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Ahmed N, Flavell S, Ferns B, Frampton D, Edwards SG, Miller RF, Grant P, Nastouli E, Gupta RK. Development of the R263K Mutation to Dolutegravir in an HIV-1 Subtype D Virus Harboring 3 Class-Drug Resistance. Open Forum Infect Dis 2018; 6:ofy329. [PMID: 30648124 PMCID: PMC6329901 DOI: 10.1093/ofid/ofy329] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 12/09/2018] [Indexed: 11/14/2022] Open
Abstract
Dolutegravir (DTG), a second-generation integrase strand-transfer inhibitor (INSTI), is equivalent or superior to current non-nucleotide reverse transcriptase inhibitors (NNRTIs), protease inhibitors (PIs), and first-generation INSTI-based antiretroviral regimens (ARVs). It has the potential to make big improvements in HIV control globally and within patients. This is perhaps the most "precious" HIV drug available. The integrase mutation R263K has been observed in tissue culture experiments and in patients treated with dolutegravir monotherapy in clinical trials. Globally, adherence and monitoring may be less than optimal and therefore DTG resistance more common. This is particularly important in low-middle-income countries, where patients may remain on failing regimens for longer periods of time and accumulate drug resistance. Data on this mutation in non-subtype B infections do not exist. We describe the first report of the R263K integrase mutation in a dolutegravir-exposed subtype D-infected individual with vertically acquired HIV. We have used deep sequencing of longitudinal samples to highlight the change in resistance over time while on a failing regimen. The case highlights that poorly adherent patients should not be offered dolutegravir even as part of a combination regimen and that protease inhibitors should be used preferentially.
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Affiliation(s)
- N Ahmed
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - S Flavell
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - B Ferns
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - D Frampton
- Division of Infection and Immunity, University College London, London, United Kingdom
| | - S G Edwards
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - R F Miller
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom.,Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
| | - P Grant
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - E Nastouli
- Department of Clinical Virology, University College London Hospitals NHS Foundation Trust, London, United Kingdom.,Department of Population, Policy and Practice, UCL GOS Institute of Child Health, London, United Kingdom
| | - R K Gupta
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, United Kingdom.,Division of Infection and Immunity, University College London, London, United Kingdom
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2
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Jain L, Mackenzie S, Bomanji JB, Shortman R, Noursadeghi M, Edwards SG, Miller RF. 18F-Fluorodeoxyglucose positron emission tomography-computed tomography imaging in HIV-infected patients with lymphadenopathy, with or without fever and/or splenomegaly. Int J STD AIDS 2017; 29:691-694. [PMID: 29198183 DOI: 10.1177/0956462417745960] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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: 11/17/2022]
Abstract
We audited whether 18F-Fluorodeoxyglucose positron emission tomography-computed tomography (18FDG PET-CT) imaging could discriminate between different diagnoses in HIV-infected patients presenting with lymphadenopathy, with or without fever and/or splenomegaly. Maximum standardised uptake (SUVmax) values were similar in lymphoma and mycobacterial and fungal infections and were lower but similar in those with human herpesvirus (HHV) 8-associated disease and HIV-associated reactive lymphadenopathy. Nodal 18FDG avidity, with SUVmax ≥10, excluded diagnoses of HHV 8-associated disease and miscellaneous conditions, and HIV-associated reactive lymphadenopathy was additionally excluded in those who had undetectable plasma HIV viral loads. This audit suggests 18FDG PET-CT imaging did not permit discrimination between specific diagnoses but has utility in identifying lymph nodes with increased avidity that could be targeted for biopsy and in ruling out significant pathology.
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Affiliation(s)
- L Jain
- 1 Central and North West London NHS Foundation Trust, London, UK.,2 T8, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Mackenzie
- 1 Central and North West London NHS Foundation Trust, London, UK.,2 T8, University College London Hospitals NHS Foundation Trust, London, UK
| | - J B Bomanji
- 3 Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, University College London Hospitals NHS Foundation Trust, London, UK
| | - R Shortman
- 3 Institute of Nuclear Medicine, University College London Hospitals NHS Foundation Trust, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Noursadeghi
- 2 T8, University College London Hospitals NHS Foundation Trust, London, UK.,4 Division of Infection and Immunity, University College London, London, UK
| | - S G Edwards
- 1 Central and North West London NHS Foundation Trust, London, UK.,2 T8, University College London Hospitals NHS Foundation Trust, London, UK
| | - R F Miller
- 1 Central and North West London NHS Foundation Trust, London, UK.,2 T8, University College London Hospitals NHS Foundation Trust, London, UK.,5 Research Department of Infection and Population Health, Institute for Global Health, University College London, London, UK.,6 Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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3
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Imathiu SM, Ray RV, Back M, Hare MC, Edwards SG. Agronomic practices influence the infection of an oats cultivar with Fusarium langsethiae. ACTA ACUST UNITED AC 2017. [DOI: 10.1556/038.52.2017.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- S. M. Imathiu
- Faculty of Agriculture, Department of Food Science and Technology, Jomo Kenyatta University of Agriculture and Technology, P.O. Box 62000-00200 Nairobi, Kenya
| | - R. V. Ray
- School of Biosciences, University of Nottingham, LE12 5RD, UK
| | - M. Back
- Harper Adams University, Crop and Environment Sciences, TF10 8NB, UK
| | - M. C. Hare
- Harper Adams University, Crop and Environment Sciences, TF10 8NB, UK
| | - S. G. Edwards
- Harper Adams University, Crop and Environment Sciences, TF10 8NB, UK
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4
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Imathiu SM, Ray RV, Back M, Hare M, Edwards SG. In vitro growth characteristics of Fusarium langsethiae isolates recovered from oats and wheat grain in the UK. ACTA ACUST UNITED AC 2016. [DOI: 10.1556/038.51.2016.2.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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5
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Edwards SG, Grover D, Scott C, Tedder RS, Pillay D, Copas A, Miller RF. Cytomegalovirus viral load testing of blood using quantitative polymerase chain reaction in acutely unwell HIV-1-positive patients lacks diagnostic utility. Int J STD AIDS 2016; 18:321-3. [PMID: 17524192 DOI: 10.1258/095646207780749600] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 11/18/2022]
Abstract
We examined the usefulness of measuring cytomegalovirus (CMV) viral load (VL) in blood using quantitative polymerase chain reaction (qPCR) in establishing a diagnosis of CMV end-organ disease in consecutive unwell HIV-infected patients. The indication for testing for CMV, CD4 count, CMV VL and presence of CMV end-organ disease were abstracted from case-notes. During a 42-month period, 216 tests were performed in 181 patients; the majority (61%) had CD4 counts <100 cells/ μL. The prevalence of detectable CMV by qPCR was 43.5% (94/216) with a prevalence of CMV end-organ disease of 7.4% (16/216). Of patients with CMV detectable by qPCR, 72 % (50/69) had CD4 counts <100 cells/ μL. For patients with definite CMV end-organ disease, the positive predictive value of detectable CMV by qPCR was 10% (9/94), and the negative predictive value was 98% (119/122). In acutely unwell HIV-infected patients, detection of CMV by qPCR is a poor predictor of CMV end-organ disease.
