops with PWHIV (n=10), and one with HIV care providers (n=6) were conducted. The workshop findings were consolidated into a questionnaire administered to PWHIV (n=300) and HIV care providers (n=107). Participants were asked to rate the importance of each of 81 presented needs and the degree to which it was currently being met. Results: Workshops provided insights into what PWHIV perceive they need, to live with and manage their condition, and its impact on their life; these included: (1) clinical science research and development; (2) information and support; (3) personal situation; (4) healthcare quality; (5) access to services; (6) access to services specific to ageing; and (7) social justice. Questionnaire results revealed that PWHIV considered information and support, and research and development most important. For providers, healthcare quality, clients' personal situation, and social justice were most important. In terms of unmet needs, PWHIV and providers both highlighted issues in the areas of social justice, and access to aged care services. Conclusions: PWHIV and HIV providers continue to report unmet needs in the areas of social justice and emerging concerns about access to aged care services. Services must continue to address these issues of access and equity.
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Abstract
As HIV has transitioned into a chronic disease, reappraisal of clinical management has occurred with chronic disease self-management (CDSM) as one possibility. However, despite extensive work on CDSM across a range of diseases, little attention has focused on psychosocial contexts of the lives of people for whom programs are intended. This article reports semi-structured interviews used to explore health practices and motivations of 33 people with HIV (PWHIV) in Australia. Within participants' accounts, different forms of subjectivity and agency emerged with implications for how they understood and valued health-related behaviors. Four themes arose: health support and disclosure, social support and stigma, employment/structure, and health decisions beyond HIV. The experience of stigma and its intersection with CDSM remains relatively un-chartered. This study found stigma shapes agency and engagement with health. Decisions concerning health behaviors are often driven by perceived social and emotional benefit embedded in concerns of disclosure and stigma.
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Affiliation(s)
- Karalyn McDonald
- Monash University, Melbourne, Victoria, Australia La Trobe University, Melbourne, Victoria, Australia
| | - Sean Slavin
- University of New South Wales, Sydney, New South Wales, Australia
| | | | - Julian H Elliott
- Monash University, Melbourne, Victoria, Australia Alfred Hospital, Melbourne, Victoria, Australia Burnet Institute, Melbourne, Victoria, Australia
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22
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Dodson S, Klassen KM, McDonald K, Millard T, Osborne RH, Battersby MW, Fairley CK, Simpson JA, Lorgelly P, Tonkin A, Roney J, Slavin S, Sterjovski J, Brereton M, Lewin SR, Crooks L, Watson J, Kidd MR, Williams I, Elliott JH. HealthMap: a cluster randomised trial of interactive health plans and self-management support to prevent coronary heart disease in people with HIV. BMC Infect Dis 2016; 16:114. [PMID: 26945746 PMCID: PMC4779564 DOI: 10.1186/s12879-016-1422-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 02/09/2016] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The leading causes of morbidity and mortality for people in high-income countries living with HIV are now non-AIDS malignancies, cardiovascular disease and other non-communicable diseases associated with ageing. This protocol describes the trial of HealthMap, a model of care for people with HIV (PWHIV) that includes use of an interactive shared health record and self-management support. The aims of the HealthMap trial are to evaluate engagement of PWHIV and healthcare providers with the model, and its effectiveness for reducing coronary heart disease risk, enhancing self-management, and improving mental health and quality of life of PWHIV. METHODS/DESIGN The study is a two-arm cluster randomised trial involving HIV clinical sites in several states in Australia. Doctors will be randomised to the HealthMap model (immediate arm) or to proceed with usual care (deferred arm). People with HIV whose doctors are randomised to the immediate arm receive 1) new opportunities to discuss their health status and goals with their HIV doctor using a HealthMap shared health record; 2) access to their own health record from home; 3) access to health coaching delivered by telephone and online; and 4) access to a peer moderated online group chat programme. Data will be collected from participating PWHIV (n = 710) at baseline, 6 months, and 12 months and from participating doctors (n = 60) at baseline and 12 months. The control arm will be offered the HealthMap intervention at the end of the trial. The primary study outcomes, measured at 12 months, are 1) 10-year risk of non-fatal acute myocardial infarction or coronary heart disease death as estimated by a Framingham Heart Study risk equation; and 2) Positive and Active Engagement in Life Scale from the Health Education Impact Questionnaire (heiQ). DISCUSSION The study will determine the viability and utility of a novel technology-supported model of care for maintaining the health and wellbeing of people with HIV. If shown to be effective, the HealthMap model may provide a generalisable, scalable and sustainable system for supporting the care needs of people with HIV, addressing issues of equity of access. TRIAL REGISTRATION Universal Trial Number (UTN) U111111506489; ClinicalTrial.gov Id NCT02178930 submitted 29 June 2014.
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Affiliation(s)
- Sarity Dodson
- School of Health and Social Development, Deakin University, Geelong, Australia. .,Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Karen M Klassen
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Karalyn McDonald
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Tanya Millard
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Richard H Osborne
- School of Health and Social Development, Deakin University, Geelong, Australia.
| | - Malcolm W Battersby
- Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, Australia.
| | - Christopher K Fairley
- Melbourne Sexual Health Centre and Department of Medicine, Central Clinical School, Monash University, Melbourne, Australia.
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | - Paula Lorgelly
- Centre for Health Economics, Monash University, Melbourne, Australia.
| | - Andrew Tonkin
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Janine Roney
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Sean Slavin
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia.
| | - Jasminka Sterjovski
- Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
| | - Margot Brereton
- Science and Engineering Faculty, Queensland University of Technology, Brisbane, Australia.
| | - Sharon R Lewin
- Department of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.
| | - Levinia Crooks
- Australasian Society for HIV Medicine, Sydney, Australia. .,Department of Public Health and Human Biosciences, La Trobe University, Melbourne, Australia.
| | - Jo Watson
- National Association of People with HIV Australia, Sydney, Australia.
| | - Michael R Kidd
- Faculty of Medicine, Nursing and Health Sciences, Flinders University, Adelaide, Australia.
| | - Irith Williams
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
| | - Julian H Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia.