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Affiliation(s)
- S G Edwards
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden Primary Care Trust, London WC1E 6JB, UK
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6
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Abstract
A 30-year-old HIV-infected intravenous drug user presented with sepsis, acute renal failure, oedema, proteinuria and iron deficiency anaemia. After extensive investigation, a diagnosis of reactive systemic AA (amyloid, serum amyloid A protein) amyloidosis was made on the basis of renal, gastric and duodenal biopsies.
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Affiliation(s)
- C Newey
- T8, University College London Hospitals, London NW1 2BU, UK
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7
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Fox-Lewis A, Brima N, Muniina P, Grant AD, Edwards SG, Miller RF, Pett SL. Tuberculosis screening in patients with HIV: An audit against UK national guidelines to assess current practice and the effectiveness of an electronic tuberculosis-screening prompt. Int J STD AIDS 2016; 27:901-5. [PMID: 26792282 DOI: 10.1177/0956462416628355] [Citation(s) in RCA: 8] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 12/29/2015] [Indexed: 11/17/2022]
Abstract
A retrospective clinical audit was performed to assess if the British HIV Association 2011 guidelines on routine screening for tuberculosis in HIV are being implemented in a large UK urban clinic, and if a tuberculosis-screening prompt on the electronic patient record for new attendees was effective. Of 4658 patients attending during the inclusion period, 385 were newly diagnosed first-time attendees and routine tuberculosis screening was recommended in 165. Of these, only 6.1% of patients had a completed tuberculosis screening prompt, and 12.1% underwent routine tuberculosis screening. This audit represents the first published UK data on routine screening rates for tuberculosis in HIV and demonstrates low rates of tuberculosis screening despite an electronic screening prompt designed to simplify adherence to the national guideline. Reasons why tuberculosis screening rates were low, and the prompt ineffective, are unclear. A national audit is ongoing, and we await the results to see if our data reflect a lack of routine tuberculosis screening in HIV-infected patients at a national level.
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Affiliation(s)
- A Fox-Lewis
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - N Brima
- Research Department of Infection and Population Health, University College London, London, UK
| | - P Muniina
- Research Department of Infection and Population Health, University College London, London, UK
| | - A D Grant
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - S G Edwards
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - R F Miller
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK Research Department of Infection and Population Health, University College London, London, UK Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - S L Pett
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK Research Department of Infection and Population Health, University College London, London, UK MRC Clinical Trials Unit at University College London, University College London, London, UK Kirby Institute, University of New South Wales, Sydney, NSW, Australia
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8
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Randall DW, Brima N, Walker D, Connolly J, Laing C, Copas AJ, Edwards SG, Batson S, Miller RF. Acute kidney injury among HIV-infected patients admitted to the intensive care unit. Int J STD AIDS 2014; 26:915-21. [PMID: 25411349 DOI: 10.1177/0956462414561034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/02/2014] [Indexed: 11/15/2022]
Abstract
We describe the incidence, associations and outcomes of acute kidney injury (AKI) among HIV-infected patients admitted to the intensive care unit (ICU). We retrospectively analysed 223 admissions to an inner-London, University-affiliated ICU between 1999 and 2012, and identified those with AKI and performed multivariate analysis to determine associations with AKI. Of all admissions, 66% were affected by AKI of any severity and 35% developed stage 3 AKI. In multivariate analysis, AKI was associated with chronic kidney disease (odds ratio [OR] = 3.19; p = 0.014), a previous AIDS-defining illness (OR = 1.93; p = 0.039) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score, (OR = 3.49; p = 0.018, if > 30). No associations were demonstrated with use of anti-retroviral medication (including tenofovir), or an individual's HIV viral load or CD4 count. AKI was associated with higher inpatient mortality and longer duration of ICU admission. Among patients with stage 3 AKI, only 41% were alive 90 days after ICU admission. Among survivors, 74% regained good renal function, the remainder were dependent on renal replacement therapy or were left with significant ongoing renal dysfunction. Of note, many patients had baseline serum creatinine concentrations well below published reference ranges. AKI among HIV-infected patients admitted to ICU carries a poor prognosis.
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Affiliation(s)
- D W Randall
- T8, University College Hospitals London NHS Foundation Trust, London UK
| | - N Brima
- Research Department of Infection and Population Health, University College London, London, UK
| | - D Walker
- Critical Care Unit, University College Hospitals London NHS Foundation Trust, London, UK
| | - J Connolly
- Centre for Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - C Laing
- Centre for Nephrology, Royal Free London NHS Foundation Trust, London, UK
| | - A J Copas
- Research Department of Infection and Population Health, University College London, London, UK
| | - S G Edwards
- T8, University College Hospitals London NHS Foundation Trust, London UK Camden Provider Services, Central & North West London NHS Foundation Trust, London, UK
| | - S Batson
- Critical Care Unit, University College Hospitals London NHS Foundation Trust, London, UK
| | - R F Miller
- T8, University College Hospitals London NHS Foundation Trust, London UK Research Department of Infection and Population Health, University College London, London, UK Camden Provider Services, Central & North West London NHS Foundation Trust, London, UK Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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9
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Nielsen LK, Cook DJ, Edwards SG, Ray RV. The prevalence and impact of Fusarium head blight pathogens and mycotoxins on malting barley quality in UK. Int J Food Microbiol 2014; 179:38-49. [PMID: 24727381 PMCID: PMC4018669 DOI: 10.1016/j.ijfoodmicro.2014.03.023] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [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] [Received: 12/19/2013] [Revised: 03/10/2014] [Accepted: 03/18/2014] [Indexed: 11/02/2022]
Abstract
Fusarium head blight (FHB) caused by Fusarium and Microdochium species can significantly affect the yield of barley grain as well as the quality and safety of malt and beer. The present study provides new knowledge on the impacts of the FHB pathogen complex on the malting and brewing quality parameters of naturally infected barley. Quantitative real-time PCR and liquid chromatography double mass spectrometry were used to quantify the predominant FHB pathogens and Fusarium mycotoxins, respectively, in commercially grown UK malting barley samples collected between 2007 and 2011. The predominant Fusarium species identified across the years were F. poae, F. tricinctum and F. avenaceum. Microdochium majus was the predominant Microdochium species in 2007, 2008, 2010 and 2011 whilst Microdochium nivale predominated in 2009. Deoxynivalenol and zearalenone quantified in samples collected between 2007 and 2009 were associated with F. graminearum and F. culmorum, whilst HT-2 and T-2, and nivalenol in samples collected between 2010 and 2011 correlated positively with F. langsethiae and F. poae, respectively. Analysis of the regional distribution and yearly variation in samples from 2010 to 2011 showed significant differences in the composition of the FHB species complex. In most regions (Scotland, the South and North of England) the harvest in 2010 had higher concentrations of Fusarium spp. than in 2011, although no significant difference was observed in the Midlands between the two years. Microdochium DNA was significantly higher in 2011 and in the North of England and Scotland compared to the South or Midlands regions. Pathogens of the FHB complex impacted negatively on grain yield and quality parameters. Thousand grain weight of malting barley was affected significantly by M. nivale and M. majus whilst specific weight correlated negatively with F. avenaceum and F. graminearum. To determine the impact of sub-acute infections of the identified Fusarium and Microdochium species on malting and brewing quality of naturally infected samples, selected malting barley cultivars (Optic, Quench and Tipple) were micromalted and subjected to malt and wort analysis of key quality parameters. F. poae and M. nivale decreased germinative energy and increased water sensitivity of barley. The fungal biomass of F. poae and F. langsethiae correlated with increased wort free amino nitrogen and with decreased extract of malt. DNA of M. nivale correlated with increased malt friability as well as decreased wort filtration volume. The findings of this study indicate that the impact of species such as the newly emerging F. langsethiae, as well as F. poae and the two non-toxigenic Microdochium species should be considered when evaluating the quality of malting barley.
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Affiliation(s)
- L K Nielsen
- Division of Plant and Crop Sciences, School of Biosciences, The University of Nottingham, Sutton Bonington, UK
| | - D J Cook
- Division of Food Science, School of Biosciences, The University of Nottingham, Sutton Bonington, UK
| | - S G Edwards
- Crop and Environment Sciences, Harper Adams University, Newport, UK
| | - R V Ray
- Division of Plant and Crop Sciences, School of Biosciences, The University of Nottingham, Sutton Bonington, UK.
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10
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Burns F, Edwards SG, Woods J, Haidari G, Calderon Y, Leider J, Morris S, Tobin R, Cartledge J, Brown M. Acceptability, feasibility and costs of universal offer of rapid point of care testing for HIV in an acute admissions unit: results of the RAPID project. HIV Med 2014; 14 Suppl 3:10-4. [PMID: 24033896 DOI: 10.1111/hiv.12056] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES UK guidance recommends that acute medical admissions are offered an HIV test. Our aim was to determine whether a dedicated staff member using a multimedia tool, a model found effective in the USA, is an acceptable, feasible, and cost-effective model when translated to a UK setting. METHODS Over 4 months in 2010, a health advisor (HA) approached 19-65-year-olds at a central London acute medical admissions unit and offered a rapid HIV point of care test (POCT) with the aid of an educational video. Feasibility and acceptability were assessed through surveys and uptake rates. Costs per case of HIV infection identified were established. RESULTS Of the 606 eligible people admitted during the pilot, 324 (53.5%) could not be approached or were individuals for whom testing was deemed inappropriate. In total, 23.0% of eligible admissions had an HIV POCT. Of the patients who watched the video and had not recently been tested for HIV, 93.6% (131 of 140) agreed to an HIV test; four further patients had an HIV test but did not watch the video. Three tests (2.2%; three of 135) were reactive and all were confirmed HIV positive on laboratory testing. HIV testing in this setting was felt to be appropriate by 97.5% of individuals. The cost per patient was £21, and the cost per case of HIV identified was £1083. CONCLUSIONS Universal POCT HIV testing in an acute medical setting, facilitated by an educational video and dedicated staff, appears acceptable, feasible, effective, and low cost. These findings support the recommendation of HIV testing for all medical admissions in high-prevalence settings, although with this model a significant proportion remained untested.
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Affiliation(s)
- F Burns
- Research Department of Infection & Population Health, University College London, London, UK
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11
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Nugent DB, Uthayakumar N, Ferrand RA, Edwards SG, Miller R, Benn P. Enhancing patient safety with an electronic results checking system in a large HIV outpatient service. Br J Hosp Med (Lond) 2013; 74:465-8. [PMID: 23958986 DOI: 10.12968/hmed.2013.74.8.465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To establish whether an automated electronic tracker system for reporting blood results would expedite clinician review of abnormal results in HIV-positive outpatients and to pilot the use of this system in routine clinical practice. SETTING An outpatient service in central London providing specialist HIV-related care to 3900 HIV positive patients. DESIGN A comparison of the time taken from sampling to identification and clinician review of abnormal blood results for biochemical tests between the original paper-based checking system and an automated electronic system during a 3-week pilot. RESULTS Of 513 patients undergoing one or more blood tests, 296 (57%) had one or more biochemical abnormalities identified by electronic checking system. Out of 371 biochemical abnormalities, 307 (82.7%) were identified simultaneously by the paper-based system. Of the 307, 33 (10.7%) were classified as urgent, 130 (42.3%) as non-urgent and 144 (46.9%) as not clinically significant. The median interval between sampling and receipt of results was 1 (interquartile range 1-2) vs 4 days ( interquartile range 3-5), P <0.0001; clinician review 3 (interquartile range 1-4) vs 3 days (interquartile range 3-6), P<0.037; and review of non-urgent abnormalities by the regular clinician 2 (interquartile range 1-4) vs 10 days ( interquartile range 9-12), P=0.136, for electronic and paper-based systems respectively. Seven (11%) of the missing paper-based system results were classified as urgent. The electronic system missed three abnormalities as a result of a software processing error which was subsequently corrected. CONCLUSIONS The electronic tracker system allows faster identification of biochemical abnormalities and allowed faster review of these results by clinicians. The pilot study allowed for a software error to be identified and corrected before full implementation. The system has since integrated successfully into routine clinical practice.
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Affiliation(s)
- D B Nugent
- Core Medical Trainee, UCLH and The Royal Free Hospital, London
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12
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Whitlock GG, Patel A, Edwards SG, Benn PD, Miller RF. The current system for prescribing antiretroviral therapy puts HIV-infected patients at risk of serious drug-drug interactions: is now the time for a paradigm shift in HIV care delivery? Clin Med (Lond) 2012; 12:300-1. [PMID: 22783792 PMCID: PMC4953504 DOI: 10.7861/clinmedicine.12-3-300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Snell L, Edwards SG, Benn PD. P20 Potential impact of updated UK guidelines for use of post exposure prophylaxis following sexual exposure in a London sexual health service. Br J Vener Dis 2012. [DOI: 10.1136/sextrans-2012-050601c.20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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14
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Allinson J, Topping W, Edwards SG, Miller RF. Sulphadiazine-induced obstructive renal failure complicating treatment of HIV-associated toxoplasmosis. Int J STD AIDS 2012; 23:210-2. [PMID: 22581877 DOI: 10.1258/ijsa.2009.009539] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [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
A patient with newly-diagnosed HIV infection and biopsy-proven cerebral toxoplasmosis was treated with sulphadiazine and pyrimethamine. Despite adequate hydration and daily examination of urine for sulphadiazine crystals obstructive uropathy due to bilateral ureteric stones with hydronephrosis occurred, resulting in rapid onset renal failure. Sulphadiazine was discontinued and clindamycin was substituted. With intravenous fluid hydration and bilateral nephrostomies the urolithiasis resolved. This case serves to remind clinicians of the need for vigilance when treating cerebral toxoplasmosis with sulphadiazine, in order to avoid this potentially serious complication of treatment.