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23
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Medland NA, McMahon JH, Chow EPF, Elliott JH, Hoy JF, Fairley CK. The HIV care cascade: a systematic review of data sources, methodology and comparability. J Int AIDS Soc 2015; 18:20634. [PMID: 26626715 PMCID: PMC4666907 DOI: 10.7448/ias.18.1.20634] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Revised: 10/19/2015] [Accepted: 11/02/2015] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION The cascade of HIV diagnosis, care and treatment (HIV care cascade) is increasingly used to direct and evaluate interventions to increase population antiretroviral therapy (ART) coverage, a key component of treatment as prevention. The ability to compare cascades over time, sub-population, jurisdiction or country is important. However, differences in data sources and methodology used to construct the HIV care cascade might limit its comparability and ultimately its utility. Our aim was to review systematically the different methods used to estimate and report the HIV care cascade and their comparability. METHODS A search of published and unpublished literature through March 2015 was conducted. Cascades that reported the continuum of care from diagnosis to virological suppression in a demographically definable population were included. Data sources and methods of measurement or estimation were extracted. We defined the most comparable cascade elements as those that directly measured diagnosis or care from a population-based data set. RESULTS AND DISCUSSIONS Thirteen reports were included after screening 1631 records. The undiagnosed HIV-infected population was reported in seven cascades, each of which used different data sets and methods and could not be considered to be comparable. All 13 used mandatory HIV diagnosis notification systems to measure the diagnosed population. Population-based data sets, derived from clinical data or mandatory reporting of CD4 cell counts and viral load tests from all individuals, were used in 6 of 12 cascades reporting linkage, 6 of 13 reporting retention, 3 of 11 reporting ART and 6 of 13 cascades reporting virological suppression. Cascades with access to population-based data sets were able to directly measure cascade elements and are therefore comparable over time, place and sub-population. Other data sources and methods are less comparable. CONCLUSIONS To ensure comparability, countries wishing to accurately measure the cascade should utilize complete population-based data sets from clinical data from elements of a centralized healthcare setting, where available, or mandatory CD4 cell count and viral load test result reporting. Additionally, virological suppression should be presented both as percentage of diagnosed and percentage of estimated total HIV-infected population, until methods to calculate the latter have been standardized.
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Affiliation(s)
- Nicholas A Medland
- Central Clinical School, Monash University, Melbourne, VIC, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia;
| | - James H McMahon
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Eric P F Chow
- Central Clinical School, Monash University, Melbourne, VIC, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
| | - Julian H Elliott
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Jennifer F Hoy
- Department of Infectious Diseases, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christopher K Fairley
- Central Clinical School, Monash University, Melbourne, VIC, Australia
- Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
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Elliott JH, McMahon JH, Chang CC, Lee SA, Hartogensis W, Bumpus N, Savic R, Roney J, Hoh R, Solomon A, Piatak M, Gorelick RJ, Lifson J, Bacchetti P, Deeks SG, Lewin SR. Short-term administration of disulfiram for reversal of latent HIV infection: a phase 2 dose-escalation study. Lancet HIV 2015; 2:e520-9. [PMID: 26614966 DOI: 10.1016/s2352-3018(15)00226-x] [Citation(s) in RCA: 190] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 10/27/2015] [Accepted: 10/27/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND In vitro, disulfiram activated HIV transcription in a primary T-cell model of HIV latency and in a pilot clinical study increased plasma HIV RNA in individuals with adequate drug exposure. We assessed the effect of disulfiram on HIV transcription in a dose-escalation study. METHODS In this prospective dose-escalation study, to optimise disulfiram exposure we included adults with HIV on suppressive antiretroviral therapy, with plasma HIV RNA of less than 50 copies per mL and a CD4 cell count greater than 350 cells per μL. Participants were allocated sequentially to one of three dosing groups (500 mg, 1000 mg, and 2000 mg) and received disulfiram daily for 3 days. Only the staff who did laboratory assays were masked to group assignment. The primary endpoint was change in cell-associated unspliced HIV RNA in CD4 cells. The primary analysis method was a negative binomial regression, with the number of copies as the outcome variable and the input total RNA or plasma volume as an exposure variable, which is equivalent to modelling copies or input. We used these models to estimate changes from before disulfiram to timepoints during and after disulfiram administration. This study is registered with ClinicalTrials.gov, number NCT01944371. FINDINGS Of 34 participants screened for eligibility at The Alfred Hospital (Melbourne, VIC, Australia), and San Francisco General Hospital (San Francisco, CA, USA), 30 people were enrolled between Sept 24, 2013, and March 31, 2014. The estimated fold increases in cell-associated unspliced HIV RNA from baseline were 1·7 (95% CI 1·3-2·2; p<0·0001) to the timepoint during disulfiram treatment and 2·1 (1·5-2·9; p<0·0001) to the timepoint after disulfiram in the 500 mg group; 1·9 (1·6-2·4; p<0·0001) and 2·5 (1·9-3·3; p<0·0001) in the 1000 mg group; and 1·6 (1·2-2·1; p=0·0026) and 2·1 (1·5-3·1; p=0·0001) in the 2000 mg group. No deaths occurred, and no serious adverse events were noted. Disulfiram was well tolerated at all doses. INTERPRETATION Short-term administration of disulfiram resulted in increases in cell-associated unspliced HIV RNA at all doses, consistent with activating HIV latency. Disulfiram may be suited for future studies of combination and prolonged therapy to activate latent HIV. FUNDING The Foundation for AIDS Research (amfAR); National Institute of Allergy and Infectious Diseases, National Institutes of Health; Australian National Health and Medical Research Council.
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Affiliation(s)
- Julian H Elliott
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, VIC, Australia
| | - James H McMahon
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, VIC, Australia
| | - Christina C Chang
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, VIC, Australia; The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Sulggi A Lee
- University of California San Francisco, San Francisco, CA, USA
| | | | | | - Rada Savic
- University of California San Francisco, San Francisco, CA, USA
| | - Janine Roney
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, VIC, Australia
| | - Rebecca Hoh
- University of California San Francisco, San Francisco, CA, USA
| | - Ajantha Solomon
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - Michael Piatak
- AIDS and Cancer Virus Program, Leidos Biomedical Research Inc, Frederick National Laboratory, Frederick, MD, USA
| | - Robert J Gorelick
- AIDS and Cancer Virus Program, Leidos Biomedical Research Inc, Frederick National Laboratory, Frederick, MD, USA
| | - Jeff Lifson
- AIDS and Cancer Virus Program, Leidos Biomedical Research Inc, Frederick National Laboratory, Frederick, MD, USA
| | - Peter Bacchetti
- University of California San Francisco, San Francisco, CA, USA
| | - Steven G Deeks
- University of California San Francisco, San Francisco, CA, USA
| | - Sharon R Lewin
- Department of Infectious Diseases, Monash University and Alfred Hospital, Melbourne, VIC, Australia; The Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia.