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Affiliation(s)
- J Allinson
- T8, University College London Hospitals Foundation Trust, University College London, London, UK
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15
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Adlakha A, Pavlou M, Walker DA, Copas AJ, Dufty N, Batson S, Edwards SG, Singer M, Miller RF. Survival of HIV-infected patients admitted to the intensive care unit in the era of highly active antiretroviral therapy. Int J STD AIDS 2012; 22:498-504. [PMID: 21890545 DOI: 10.1258/ijsa.2011.010496] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [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
We retrospectively studied outcomes for HIV-infected patients admitted to the intensive care unit (ICU) between January 1999 and June 2009. Patient demographics, receipt of highly active antiretroviral therapy (HAART), reason for ICU admission and survival to ICU and hospital discharge were recorded. Comparison was made against outcomes for general medical patients contemporaneously admitted to the same ICU. One hundred and ninety-two HIV-infected patients had 222 ICU admissions; 116 patients required mechanical ventilation (MV) and 43 required renal replacement therapy. ICU admission was due to an HIV-associated diagnosis in 113 patients; 37 had Pneumocystis pneumonia. Survival to ICU discharge and hospital discharge for HIV-infected patients was 78% and 70%, respectively, and was 75% and 68% among 2065 general medical patients with 2274 ICU admissions; P = 0.452 and P = 0.458, respectively. HIV infection was newly diagnosed in 42 patients; their ICU and hospital survival was 69% and 57%, respectively. From multivariable analysis, factors associated with ICU survival were patient's age (odds ratio [OR] = 0.74 [95% confidence interval (CI) = 0.53-1.02] per 10-year increase), albumin (OR = 1.05 [1.00-1.09] per 1 g/dL increase), Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR = 0.55 [0.35-0.87] per 10 unit increase), receipt of HAART (OR = 2.44 [1.01-4.94]) and need for MV (OR = 0.14 [0.06-0.36]). In the era of HAART, HIV-infected patients should be offered ICU admission if it is likely to be of benefit.
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Affiliation(s)
- A Adlakha
- Critical Care Unit, University College London Hospitals, London, UK
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16
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Armstrong-James D, Copas AJ, Walzer PD, Edwards SG, Miller RF. A prognostic scoring tool for identification of patients at high and low risk of death from HIV-associated Pneumocystis jirovecii pneumonia. Int J STD AIDS 2011; 22:628-34. [DOI: 10.1258/ijsa.2011.011040] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [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
A prognostic scoring tool (PST) was created to aid prediction of outcome from HIV-associated Pneumocystis jirovecii pneumonia (PCP) using data obtained from 577 episodes of PCP among 540 patients presenting to a specialist HIV treatment centre in London, UK. It used risk factors identifiable at/soon after hospitalization, previously identified as being associated with mortality: repeat episode of PCP, patient's age, haemoglobin (Hb) and oxygen partial pressure (PaO2) on admission, presence of medical co-morbidity (Comorb) and of pulmonary Kaposi sarcoma (PKS). The derived PST was 25.5+(age in years/10) + 2 (if a repeat episode of PCP) + 3 (if Comorb present) + 4 (if PKS detected) – PaO2 (kPa) – Hb (g/dL), and produced scores that ranged between 0 and 19. Patients were divided into five groups according to their prognostic score: 0-3.9 = group 1 (0% mortality), 4-7.9 = group 2 (3% mortality), 8-10.9 = group 3 (9% mortality), 11-14.9 = group 4 (29% mortality) and ≥15 = group 5 (52% mortality). This PST facilitates rapid identification of patients early in their hospitalization who have mild or severe HIV-associated PCP and who are at high and low risk of in-hospital death from PCP. The PST may aid assessment of severity of illness and in directing treatment strategies, but requires validation in patient cohorts from other healthcare institutions.
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Affiliation(s)
- D Armstrong-James
- Section of Infectious Diseases and Immunity, Imperial College London
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine
| | - A J Copas
- Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Division of Population Health, University College London, London, UK
| | - P D Walzer
- Research Service, Veterans Affairs Medical Center
- Division of Infectious Diseases. Department of Internal Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - S G Edwards
- Department of Genitourinary Medicine, Mortimer Market Centre. Camden Provider Services NHS Trust, London, UK
| | - R F Miller
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine
- Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Division of Population Health, University College London, London, UK
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Sayer R, Paul J, Tuke PW, Hargreaves S, Noursadeghi M, Tedder RS, Grant P, Edwards SG, Miller RF. Can plasma HHV8 viral load be used to differentiate multicentric Castleman disease from Kaposi sarcoma? Int J STD AIDS 2011; 22:585-9. [DOI: 10.1258/ijsa.2011.010464] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We measured plasma human herpesvirus 8 (HHV8) DNA load in consecutive patients presenting with HIV-associated multicentric Castleman disease (MCD) and in contemporaneous patients who had Kaposi sarcoma (KS), lymphoma or other diagnoses. All 11 patients with MCD had detectable plasma HHV8 DNA compared with 18 (72%) of 25 patients with KS, none with lymphoma and one of 38 patients with other diagnoses. Detectable plasma HHV8 DNA levels were higher among MCD patients, median (interquartile range [IQR]) = 43,500 (5200–150,000) copies/mL, when compared with those with KS, median (IQR) = 320 (167–822) copies/mL and those with lymphoma and other diagnoses (one-way analysis of variance; P = 0.0303). Using receiver operating characteristic analysis, a cut-off of >1000 copies HHV8 DNA/mL of plasma helped to discriminate between MCD and other diagnoses, with a specificity of 94.7% and a negative predictive value of 97.3%. The level of HHV8 viraemia, while not diagnostic, may aid discrimination between patients with MCD and those with KS and other systemic illnesses.
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Affiliation(s)
- R Sayer
- Mortimer Market Centre, Camden Provider Services
- T8, University College London Hospitals NHS Trust
| | - J Paul
- Department of Virology, University College London Hospitals
| | - P W Tuke
- Blood Borne Viruses Unit, Virus Reference Department, Centre for Infections, Health Protection Agency
| | - S Hargreaves
- Mortimer Market Centre, Camden Provider Services
| | - M Noursadeghi
- T8, University College London Hospitals NHS Trust
- Division of Infection and Immunity
| | - R S Tedder
- Blood Borne Viruses Unit, Virus Reference Department, Centre for Infections, Health Protection Agency
| | - P Grant
- Department of Virology, University College London Hospitals
| | - S G Edwards
- Mortimer Market Centre, Camden Provider Services
- T8, University College London Hospitals NHS Trust
| | - R F Miller
- Mortimer Market Centre, Camden Provider Services
- T8, University College London Hospitals NHS Trust
- Research Department of Infection and Population Health, Division of Population Health, University CollegeLondon
- Department of Clinical Research, Faculty of Infections and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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18
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Abstract
The British HIV Association (BHIVA) recommends that specialist clinical networks are involved in care of HIV-positive patients admitted to district general hospitals (DGHs) and that transfer to a specialist HIV treatment centre is considered for each patient. We audited our experience of 29 patients transferred to our specialist inpatient unit over a two year period. Fifteen (52%) patients were known to be HIV-infected before admission to the referring hospital. Ten (71%) of 14 patients with newly diagnosed HIV had an opportunistic infection at transfer. At the referring hospital the time taken to diagnose HIV infection ranged from one to 26 days (median = 3.5). Only five patients (17%) were transferred by 72 hours of admission to the referring hospital. The duration of stay at our centre was 1–212 days (median = 15): seven patients (24%) required admission to the intensive care unit. Seven patients died; of these, three had newly diagnosed HIV infection. This audit demonstrates that sick HIV-infected patients transferred to a specialist HIV unit had a poor outcome and lengthy hospital admissions. Our audit supports roll-out of HIV testing to avoid adverse outcomes associated with late diagnosis and development of clinical networks involving specialist HIV treatment centres in order to support provision of HIV care in DGHs.