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25
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Ng L, Pitt V, Huckvale K, Clavisi O, Turner T, Gruen R, Elliott JH. Title and Abstract Screening and Evaluation in Systematic Reviews (TASER): a pilot randomised controlled trial of title and abstract screening by medical students. Syst Rev 2014; 3:121. [PMID: 25335439 PMCID: PMC4217707 DOI: 10.1186/2046-4053-3-121] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/30/2014] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND The production of high quality systematic reviews requires rigorous methods that are time-consuming and resource intensive. Citation screening is a key step in the systematic review process. An opportunity to improve the efficiency of systematic review production involves the use of non-expert groups and new technologies for citation screening. We performed a pilot study of citation screening by medical students using four screening methods and compared students' performance to experienced review authors. METHODS The aims of this pilot randomised controlled trial were to provide preliminary data on the accuracy of title and abstract screening by medical students, and on the effect of screening modality on screening accuracy and efficiency. Medical students were randomly allocated to title and abstract screening using one of the four modalities and required to screen 650 citations from a single systematic review update. The four screening modalities were a reference management software program (EndNote), Paper, a web-based systematic review workflow platform (ReGroup) and a mobile screening application (Screen2Go). Screening sensitivity and specificity were analysed in a complete case analysis using a chi-squared test and Kruskal-Wallis rank sum test according to screening modality and compared to a final set of included citations selected by expert review authors. RESULTS Sensitivity of medical students' screening decisions ranged from 46.7% to 66.7%, with students using the web-based platform performing significantly better than the paper-based group. Specificity ranged from 93.2% to 97.4% with the lowest specificity seen with the web-based platform. There was no significant difference in performance between the other three modalities. CONCLUSIONS Medical students are a feasible population to engage in citation screening. Future studies should investigate the effect of incentive systems, training and support and analytical methods on screening performance. SYSTEMATIC REVIEW REGISTRATION Cochrane Database CD001048.
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Affiliation(s)
- Lauren Ng
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3168, Australia
| | - Veronica Pitt
- National Trauma Research Institute, 85-89 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Kit Huckvale
- Global eHealth Unit, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Ornella Clavisi
- National Trauma Research Institute, 85-89 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Tari Turner
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC 3168, Australia
- World Vision Australia, 1 Vision Drive, Burwood East, Melbourne, VIC 3151, Australia
| | - Russell Gruen
- National Trauma Research Institute, 85-89 Commercial Rd, Melbourne, VIC 3004, Australia
| | - Julian H Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, 2nd Floor, Burnet Tower, Alfred Hospital, Commercial Road, Melbourne, VIC 3004, Australia
- Australasian Cochrane Centre, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, VIC 3004, Australia
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Abstract
The current difficulties in keeping systematic reviews up to date leads to considerable inaccuracy, hampering the translation of knowledge into action. Incremental advances in conventional review updating are unlikely to lead to substantial improvements in review currency. A new approach is needed. We propose living systematic review as a contribution to evidence synthesis that combines currency with rigour to enhance the accuracy and utility of health evidence. Living systematic reviews are high quality, up-to-date online summaries of health research, updated as new research becomes available, and enabled by improved production efficiency and adherence to the norms of scholarly communication. Together with innovations in primary research reporting and the creation and use of evidence in health systems, living systematic review contributes to an emerging evidence ecosystem.
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Affiliation(s)
- Julian H. Elliott
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- * E-mail:
| | - Tari Turner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- World Vision Australia, Melbourne, Australia
| | - Ornella Clavisi
- National Trauma Research Institute, Alfred Hospital, Melbourne, Australia
| | - James Thomas
- EPPI-Centre, Institute of Education, University of London, London, England
| | - Julian P. T. Higgins
- School of Social and Community Medicine, University of Bristol, Bristol, England
- Centre for Reviews and Dissemination, University of York, York, England
| | - Chris Mavergames
- Informatics and Knowledge Management Department, The Cochrane Collaboration, Freiburg, Germany
| | - Russell L. Gruen
- National Trauma Research Institute, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
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27
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Purcell DFJ, Elliott JH, Ross AL, Frater J. Towards an HIV cure: science and debate from the International AIDS Society 2013 symposium. Retrovirology 2013; 10:134. [PMID: 24224983 PMCID: PMC3828479 DOI: 10.1186/1742-4690-10-134] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 11/04/2013] [Indexed: 11/25/2022] Open
Abstract
The International AIDS Society convened the multi-stakeholder “Towards an HIV Cure” symposium in Kuala Lumpur, Malaysia in 2013 to address the significant research challenges posed by the search for a cure for HIV infection. Current antiretroviral regimens select for a small reservoir of cells that harbour latent HIV provirus, produce few or no HIV virions, and resist detection or clearance by host immunity. The symposium examined basic molecular science and animal model data, and emerging and ongoing clinical trial results to prioritise strategies and determine the viral and immune responses that could lead to HIV remission without ART. Here we review the presentations that scrutinized the molecular mechanisms controlling virus expression from proviral DNA, and the intrinsic cellular restriction and immune mechanisms preventing viral production. Insights from the basic science have translated into new therapeutic strategies seeking HIV remission without ongoing therapy, and much interest was focused on these ongoing trials. We also summarise the emerging ethical issues and patient expectations as concepts move into the clinic.
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Affiliation(s)
- Damian F J Purcell
- Department of Microbiology and Immunology, The University of Melbourne, Parkville, VIC 3010, Australia.
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McMahon JH, Manoharan A, Wanke C, Mammen S, Jose H, Malini T, Kadavanu T, Jordan MR, Elliott JH, Lewin SR, Mathai D. Targets for intervention to improve virological outcomes for patients receiving free antiretroviral therapy in Tamil Nadu, India. AIDS Care 2013; 26:559-66. [PMID: 24125035 DOI: 10.1080/09540121.2013.845282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Operational research to identify factors predicting poor clinical outcomes is critical to maximize patient care and prolong first-line regimens for those receiving free antiretroviral therapy (ART) in India. We sought to identify social or clinical factors amenable to intervention that predict virological outcomes after 12 months of ART. We examined a retrospective cohort of consecutive adults initiating free nonnucleoside reverse transcriptase inhibitor-based regimens. Individuals remaining in care 12 months post-ART initiation were tested for HIV viral load and surveyed to identify barriers and facilitators to adherence, and to determine clinic travel times and associated costs. Uni- and multivariate logistic regression identified factors predicting HIV viral load >200 copies/mL after 12 months of ART. Of 230 adults initiating ART, 10% of patients died, 8% transferred out, 5% were lost to follow-up, and 174/230 (76%) completed 12 months of ART, the questionnaire, and viral load testing. HIV viral load was <200 copies/mL in 140/174 (80%) patients. In multivariate models, being busy with work or caring for others (OR 2.9, p < 0.01), having clinic transport times ≥ 3 hours (OR 3.0, p = 0.02), and alcohol use (OR 4.8, p = 0.03) predicted viral load >200 copies/mL after 12 months of ART. Clinical outcomes following ART are related to programmatic factors such as prolonged travel time and individual factors such as being busy with family or using alcohol. Simple interventions that alter these factors should be evaluated to improve clinical outcomes for populations receiving free ART in similar settings.