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Affiliation(s)
| | - S G Edwards
- University College London Hospitals
- Mortimer Market Centre, Camden Provider Services PCT
| | - J D Cartledge
- University College London Hospitals
- Mortimer Market Centre, Camden Provider Services PCT
| | - R F Miller
- University College London Hospitals
- Mortimer Market Centre, Camden Provider Services PCT
- Centre for Sexual Health and HIV Research, University College London, London, UK
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19
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Miller RF, Evans HER, Copas AJ, Huggett JF, Edwards SG, Walzer PD. Seasonal variation in mortality of Pneumocystis jirovecii pneumonia in HIV-infected patients. Int J STD AIDS 2011; 21:497-503. [PMID: 20852200 DOI: 10.1258/ijsa.2010.010148] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A seasonal variation in the presentation of Pneumocystis jirovecii pneumonia (PCP) has been reported and a previous study from this centre noted a seasonal variation in mortality rates. This study examined seasonal influences (including climatic factors) within-host factors (clinical and laboratory-derived variables), the infectious burden of P. jirovecii in bronchoalveolar lavage (BAL) fluid, the presence of dihydropteroate synthase (DHPS) mutations in P. jirovecii, variations in knowledge and skills of junior medical staff, and mortality in 547 episodes of PCP occurring in 494 HIV-infected patients. The overall mortality rate was 13.5%. There was a seasonal variation in mortality: highest in autumn (21.2%) and lowest in spring (9.7%), P = 0.047. After adjustment was made for prognostic factors previously identified as being associated with mortality (increasing patient age, second/third episode of PCP, low haemoglobin, low PaO(2), presence of medical co-morbidity and pulmonary Kaposi sarcoma), there was no seasonal association with mortality, P = 0.249. The quantity of P. jirovecii DNA in BAL fluid showed no evidence of seasonal variation, P = 0.67; DHPS mutations were identified with equal frequency in each season and the mortality rate for February and August (when junior medical staff arrive in new posts) was 16.7%, only slightly greater than for other months (13.0%).
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Affiliation(s)
- R F Miller
- Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, Division of Population Health, University College London, UK.
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20
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Abstract
The purposes of this study were to define the range of laxity of the interosseous ligaments in cadaveric wrists and to determine whether this correlated with age, the morphology of the lunate, the scapholunate (SL) gap or the SL angle. We evaluated 83 fresh-frozen cadaveric wrists and recorded the SL gap and SL angle. Standard arthroscopy of the wrist was then performed and the grades of laxity of the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) and the morphology of the lunate were recorded. Arthroscopic evaluation of the SLIL revealed four (5%) grade I specimens, 28 (34%) grade II, 40 (48%) grade III and 11 (13%) grade IV. Evaluation of the LTIL showed 17 (20%) grade I specimens, 40 (48%) grade II, 28 (30%) grade III and one (1%) grade IV. On both bivariate and multivariate analysis, the grade of both the SLIL and LTIL increased with age, but decreased with female gender. The grades of SLIL or LTIL did not correlate with the morphology of the lunate, the SL gap or the SL angle. The physiological range of laxity at the SL and lunotriquetral joints is wider than originally described. The intercarpal ligaments demonstrate an age-related progression of laxity of the SL and lunotriquetral joints. There is no correlation between the grades of laxity of the SLIL or LTIL and the morphology of the lunate, the SL gap or the SL grade. Based on our results, we believe that the Geissler classification has a role in describing intercarpal laxity, but if used alone it cannot adequately diagnose pathological instability. We suggest a modified classification with a mechanism that may distinguish physiological laxity from pathological instability.
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Affiliation(s)
- T R Rimington
- Department of Orthopaedic Surgery, Georgetown University Hospital, 3800 Reservoir Road, 1 Main West, Washington, DC 20007, USA
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21
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Armstrong-James D, Copas AJ, Walzer PD, Edwards SG, Miller RF. S129 Predicting outcome from HIV-associated pneumocystis pneumonia. Thorax 2010. [DOI: 10.1136/thx.2010.150946.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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22
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Adlakha AG, Pavlou M, Walker D, Copas AJ, Batson S, Edwards SG, Singer M, Miller RF. S82 Survival of HIV-infected patients admitted to the intensive care unit. Thorax 2010. [DOI: 10.1136/thx.2010.150938.33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Sage EK, Noursadeghi M, Evans HE, Parker SJ, Copas AJ, Edwards SG, Miller RF. Prognostic value of C-reactive protein in HIV-infected patients with Pneumocystis jirovecii pneumonia. Int J STD AIDS 2010; 21:288-92. [PMID: 20378904 DOI: 10.1258/ijsa.2010.009551] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [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
C-reactive protein (CRP) is a sensitive marker of inflammation and tissue damage. We aimed to describe CRP responses in HIV-infected patients presenting with Pneumocystis pneumonia (PCP), bacterial pneumonia (BP) and pulmonary tuberculosis (TB) and, in patients with PCP, to identify if elevated CRP has prognostic significance. Data obtained by case-note review of consecutive HIV-infected adults with acute respiratory episodes included admission CRP (elevated >5 mg/L), haemoglobin, white blood count, CD4 count and partial pressure of oxygen in the blood (PaO(2)), presence of pulmonary co-pathology/intercurrent infection and outcome (survival). Median (range) CRP in patients with BP = 120 mg/L (<5-620 mg/L), TB = 44 mg/L (<5-256.3 mg/L) and PCP = 35 mg/L (<5-254 mg/L). CRP was elevated in 93/103 (90.3%) patients with PCP; six patients died; and all had an elevated CRP. PaO(2) and CRP values were associated as follows: average CRP levels declined by 10% (95% confidence interval [CI] 0.20%) per kPa increase in PaO(2) = 0.002. Factors associated with death were higher CRP, odds ratio (OR) (95% CI) = 5.30 (1.61 to 17.51) per 100 mg/L increase, P = 0.006 and haemoglobin, OR (95% CI) = 0.52 (0.29 to 0.93) per g/dL, P = 0.033. CRP is elevated in the majority of HIV-infected patients with PCP, BP and TB. Admission CRP measurement lacks specificity, but in PCP elevations of CRP are associated with disease severity (PaO(2)) and poor outcome and might be used prognostically, together with other mortality risk factors; further prospective evaluation is needed.