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Affiliation(s)
- James H McMahon
- a Infectious Diseases Unit , Alfred Hospital , Melbourne , VIC , Australia
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Chang CC, Omarjee S, Lim A, Spelman T, Gosnell BI, Carr WH, Elliott JH, Moosa MYS, Ndung'u T, French MA, Lewin SR. Chemokine levels and chemokine receptor expression in the blood and the cerebrospinal fluid of HIV-infected patients with cryptococcal meningitis and cryptococcosis-associated immune reconstitution inflammatory syndrome. J Infect Dis 2013; 208:1604-12. [PMID: 23908492 DOI: 10.1093/infdis/jit388] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [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] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus-infected patients with treated cryptococcal meningitis who start combination antiretroviral therapy (cART) are at risk of further neurological deterioration, in part caused by paradoxical cryptococcosis-associated immune reconstitution inflammatory syndrome (C-IRIS). We hypothesized that C-IRIS is associated with alterations of chemokine receptor expression on T cells and chemokine concentrations in cerebrospinal fluid (CSF) that enhance recruitment of T-helper 1 cells and/or myeloid cells to the central nervous system. METHODS In a prospective study of 128 human immunodeficiency virus-infected patients with cryptococcal meningitis who received antifungal therapy followed by cART, we examined the proportions of CD4(+) and CD8(+) T cells expressing CCR5 and/or CXCR3, in CSF and whole blood and the concentrations of CXCL10, CCL2, and CCL3 in stored CSF and plasma. RESULTS The proportion of CD4(+) and CD8(+) T cells expressing CXCR3(+)CCR5(+) and the concentrations of CXCL10, CCL2 and CCL3 were increased in CSF compared with blood at cART initiation (P < .0001). Patients with C-IRIS (n = 26), compared with those with no neurological deterioration (n = 63), had higher CSF ratios of CCL2/CXCL10 and CCL3/CXCL10 and higher proportions of CXCR3(+)CCR5(+)CD8(+)T cells in CSF compared with blood at cART initiation (P = .03, .0053, and .02, respectively). CONCLUSION CD8(+) T-cell and myeloid cell trafficking to the central nervous system may predispose patients to C-IRIS.
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Marshall CS, Curtis AJ, Spelman T, O'Brien DP, Greig J, Shanks L, du Cros P, Casas EC, da Fonseca MS, Athan E, Elliott JH. Impact of HIV-associated conditions on mortality in people commencing anti-retroviral therapy in resource limited settings. PLoS One 2013; 8:e68445. [PMID: 23935870 PMCID: PMC3720807 DOI: 10.1371/journal.pone.0068445] [Citation(s) in RCA: 15] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 05/29/2013] [Indexed: 11/24/2022] Open
Abstract
Objectives To identify associations between specific WHO stage 3 and 4 conditions diagnosed after ART initiation and all cause mortality for patients in resource-limited settings (RLS). Design, Setting Analysis of routine program data collected prospectively from 25 programs in eight countries between 2002 and 2010. Subjects, Participants 36,664 study participants with median ART follow-up of 1.26 years (IQR 0.55–2.27). Outcome Measures Using a proportional hazards model we identified factors associated with mortality, including the occurrence of specific WHO clinical stage 3 and 4 conditions during the 6-months following ART initiation. Results There were 2922 deaths during follow-up (8.0%). The crude mortality rate was 5.41 deaths per 100 person-years (95% CI: 5.21–5.61). The diagnosis of any WHO stage 3 or 4 condition during the first 6 months of ART was associated with increased mortality (HR: 2.21; 95% CI: 1.97–2.47). After adjustment for age, sex, region and pre-ART CD4 count, a diagnosis of extrapulmonary cryptococcosis (aHR: 3.54; 95% CI: 2.74–4.56), HIV wasting syndrome (aHR: 2.92; 95%CI: 2.21 -3.85), non-tuberculous mycobacterial infection (aHR: 2.43; 95% CI: 1.80–3.28) and Pneumocystis pneumonia (aHR: 2.17; 95% CI 1.80–3.28) were associated with the greatest increased mortality. Cerebral toxoplasmosis, pulmonary and extra-pulmonary tuberculosis, Kaposi’s sarcoma and oral and oesophageal candidiasis were associated with increased mortality, though at lower rates. Conclusions A diagnosis of certain WHO stage 3 and 4 conditions is associated with an increased risk of mortality in those initiating ART in RLS. This information will assist initiatives to reduce excess mortality, including prioritization of resources for diagnostics, therapeutic interventions and research.
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McMahon JH, Manoharan A, Wanke CA, Mammen S, Jose H, Malini T, Kadavanu T, Jordan MR, Elliott JH, Lewin SR, Mathai D. Pharmacy and self-report adherence measures to predict virological outcomes for patients on free antiretroviral therapy in Tamil Nadu, India. AIDS Behav 2013; 17:2253-9. [PMID: 23435750 DOI: 10.1007/s10461-013-0436-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Over 480,000 individuals receive free antiretroviral therapy (ART) in India yet data associating ART adherence with HIV viral load for populations exclusively receiving free ART are not available. Additionally estimates of adherence using pharmacy data on ART pick-up are not available for any population in India. After 12-months ART we found self-reported estimates of adherence were not associated with HIV viral load. Individuals with <100% adherence using pharmacy data predicted HIV viral load, and estimates combining pharmacy data and self-report were also predictive. Pharmacy adherence measures proved a feasible method to estimate adherence in India and appear more predictive of virological outcomes than self-report. Predictive adherence measures identified in this study warrant further investigation in populations receiving free ART in India to allow for identification of individuals at risk of virological failure and in need of adherence support.
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Chang CC, Lim A, Omarjee S, Levitz SM, Gosnell BI, Spelman T, Elliott JH, Carr WH, Moosa MYS, Ndung'u T, Lewin SR, French MA. Cryptococcosis-IRIS is associated with lower cryptococcus-specific IFN-γ responses before antiretroviral therapy but not higher T-cell responses during therapy. J Infect Dis 2013; 208:898-906. [PMID: 23766525 DOI: 10.1093/infdis/jit271] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Cryptococcosis-associated immune reconstitution inflammatory syndrome (C-IRIS) may be driven by aberrant T-cell responses against cryptococci. We investigated this in human immunodeficiency virus (HIV)-infected patients with treated cryptococcal meningitis (CM) commencing combination antiretroviral therapy (cART). METHODS Mitogen- and cryptococcal mannoprotein (CMP)-activated (CD25+CD134+) CD4+ T cells and -induced production of interferon-gamma (IFN-γ), IL-10, and CXCL10 were assessed in whole blood cultures in a prospective study of 106 HIV-CM coinfected patients. RESULTS Patients with paradoxical C-IRIS (n = 27), compared with patients with no neurological deterioration (no ND; n = 63), had lower CMP-induced IFN-γ production in 24-hour cultures pre-cART and 4 weeks post-cART (P = .0437 and .0257, respectively) and lower CMP-activated CD4+ T-cell counts pre-cART (P = .0178). Patients surviving to 24 weeks had higher proportions of mitogen-activated CD4+ T cells and higher CMP-induced CXCL10 and IL-10 production in 24-hour cultures pre-cART than patients not surviving (P = .0053, .0436 and .0319, respectively). C-IRIS was not associated with higher CMP-specific T-cell responses before or during cART. CONCLUSION Greater preservation of T-cell function and higher CMP-induced IL-10 and CXCL10 production before cART are associated with improved survival while on cART. Lower CMP-induced IFN-γ production pre-cART, but not higher CMP-specific T-cell responses after cART, were risk factors for C-IRIS.