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Affiliation(s)
- E K Sage
- University College London Hospitals NHS Trust, UK
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24
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Abstract
Every year between 2002 and 2005 approximately 100 samples of oats from fields of known agronomy were analysed by GC/MS for 10 trichothecenes: deoxynivalenol (DON), nivalenol, 3-acetylDON, 15-acetylDON, fusarenone X, T-2 toxin (T2), HT-2 toxin (HT2), diacetoxyscirpenol, neosolaniol and T-2 triol. Samples were also analysed for moniliformin and zearalenone by HPLC. Of the 10 trichothecenes analysed from 458 harvest samples of oat only three, 15-acetylDON, fusarenone X and diacetoxyscirpenol, were not detected. Moniliformin and zearalenone were absent or rarely detected, respectively. HT2 and T2 were the most frequently detected fusarium mycotoxins, present above the limit of quantification (10 microg kg(-1)) in 92 and 84% of samples, respectively, and were usually present at the highest concentrations. The combined mean and median for HT2 and T2 (HT2 + T2) was 570 and 213 microg kg(-1), respectively. There were good correlations between concentrations of HT2 and all other type A trichothecenes detected (T2, T2 triol and neosolaniol). Year and region had a significant effect on HT2 + T2 concentration. There was also a highly significant difference between HT2 + T2 content in organic and conventional samples, with the predicted mean for organic samples five times lower than that of conventional samples. This is the largest difference reported for any mycotoxin level in organic and conventional cereals. No samples exceeded the legal limits for DON or zearalenone in oats intended for human consumption. Legislative limits for HT2 and T2 are currently under consideration by the European Commission. Depending on the limits set for unprocessed oats intended for human consumption, the levels detected here could have serious consequences for the UK oat-processing industry.
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Affiliation(s)
- S G Edwards
- Crop and Environment Research Centre, Harper Adams University College, Newport, Shropshire, UK.
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25
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Wilson AJ, Sayer RA, Edwards SG, Cartledge JD, Miller RF. A comparison of computed tomography and magnetic resonance brain imaging in HIV-positive patients with neurological symptoms. Int J STD AIDS 2010; 21:198-201. [DOI: 10.1258/ijsa.2009.009323] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [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
We reviewed our practice in order to determine the optimum neuroimaging strategy for HIV-infected patients with acute neurological presentations between April 2007 and August 2008. Overall magnetic resonance imaging (MRI) detected cranial abnormalities in more than twice as many patients as did computed tomography (CT) (74% and 32%, n = 54 and 38, respectively). Replacement of CT by first-line MRI for all patients would have required an additional 16 MRI scans, although at a saving of 38 CT scans. Our study highlights the importance of first-line MRI brain imaging in HIV patients with neurological symptoms and reinforces the need for early transfer of patients from centres that do not have rapid access to (or expert interpretation of) MRI scanning, to an appropriate HIV specialist centre.
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Affiliation(s)
- A J Wilson
- T8, University College London Hospitals, London NW1 8BU
- Centre for Sexual Health and HIV Research, University College London, London WC1E 6JB
| | - R A Sayer
- T8, University College London Hospitals, London NW1 8BU
- Mortimer Market Centre, Camden Provider Services PCT, London WC1E 6JB, UK
| | - S G Edwards
- T8, University College London Hospitals, London NW1 8BU
- Mortimer Market Centre, Camden Provider Services PCT, London WC1E 6JB, UK
| | - J D Cartledge
- T8, University College London Hospitals, London NW1 8BU
- Mortimer Market Centre, Camden Provider Services PCT, London WC1E 6JB, UK
| | - R F Miller
- T8, University College London Hospitals, London NW1 8BU
- Centre for Sexual Health and HIV Research, University College London, London WC1E 6JB
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Harte D, Dosekun O, Sethi G, Chadborn T, de Ruiter A, Copas A, Edwards SG, Miller RF. Immunosuppression among HIV-1-positive patients attending for care: experience from two large HIV centres in the United Kingdom. HIV Med 2010; 11:114-20. [DOI: 10.1111/j.1468-1293.2009.00753.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
A retrospective case-notes audit of 359 HIV-1-infected adult patients with first-episode laboratory-confirmed Pneumocystis jirovecii pneumonia treated with co-trimoxazole (from 1987 adjuvant steroids were used if PaO2 <9.3 kPa) showed that only 230/359 (64%) patients completed treatment; 104 (29%) patients had treatment-limiting toxicity; rash occurred in 4/60 (6.7%) patients in 1985–1988 and in 15/47 (31.9%) in 2005–2008. Twenty-five patients (7%) failed co-trimoxazole treatment. Overall mortality was 13.6% (49/359); mortality among patients who failed co-trimoxazole treatment was 48% (12/25) and by contrast mortality was 4.8% (5/104) among patients with treatment-limiting toxicity.
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Affiliation(s)
- M Fisk
- Department of Genitourinary Medicine, Camden Provider Services PCT, Mortimer Market Centre, London WC1E 6JB
- T8, University College London Hospitals, London NW1 8BU
| | - E K Sage
- T8, University College London Hospitals, London NW1 8BU
| | - S G Edwards
- Department of Genitourinary Medicine, Camden Provider Services PCT, Mortimer Market Centre, London WC1E 6JB
| | - J D Cartledge
- Department of Genitourinary Medicine, Camden Provider Services PCT, Mortimer Market Centre, London WC1E 6JB
- T8, University College London Hospitals, London NW1 8BU
| | - R F Miller
- T8, University College London Hospitals, London NW1 8BU
- Department of Infection and Population Health, University College London Medical School, University College London, London W1E 6JB, UK
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28
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Abstract
Patients with HIV are dying due to late diagnosis and physicians are being encouraged to increase HIV testing. The uptake of opt-in HIV screening for 113 lymphoma patients was audited at University College London Hospital. Of the 113 patients, 46 were not tested (41%). Previous research in the antenatal setting suggests that adopting opt-out screening would increase testing rates.
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Affiliation(s)
- J Cave
- University College London Hospitals
| | | | | | | | - SM Lee
- University College London Hospitals
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29
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Abstract
OBJECTIVES The aims of the study were to describe the clinical presentation and renal and bone abnormalities in a case series of HIV-infected patients receiving treatment with tenofovir (TDF), and to recommend appropriate screening for toxicity related to TDF. METHODS Patients were identified from referrals to a specialist HIV renal clinic. Patients were included if treatment with TDF was assessed as the primary cause of the renal function impairment and clinical data were available prior to and following discontinuation of TDF treatment. Data were collected from case note review and clinic databases. RESULTS Twenty-two patients (1.6% of all those who received TDF) were identified with TDF-associated renal toxicity. All had normal serum creatinine prior to TDF therapy. All presented with proteinuria. On stopping TDF, renal function improved. Eight patients had confirmed Fanconi syndrome. Twelve patients presented with bone pain and osteomalacia was confirmed on an isotope bone scan in seven of these patients. The findings (in those patients tested) of tubular proteinuria, reduced tubular transport maximum of phosphate (TmP), and glycosuria were all consistent with the proximal tubule being the site of toxicity. CONCLUSION Renal toxicity remains a concern in patients treated with TDF. Clinical presentation may be with renal dysfunction, Fanconi syndrome or osteomalacia. Our investigations suggest proximal tubular toxicity as a common pathogenic mechanism.