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Affiliation(s)
- Christina C Chang
- Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
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McMahon JH, Elliott JH, Bertagnolio S, Kubiak R, Jordan MR. Viral suppression after 12 months of antiretroviral therapy in low- and middle-income countries: a systematic review. Bull World Health Organ 2013; 91:377-385E. [PMID: 23678201 PMCID: PMC3646348 DOI: 10.2471/blt.12.112946] [Citation(s) in RCA: 101] [Impact Index Per Article: 9.2] [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: 09/16/2012] [Revised: 01/01/2013] [Accepted: 01/21/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To establish estimates of viral suppression in low- and middle-income countries (LMICs) in patients who received antiretroviral therapy (ART) for human immunodeficiency virus (HIV) infection. METHODS Data on viral suppression after 12 months of ART in LMICs were collected from articles published in 2003 to 2011 and from abstracts of conferences held between 2009 and 2011. Pooled proportions for on-treatment and intention-to-treat populations were used as summary estimates. Random-effects models were used for heterogeneous groups of studies (I (2) > 75%). FINDINGS Overall, 49 studies covering 48 cohorts and 30 016 individuals met the inclusion criteria. With thresholds for suppression between 300 and 500 copies of viral ribonucleic acid (RNA) per ml of plasma, 84.3% (95% confidence interval, CI: 80.4-87.9) of the pooled on-treatment population and 70.5% (95% CI: 65.2-75.6) of the intention-to-treat population showed suppression. Use of different viral RNA thresholds changed the proportions showing suppression: to 84% and 76% of the on-treatment population with thresholds set above 300 and at or below 200 RNA copies per ml, respectively, and to 78%, 71% and 63% of the intention-to-treat population at thresholds set at 1000, 300 to 500, and 200 or fewer copies per ml, respectively. CONCLUSION The pooled estimates of viral suppression recorded after 12 months of ART in LMICs provide benchmarks that other ART programmes can use to set realistic goals and perform predictive modelling. Evidence from this review suggests that the current international target - i.e. viral suppression in > 70% of the intention-to-treat population, with a threshold of 1000 copies per ml - should be revised upwards.
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Affiliation(s)
- James H McMahon
- Infectious Diseases Unit, Alfred Hospital, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia
| | - Julian H Elliott
- Infectious Diseases Unit, Alfred Hospital, Level 2 Burnet Tower, 85 Commercial Road, Melbourne, 3004, Australia
| | | | - Rachel Kubiak
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, United States of America
| | - Michael R Jordan
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, United States of America
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Elliott JH, Mavergames C, Becker L, Meerpohl J, Thomas J, Gruen R, Tovey D. The efficient production of high quality evidence reviews is important for the public good. BMJ 2013; 346:f846. [PMID: 23407729 DOI: 10.1136/bmj.f846] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McMahon JH, Elliott JH, Hong SY, Bertagnolio S, Jordan MR. Effects of physical tracing on estimates of loss to follow-up, mortality and retention in low and middle income country antiretroviral therapy programs: a systematic review. PLoS One 2013; 8:e56047. [PMID: 23424643 PMCID: PMC3570556 DOI: 10.1371/journal.pone.0056047] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [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: 07/06/2012] [Accepted: 01/08/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND A large proportion of patients receiving antiretroviral therapy (ART) in low and middle income countries (LMICs) have unknown treatment outcomes and are classified as lost to follow-up (LTFU). Physical tracing of patients classified as LTFU is common; however, effects of tracing on outcomes remains unclear. The objective of this systematic review is to compare estimates of LTFU, mortality and retention in LMIC in cohorts of patients with and without physical tracing. METHODS AND FINDINGS We systematically identified studies in LMIC programmatic settings using MEDLINE (2003-2011) and HIV conference abstracts (2009-2011). Studies reporting the proportion LTFU 12-months after ART initiation were included. Tracing activities were determined from manuscripts or by contacting study authors. Studies were classified as "tracing studies" if physical tracing was available for the majority of patients. Summary estimates from the 2 groups of studies (tracing and non-tracing) for LTFU, mortality, stop of ART, transfers out, and retention on ART were determined. 261 papers and 616 abstracts were identified of which 39 studies comprising 54 separate cohorts (n = 187,666) met inclusion criteria. Of those, physical tracing was available for 46% of cohorts. Treatment programs with physical tracing activities had lower estimated LTFU (7.6% vs. 15.1%; p<.001), higher estimated mortality (10.5% vs. 6.6%; p = .006), higher retention on ART (80.0 vs. 75.8%; p = .04) and higher retention at the original site (80.0% vs. 72.9%; p = .02). CONCLUSIONS Knowledge of patient tracing is critical when interpreting program outcomes of LTFU, mortality and retention. The reduction of the proportion LTFU in tracing studies was only partially explained by re-classification of unknown outcomes. These data suggest that tracing may lead to increased re-engagement of patients in care, rather than just improved classification of unknown outcomes.
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Affiliation(s)
- James H McMahon
- Infectious Diseases Unit, Alfred Hospital, Melbourne, Victoria, Australia.
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Moshabela M, MacPherson P, Ezard N, Frean E, Mashimbye L, Elliott JH, Oldenburg B. Clinical and social determinants of diarrhoeal disease in a rural HIV/AIDS clinic, South Africa: a case-control study. Int J STD AIDS 2012; 23:346-50. [PMID: 22648889 PMCID: PMC3966081 DOI: 10.1258/ijsa.2011.011285] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [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] [Indexed: 11/18/2022]
Abstract
Diarrhoeal diseases are a common cause of morbidity and are associated with mortality in HIV-infected populations. Little is known about the contribution of clinical and socio-environmental factors to the risk of diarrhoea in these populations in rural sub-Saharan Africa. We conducted a case-control study of people attending a rural HIV clinic with an episode of diarrhoea in Bushbuckridge, South Africa. Cases were defined as HIV-positive adults with symptoms of diarrhoea before or after initiation of antiretroviral therapy (ART). Controls without diarrhoea were randomly selected from clinic attendees. Structured questionnaires and case-file reviews were undertaken to describe clinical and socioenvironmental risk factors. We recruited 103 cases of diarrhoea from 121 patients meeting case definitions. Cases were more likely to be women (P = 0.013), aged over 45 years (P = 0.002), divorced or separated (P = 0.006), have limited formal education (P = 0.003), have inadequate access to sanitation facilities (P = 0.045), have water access limited to less than three days per week (P = 0.032) and not yet initiated on ART (P < 0.001). In multivariate analysis, diarrhoea remained associated with female gender (adjusted odds ratio [aOR]: 2.02, 95% CI 1.10-3.73), older age (aOR: 6.31, 95% CI 1.50-26.50), limited access to water (aOR: 2.66, 95% CI 1.32-5.35) and pre-ART status (aOR: 5.87, 95% CI 3.05-11.27). Clinical and socio-environmental factors are associated with occurrence of diarrhoeal disease among rural HIV patients in South Africa. Further intervention research is urgently needed, combining community- and clinic-based approaches, to improve access to water, sanitation and ART for rural areas with high HIV prevalence, along with structural interventions to address gender inequities.