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Benn P, Sauret-Jackson V, Cartledge J, Ruff C, Sabin CA, Moyle G, Linney A, Reilly G, Edwards SG. Improvements in cheek volume in lipoatrophic individuals switching away from thymidine nucleoside reverse transcriptase inhibitors. HIV Med 2009; 10:351-5. [PMID: 19490181 DOI: 10.1111/j.1468-1293.2009.00694.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Thymidine nucleoside reverse transcriptase inhibitors (NRTIs) are associated with subcutaneous fat loss. Facial changes cannot be assessed by dual-energy X-ray absorptiometry (DEXA) scans. There are limited objective data on the reversibility of facial lipoatrophy. METHODS We performed a facial volume substudy of a randomized thymidine NRTI replacement study carried out in HIV-infected subjects with moderate to severe lipoatrophy. Facial volume changes were assessed using validated 3D laser imaging. Changes in body composition were measured using DEXA scans. The association between changes in facial volume and body composition parameters at 48 weeks was measured using Spearman's rank correlation. RESULTS Forty-seven individuals (46 male), 11 receiving zidovudine and 36 receiving stavudine, switched to either tenofovir disoproxil fumarate (DF) (n=23) or abacavir (ABC) (n=24). Thirty-nine of these 47 patients (84.8%) reported facial lipoatrophy at baseline. The median volume increase in both cheeks from baseline was 1857.3 mm(3). These volume changes and increases in limb fat at 48 weeks were similar in the two groups and correlated significantly (Spearman's r=0.41, P=0.004). CONCLUSIONS Facial volume in lipoatrophic individuals was found to increase after thymidine NRTI replacement. We demonstrated a significant correlation between improvements in facial and limb fat parameters. Switching from thymidine NRTIs in patients with facial lipoatrophy could potentially reduce the need for cosmetic interventions.
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Affiliation(s)
- P Benn
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, Off Capper Street, London WC1E 6JB, UK.
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31
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Benn PD, Miller RF, Evans L, Minton J, Edwards SG. Devolving of statin prescribing to general practitioners for HIV-infected patients receiving antiretroviral therapy. Int J STD AIDS 2009; 20:202-4. [DOI: 10.1258/ijsa.2008.008273] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Summary Serious adverse events and medication errors are common in clinical practice and are associated with significant morbidity and mortality. Management of HIV-positive patients is likely to become more complex as people age, developing multiple medical conditions and thus requiring polypharmacy. We undertook a casenote review and interview of patients on antiretroviral therapy (ART) to audit the safety of devolving statin prescribing to general practitioners (GPs). Of 26 patients only 50% had their statin prescribing successfully been devolved to GPs. Many experienced significant difficulties and two of 26 (8%) were switched to simvastatin while receiving a protease inhibitor. We demonstrate that prescribing ART and non-ART medication by different practitioners on different sites can potentially expose patients to serious life-threatening adverse events. We make recommendations to minimize these risks and suggest that care pathways are reviewed to ensure they remain both convenient and user-friendly without compromising patient safety.
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Affiliation(s)
- P D Benn
- Department of Genitourinary Medicine, Camden PCT, The Mortimer Market Centre, Off Capper Street, London WC1E 6JB
| | - R F Miller
- Centre for Sexual Health and HIV Research, Royal Free and University College Medical School, University College London, London
| | - L Evans
- Department of Genitourinary Medicine, Camden PCT, The Mortimer Market Centre, Off Capper Street, London WC1E 6JB
| | - J Minton
- University College Hospitals NHS Foundation Trust, London, UK
| | - S G Edwards
- Department of Genitourinary Medicine, Camden PCT, The Mortimer Market Centre, Off Capper Street, London WC1E 6JB
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Chilton D, Edwards SG, Pellegrino P, Miller RF. Factors influencing delay in initiating antiretroviral therapy among HIV infected patients coinfected with tuberculosis. Thorax 2008; 63:935-6. [PMID: 18820121 DOI: 10.1136/thx.2008.104232] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Forsyth SF, Agogo EA, Dipgum LL, Jungmann E, Man S, Edwards SG, Robinson AJ. Would offering rapid point-of-care testing or non-invasive methods improve uptake of HIV testing among high-risk genitourinary medicine clinic attendees? A patient perspective. Int J STD AIDS 2008; 19:550-2. [DOI: 10.1258/ijsa.2008.008141] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
While most genitourinary (GU) medicine clinics achieve a high uptake for testing HIV in new patients, they may still miss testing those at highest risk. Point-of-care testing (POCT) and salivary samples are acceptable and feasible but have not yet been shown to increase uptake among high-risk patients (HRP). This study aimed to describe reasons why HRP decline HIV testing and whether offering POCT along with standard testing would increase the uptake of testing HIV in two London GU medicine clinics. Anonymous self-administered questionnaires were offered to all new and rebooked patients. Eight hundred and ninety-nine questionnaires were analysed of which 598 were HRP. Uptake of HIV testing was 77.1 % among HRP and 65.8% among the rest. A total of 51.1 % of HRP who declined HIV testing said they would be more likely to accept a POCT and 32.8% a salivary test. Introduction of rapid POCT for HIV would increase patient's choice and may increase the likelihood of HRP accepting an HIV test.
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Affiliation(s)
- S F Forsyth
- Mortimer Market Centre, off Capper Street, London WC1E 6AU
| | - E A Agogo
- Mortimer Market Centre, off Capper Street, London WC1E 6AU
| | - L Lau Dipgum
- Mortimer Market Centre, off Capper Street, London WC1E 6AU
| | | | - S Man
- UCL Centre for Sexual Health and HIV Research, London UK
| | - S G Edwards
- Mortimer Market Centre, off Capper Street, London WC1E 6AU
| | - A J Robinson
- Mortimer Market Centre, off Capper Street, London WC1E 6AU
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Lowe SM, Kocjan GI, Edwards SG, Miller RF. Diagnostic yield of fine-needle aspiration cytology in HIV-infected patients with lymphadenopathy in the era of highly active antiretroviral therapy. Int J STD AIDS 2008; 19:553-6. [DOI: 10.1258/ijsa.2008.008074] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [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
Fine-needle aspiration (FNA) cytology has an established role in the investigation of lymphadenopathy in HIV-infected patients. However, changes in the spectrum of disease have been observed since the introduction of highly active antiretroviral therapy (HAART). The aim of the study was to establish whether FNA cytology remains a useful investigative tool in the post-HAART era and to determine whether the cytology results reflect the changing patterns of disease. Retrospective search of the cytopathology database at University College London Hospitals identified 73 FNA cytology procedures performed in 62 patients between January 1998 and December 2006. FNA cytology showed significant disease in 90% of adequate samples. The most common diagnoses were persistent generalized lymphadenopathy (PGL, 50%), infection (22%) and malignancy (18%). Diagnoses could not be made in 31 % of patients because of inadequate sampling. An open lymph node biopsy was subsequently performed in 27% of patients. FNA cytology remains an important initial investigation in the post-HAART era, particularly in the diagnosis of PGL, infection and malignancy. Difficulties in diagnosis of Castleman disease and Hodgkin's lymphoma by FNA cytology are recognized.