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Affiliation(s)
- M Moshabela
- Rural AIDS and Development Action Research (RADAR), School of Public Health, University of Witwatersrand, PO Box 02, Acornhoek, Mpumalanga 1360, South Africa.
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Sumatoh HR, Oliver BG, Kumar M, Elliott JH, Vonthanak S, Vun MC, Singh S, Agarwal U, Kumar A, Tan HY, Kamarulzaman A, Yunihastuti E, Saraswati H, Price P. Mycobacterial antibody levels and immune restoration disease in HIV patients treated in South East Asia. Biomark Med 2011; 5:847-53. [PMID: 22103621 DOI: 10.2217/bmm.11.79] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIM Immune restoration disease (IRD) associated with Mycobacterium tuberculosis parallels the reconstitution of a pathogen-specific Th1 response. However, it is not clear whether humoral responses to M. tuberculosis antigens also rise, or whether antibody levels predict IRD. Here, humoral immunity to M. tuberculosis antigens was investigated in four Asian cohorts. METHODS Plasma samples were obtained from longitudinal prospective studies of HIV patients beginning antiretroviral therapy (ART) in New Delhi (India), Kuala Lumpur (Malaysia), Jakarta (Indonesia) and Phnom Penh (Cambodia). IgG antibodies to purified protein derivative, lipoarabinomannan and 38-kDa antigens of M. tuberculosis were quantitated using in-house ELISAs. IRD was defined as exacerbated symptoms of tuberculosis in patients on anti-tuberculosis therapy or a novel presentation of tuberculosis on ART. RESULTS Pre-ART IgG levels to purified protein derivative, lipoarabinomannan and 38-kDa antigen were similar in the IRD and control groups from each site. Compared with non-IRD controls, a higher proportion of IRD patients had elevated IgG levels to lipoarabinomannan (defined as a greater than twofold increase) over 12 weeks of ART. However, this trend was not significant for the other antigens and longitudinal analyses did not reveal clear rises in antibody levels at the time of IRD. CONCLUSION Levels of antibody to mycobacterial antigens do not predict IRD, but levels of antibody reactive with lipoarabinomannan rise during an IRD in some patients.
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Affiliation(s)
- Hermi R Sumatoh
- School of Pathology & Laboratory Medicine, University of Western Australia, Perth, Australia
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Rotty J, Anderson D, Garcia M, Diaz J, Van de Waarsenburg S, Howard T, Dennison A, Lewin SR, Elliott JH, Hoy J. Preliminary assessment of Treponema pallidum-specific IgM antibody detection and a new rapid point-of-care assay for the diagnosis of syphilis in human immunodeficiency virus-1-infected patients. Int J STD AIDS 2011; 21:758-64. [PMID: 21187358 DOI: 10.1258/ijsa.2010.010237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aims of the study were to assess whether Treponema pallidum-specific IgM may provide a useful marker of infectious syphilis in human immunodeficiency virus (HIV)-infected patients, and to compare the performance of a prototype IgM-rapid point-of-care test (PoCT) with a standard IgM-enzyme immunoassay (EIA). Twenty samples from HIV-infected patients with untreated syphilis (n = 4 primary syphilis, n = 11 secondary and n = 5 early latent) and 51 follow-up samples at three, six or 12 months after treatment were tested for the presence of IgM with the Mercia-EIA (Microgen Bioproducts Ltd, Camberley, UK) and a prototype PoCT (Select Vaccines Ltd, Melbourne, Australia). Although sample numbers were small, IgM detection by EIA appears to be a reliable marker for untreated syphilis in HIV-infected patients with primary (4/4 IgM-positive) or secondary syphilis (10/11 IgM-positive, 1/11 equivocal). After treatment, IgM was no longer detected after three months in the majority of patients (87%) and was either negative or equivocal in all patients after six and 12 months. The overall sensitivity of the IgM-PoCT was 82% and varied with clinical stage, being highest in secondary (10/10 EIA positives) but lower in primary (2/4 EIA positives) and early latent syphilis (2/3 EIA positives). Overall specificity was 95%. Rapid detection of IgM would enable clinicians to distinguish between past-treated and infectious syphilis and allow for diagnosis and treatment in a single visit.
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Affiliation(s)
- J Rotty
- Infectious Diseases Unit, Alfred Hospital, Victoria 3181,Australia.
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Lewin SR, Evans VA, Elliott JH, Spire B, Chomont N. Finding a cure for HIV: will it ever be achievable? J Int AIDS Soc 2011; 14:4. [PMID: 21255462 PMCID: PMC3037295 DOI: 10.1186/1758-2652-14-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 01/24/2011] [Indexed: 12/03/2022] Open
Abstract
Combination antiretroviral therapy (cART) has led to a major reduction in HIV-related mortality and morbidity. However, HIV still cannot be cured. With the absence of an effective prophylactic or therapeutic vaccine, increasing numbers of infected people, emerging new toxicities secondary to cART and the need for life-long treatment, there is now a real urgency to find a cure for HIV. There are currently multiple barriers to curing HIV. The most significant barrier is the establishment of a latent or "silent" infection in resting CD4+ T cells. In latent HIV infection, the virus is able to integrate into the host cell genome, but does not proceed to active replication. As a consequence, antiviral agents, as well as the immune system, are unable to eliminate these long-lived, latently infected cells. Reactivation of latently infected resting CD4+ T cells can then re-establish infection once cART is stopped. Other significant barriers to cure include residual viral replication in patients receiving cART, even when the virus is not detectable by conventional assays. In addition, HIV can be sequestered in anatomical reservoirs, such as the brain, gastrointestinal tract and genitourinary tract. Achieving either a functional cure (long-term control of HIV in the absence of cART) or a sterilizing cure (elimination of all HIV-infected cells) remains a major challenge. Several studies have now demonstrated that treatment intensification appears to have little impact on latent reservoirs. Some potential and promising approaches that may reduce the latent reservoir include very early initiation of cART and the use of agents that could potentially reverse latent infection. Agents that reverse latent infection will promote viral production; however, simultaneous administration of cART will prevent subsequent rounds of viral replication. Such drugs as histone deacetylase inhibitors, currently used and licensed for the treatment of some cancers, or activating latently infected resting cells with cytokines, such as IL-7 or prostratin, show promising results in reversing latency in vitro when used either alone or in combination. In order to move forward toward clinical trials that target eradication, there needs to be careful consideration of the risks and benefits of these approaches, agreement on the most informative endpoints for eradication studies and greater engagement of the infected community.
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Affiliation(s)
- Sharon R Lewin
- Department of Medicine, Monash University, Melbourne, Australia.
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McMahon JH, Jordan MR, Kelley K, Bertagnolio S, Hong SY, Wanke CA, Lewin SR, Elliott JH. Pharmacy adherence measures to assess adherence to antiretroviral therapy: review of the literature and implications for treatment monitoring. Clin Infect Dis 2011; 52:493-506. [PMID: 21245156 DOI: 10.1093/cid/ciq167] [Citation(s) in RCA: 118] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Prescription or pill-based methods for estimating adherence to antiretroviral therapy (ART), pharmacy adherence measures (PAMs), are objective estimates calculated from routinely collected pharmacy data. We conducted a literature review to evaluate PAMs, including their association with virological and other clinical outcomes, their efficacy compared with other adherence measures, and factors to consider when selecting a PAM to monitor adherence. PAMs were classified into 3 categories: medication possession ratio (MPR), pill count (PC), and pill pick-up (PPU). Data exist to recommend PAMs over self-reported adherence. PAMs consistently predicted patient outcomes, but additional studies are needed to determine the most predictive PAM parameters. Current evidence suggests that shorter duration of adherence assessment (≤ 6 months) and use of PAMs to predict future outcomes may be less accurate. PAMs which incorporate the number of days for which ART was prescribed without the counting of remnant pills, are reasonable minimum-resource methods to assess adherence to ART.
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Affiliation(s)
- James H McMahon
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston MA, USA.
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Oliver BG, Elliott JH, Saphonn V, Vun MC, French MA, Price P. Interferon-γ and IL-5 production correlate directly in HIV patients co-infected with mycobacterium tuberculosis with or without immune restoration disease. AIDS Res Hum Retroviruses 2010; 26:1287-9. [PMID: 20860531 DOI: 10.1089/aid.2010.0004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IL-5 and interferon-γ responses were investigated in mitogen-stimulated whole-blood cultures from HIV patients with and without Mycobacterium tuberculosis disease, to determine whether an imbalance of Th1/Th2 cytokines contributes to susceptibility to M. tuberculosis disease or to immune restoration disease (IRD) associated with M. tuberculosis after starting antiretroviral therapy (ART). Interferon-γ levels were constant on ART, whilst IL-5 levels generally rose over time. We suggest that increased IL-5 production reflects a recovery of CD4(+) T cell function and that a Th1/Th2 imbalance is not associated with increased susceptibility to M. tuberculosis disease or IRD associated with M. tuberculosis upon starting ART.
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Affiliation(s)
- Benjamin G. Oliver
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
| | - Julian H. Elliott
- Alfred Hospital, Melbourne, Australia
- Burnet Institute, Melbourne, Australia
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia
| | - Vonthanak Saphonn
- National Centre for HIV/AIDS, Dermatology and STDs, Ministry of Health, Phnom Penh, Cambodia
- National Institute for Public Health, Phnom Penh, Cambodia
| | - Mean Chhi Vun
- National Centre for HIV/AIDS, Dermatology and STDs, Ministry of Health, Phnom Penh, Cambodia
| | - Martyn A. French
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
- Clinical Immunology and Immunogenetics, Royal Perth Hospital, Perth, Australia
| | - Patricia Price
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia
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Elliott JH, Vohith K, Saramony S, Savuth C, Dara C, Sarim C, Huffam S, Oelrichs R, Sophea P, Saphonn V, Kaldor J, Cooper DA, Chhi Vun M, French MA. Immunopathogenesis and diagnosis of tuberculosis and tuberculosis-associated immune reconstitution inflammatory syndrome during early antiretroviral therapy. J Infect Dis 2009; 200:1736-45. [PMID: 19874177 DOI: 10.1086/644784] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND In many settings, the benefits of antiretroviral therapy (ART) are reduced by the high early incidence of tuberculosis and tuberculosis-associated immune reconstitution inflammatory syndrome (TB-IRIS). METHODS We used tuberculin skin testing and the QuantiFERON-TB Gold In-Tube assay to investigate cellular immune responses to purified protein derivative (PPD) and region of difference 1 (RD1) antigens during the first 24 weeks of ART. RESULTS TB-IRIS and ART-associated tuberculosis occurred in 15 of 75 (20%) and 11 of 231 (4.8%) participants at risk, respectively. Greater increases in interferon gamma (IFN-gamma) and skin test responses to PPD were seen at week 24 and 12 in participants with TB-IRIS (P< or = .04), respectively. Raw IFN-gamma responses to RD1 antigens and PPD corrected for pre-ART CD4(+) T cell counts were higher at all time points in individuals with ART-associated tuberculosis (P<.001) and were associated with areas under receiver operator characteristic curves of 0.90 for RD1 (95% confidence interval [CI], 0.78-1.00) and 0.92 for PPD (95% CI, 0.83-1.00) for the diagnosis of ART-associated tuberculosis. Pre-ART IFN-gamma responses enabled stratification of participants into groups with risks of subsequent tuberculosis of 0.7%, 9.3%, and 30.0%. CONCLUSIONS Type 1 effector T cell responses are prominent in ART-associated tuberculosis, but additional immune defects may be more important in paradoxical TB-IRIS. IFN-gamma release assays may contribute to the prediction and diagnosis of tuberculosis during early ART.
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Affiliation(s)
- Julian H Elliott
- National Centre in HIV Epidemiology and Clinical Research, University of New South Wales, Sydney, Australia.
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Denholm JT, Yong MK, Elliott JH. Long term management of people with HIV. Aust Fam Physician 2009; 38:574-577. [PMID: 19893777] [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] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND Advances in the treatment of human immunodeficiency virus (HIV) have resulted in sustained improvements in the general health and longevity of people living with the virus. Primary care continues to be predominantly delivered by high caseload general practitioners and specialists, but GPs with limited HIV experience are increasingly likely to have contact with HIV positive patients through shared care arrangements. OBJECTIVE The aim of this article is to review the management of stable patients with HIV and to provide an approach to important elements of their ongoing care. DISCUSSION The long term care of people living with HIV is increasingly focused on chronic disease management and health promotion. Specific issues include mental health; drug and alcohol use; sexual and reproductive health; cardiovascular, renal, liver and bone disease; malignancies; and prevention, including immunisation. Treatment side effects such as lipodystrophy and peripheral neuropathy are less common with newer agents, but other toxicities are increasingly recognised. The majority of people living with HIV can be managed in the general practice setting, with specialist support where appropriate.
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Affiliation(s)
- Justin T Denholm
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Victoria.
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Abstract
Planning for programme sustainability is a key contributor to health and development, especially in low-income and middle-income countries. A consensus evidence-based operational framework would facilitate policy and research advances in understanding, measuring, and improving programme sustainability. We did a systematic review of both conceptual frameworks and empirical studies about health-programme sustainability. On the basis of the review, we propose that sustainable health programmes are regarded as complex systems that encompass programmes, health problems targeted by programmes, and programmes' drivers or key stakeholders, all of which interact dynamically within any given context. We show the usefulness of this approach with case studies drawn from the authors' experience.
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Affiliation(s)
- Russell L Gruen
- Department of Surgery, the Royal Melbourne Hospital and University of Melbourne, Melbourne, VIC, Australia
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Meintjes G, Lawn SD, Scano F, Maartens G, French MA, Worodria W, Elliott JH, Murdoch D, Wilkinson RJ, Seyler C, John L, van der Loeff MS, Reiss P, Lynen L, Janoff EN, Gilks C, Colebunders R. Tuberculosis-associated immune reconstitution inflammatory syndrome: case definitions for use in resource-limited settings. Lancet Infect Dis 2008; 8:516-23. [PMID: 18652998 DOI: 10.1016/s1473-3099(08)70184-1] [Citation(s) in RCA: 502] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The immune reconstitution inflammatory syndrome (IRIS) has emerged as an important early complication of antiretroviral therapy (ART) in resource-limited settings, especially in patients with tuberculosis. However, there are no consensus case definitions for IRIS or tuberculosis-associated IRIS. Moreover, previously proposed case definitions are not readily applicable in settings where laboratory resources are limited. As a result, existing studies on tuberculosis-associated IRIS have used a variety of non-standardised general case definitions. To rectify this problem, around 100 researchers, including microbiologists, immunologists, clinicians, epidemiologists, clinical trialists, and public-health specialists from 16 countries met in Kampala, Uganda, in November, 2006. At this meeting, consensus case definitions for paradoxical tuberculosis-associated IRIS, ART-associated tuberculosis, and unmasking tuberculosis-associated IRIS were derived, which can be used in high-income and resource-limited settings. It is envisaged that these definitions could be used by clinicians and researchers in a variety of settings to promote standardisation and comparability of data.
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Affiliation(s)
- Graeme Meintjes
- Institute of Infectious Diseases and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa
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Elliott JH, Anstey NM, Jacups SP, Fisher DA, Currie BJ. Community-acquired pneumonia in northern Australia: low mortality in a tropical region using locally-developed treatment guidelines. Int J Infect Dis 2005; 9:15-20. [PMID: 15603991 DOI: 10.1016/j.ijid.2004.09.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2003] [Revised: 07/25/2004] [Accepted: 09/08/2004] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To investigate the epidemiology and outcome of adult community-acquired pneumonia (CAP) in tropical Australia. METHODS A prospective study was performed of all adult patients with CAP admitted to the Royal Darwin Hospital, a major hospital in tropical northern Australia. A standard definition of CAP was used and data collected on demographics, risk factors, history, examination, investigations, treatment and outcome. Locally-developed treatment guidelines were used. RESULTS One hundred and sixty-seven adults were included in the analysis. Aboriginal people were over-represented, younger and were more likely to have risk factors for CAP. The most frequent pathogens isolated were Streptococcus pneumoniae and Burkholderia pseudomallei. 'Atypical pneumonia' organisms were uncommon. Treatment guidelines included penicillin for mild pneumonia but emphasised coverage of Burkholderia pseudomallei in those with risk factors, especially during the monsoon season. The mortality rate from pneumonia was low with three deaths in 167 cases (1.8%). CONCLUSIONS International guidelines for the management of CAP have been based on populations and organisms from temperate regions and may not necessarily be applicable to tropical regions. Guidelines based upon local epidemiology must therefore be developed. This study illustrates how mortality can be minimised using a process of determining local CAP etiology, developing treatment guidelines and auditing patient management.
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Affiliation(s)
- Julian H Elliott
- Royal Darwin Hospital and Northern Territory Clinical School, Flinders University, Darwin, Australia
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Ryan CE, Elliott JH, Middleton T, Mijch AM, Street AC, Hellard M, Crofts N, Crowe SM, Oelrichs RB. The molecular epidemiology of HIV type 1 among Vietnamese Australian injecting drug users in Melbourne, Australia. AIDS Res Hum Retroviruses 2004; 20:1364-7. [PMID: 15650430 DOI: 10.1089/aid.2004.20.1364] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The proportion of human immunodeficiency virus type 1 (HIV-1) among Vietnamese injecting drug users (IDUs) in Melbourne, Australia exceeds that of the background population. To investigate the molecular epidemiology of HIV-1 among this group, the C2-V4 region of the HIV-1 envelope was directly sequenced from 11 Vietnamese Australians and 19 non-Vietnamese Australian controls. A significant difference in the distribution of the HIV-1 subtypes was demonstrated, with greater than 50% of Vietnamese Australian IDU shown to be infected with CRF01_AE-the predominant subtype in Southeast Asia, rather than subtype B, which dominates the Australian epidemic and which was found in 89.5% of the non-Vietnamese controls. The genetic diversity of the CRF01_AE epidemic in Vietnamese Australian IDUs was substantially lower that that of the background subtype B, consistent with a more recent introduction of a limited number of viral strains from Vietnam. These results support public health policy targeting Australian IDUs of Vietnamese ethnicity as a distinct vulnerable population.
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Affiliation(s)
- Claire E Ryan
- The Macfarlane Burnet Institute for Medical Research and Public Health, Prahran, Victoria, Australia.
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Elliott JH, O'Brien D, Leder K, Kitchener S, Schwartz E, Weld L, Brown GV, Kain KC, Torresi J. Imported Plasmodium vivax malaria: demographic and clinical features in nonimmune travelers. J Travel Med 2004; 11:213-7. [PMID: 15541223 DOI: 10.2310/7060.2004.19004] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Imported malaria is an important problem in nonendemic countries due to increasing travel to and immigration from malaria-endemic countries. Plasmodium vivax malaria is relatively common in travelers but there are few published data regarding the outcome of P. vivax malaria in this group. METHODS We analyzed 209 cases of P. vivax malaria that were reported to the GeoSentinel network and the VIDS database, Royal Melbourne Hospital. Analyses were performed on data including demographics, pretravel encounter, antimalarial prophylaxis, exposure history, type of travel, countries of recent and past travel, clinical presentation, treatment, outcome and final diagnoses. RESULTS The majority of patients were travelers (61%), followed by expatriates (13%) and recent immigrants or foreign visitors (12%). Recent travel to Oceania, sub-Saharan Africa, and South and Central America was significantly more likely to be associated with P. vivax malaria than travel to all other regions. The clinical presentation of P. vivax malaria acquired in the Pacific region is indistinguishable from infection with P. falciparum. The use of chloroquine prophylaxis did not prolong the incubation period. Relapse of infection was not infrequent, and the only significant predictor of relapse was travel to Papua New Guinea (PNG), regardless of primaquine dose. Travelers returning from PNG were eight times more likely to relapse after primaquine treatment compared to travelers with P. vivax malaria acquired elsewhere. CONCLUSIONS We have presented details of the epidemiology, clinical presentation and management of infection with P. vivax malaria in travelers. P. vivax malaria is an important cause of morbidity in travelers, and relapse following primaquine treatment is especially problematic with P. vivax malaria acquired in PNG.
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Affiliation(s)
- Julian H Elliott
- Victorian Infectious Diseases Service, Royal Melbourne Hospital, Victoria, Australia
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