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Affiliation(s)
- S M Lowe
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, London WC1E 6JB
| | - G I Kocjan
- Department of Histopathology, University College London Hospitals Foundation Trust, London WC1E 6JJ
| | - S G Edwards
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, London WC1E 6JB
| | - R F Miller
- Centre for Sexual Health and HIV Research, Department of Population Sciences and Primary Care, University College London, Mortimer Market Centre, London WC1E 6JB, UK
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Harte D, Hamill M, Edwards SG, Copas AJ, Minton J, Jones VL, Allason-Jones E, Williams IG, Miller RF. Evaluation of a home-delivery service for HIV-infected patients attending an inner London HIV treatment centre. Int J STD AIDS 2008; 19:533-5. [DOI: 10.1258/ijsa.2007.007311] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Home delivery (HD) of medication is a goal of the Department of Health's Pharmacy in the Future; Implementing the NHS Plan. We evaluated the safety and effectiveness of an HD service for antiretroviral therapy (ART). Patients on ART with stable viral load (VL) <50 were identified. Comparison was made between patients using HD and those using the clinic-based pharmacy (CP). The primary endpoint was HIV virological failure (VF) (HIV VL >400 copies/mL on two consecutive occasions). Secondary endpoints included frequency of outpatient attendances (OPA) and an incidence of adverse events. Cumulative incidences (Culmln) for each outcome event were calculated. Incidence-rate ratios (IRR) were obtained using Poisson regression. Of 1663 patients identified; 450 received HD and 1213 used CP. Culmln of VF was =4% in those using HD and =7% in those using CP (IRR [95% confidence intervals, CI] =0.53, 0.32-0.90). HD patients had fewer OPA, less frequent blood test monitoring and less frequent abnormal liver function results (IRR [95% Cl]= 0.63 [0.59-0.67] and 0.59 [0.53-0.67], 0.68 [0.65-0.71] and 0.64 [0.53-0.78], respectively). Patients deemed stable enough on social, psychological and medical grounds to receive HD of ART had a lower risk of VF, fewer OPA and no increase in adverse events when compared with patients using CP.
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Affiliation(s)
- D Harte
- The Mortimer Market Centre, Department of Genitourinary Medicine, Camden PCT, London
| | - M Hamill
- The Mortimer Market Centre, Department of Genitourinary Medicine, Camden PCT, London
| | - S G Edwards
- The Mortimer Market Centre, Department of Genitourinary Medicine, Camden PCT, London
| | - A J Copas
- Centre for Sexual Health and HIV Research. Department of Population Sciences and Primary Care, University College London, The Mortimer Market Centre, London WC1E 6JB
| | - J Minton
- Pharmacy Services, University College London Hospitals NHS Foundation Trust, London NW1 2BU, UK
| | - V L Jones
- Centre for Sexual Health and HIV Research. Department of Population Sciences and Primary Care, University College London, The Mortimer Market Centre, London WC1E 6JB
| | - E Allason-Jones
- The Mortimer Market Centre, Department of Genitourinary Medicine, Camden PCT, London
| | - I G Williams
- Centre for Sexual Health and HIV Research. Department of Population Sciences and Primary Care, University College London, The Mortimer Market Centre, London WC1E 6JB
| | - R F Miller
- Centre for Sexual Health and HIV Research. Department of Population Sciences and Primary Care, University College London, The Mortimer Market Centre, London WC1E 6JB
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Roedling S, Reeves I, Copas AJ, Beattie A, Edwards SG, Fisher M, Benn P. Changes in the provision of post-exposure prophylaxis for HIV after sexual exposure following introduction of guidelines and publicity campaigns. Int J STD AIDS 2008; 19:241-2. [DOI: 10.1258/ijsa.2007.007216] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In July 2004, British Association of Sexual Health and HIV (BASHH) published guidelines for post-exposure prophylaxis following sexual exposure (PEPSE) and the Terence Higgins Trust (THT) launched a campaign promoting PEPSE among men who have sex with men (MSM). We evaluated subsequent changes in PEPSE attendances. Individuals requesting PEPSE in 2004 were identified from clinic databases. Comparisons of clinical data, exposure characteristics and follow-up were made pre and post campaign. Data were available for 197/216 (91%) PEP attendances. The proportion requesting PEP following sexual exposure increased significantly following the campaign. The majority commencing PEPSE were MSM, with the proportion of MSM increasing significantly from 36/46 (78%) pre to 76/80 (95%) following the campaign. Most prescriptions were in high-risk groups and within guidelines. Times to initiation and completion rates were unchanged. Access to PEPSE following the THT campaign and introduction of BASHH guidelines increased. Promotion of earlier initiation of PEPSE and improvement of completion and follow-up is required.
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Affiliation(s)
- S Roedling
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, London WC1E 6JB
| | - I Reeves
- Department of Genitourinary Medicine/HIV, Brighton and Sussex University Hospitals NHS Trust, Brighton BN1 5BE
| | - A J Copas
- Centre for HIV and Sexual Health Research, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, London WC1E 6JB, UK
| | - A Beattie
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, London WC1E 6JB
| | - S G Edwards
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, London WC1E 6JB
| | - M Fisher
- Department of Genitourinary Medicine/HIV, Brighton and Sussex University Hospitals NHS Trust, Brighton BN1 5BE
| | - P Benn
- Department of Genitourinary Medicine, Mortimer Market Centre, Camden PCT, London WC1E 6JB
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Grover D, Copas A, Green H, Edwards SG, Dunn DT, Sabin C, Phillips A, Allen E, Pillay D. What is the risk of mortality following diagnosis of multidrug-resistant HIV-1? J Antimicrob Chemother 2008; 61:705-13. [DOI: 10.1093/jac/dkm522] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Xu XM, Nicholson P, Thomsett MA, Simpson D, Cooke BM, Doohan FM, Brennan J, Monaghan S, Moretti A, Mule G, Hornok L, Beki E, Tatnell J, Ritieni A, Edwards SG. Relationship between the fungal complex causing Fusarium head blight of wheat and environmental conditions. Phytopathology 2008; 98:69-78. [PMID: 18943240 DOI: 10.1094/phyto-98-1-0069] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
ABSTRACT Over 4 years, the environmental conditions and the causal agents of Fusarium head blight (FHB) disease of wheat were determined in field sites in four European countries: Hungary, Ireland, Italy, and the United Kingdom. Polymerase chain reaction-based methods were used to detect each species causing FHB and quantify its DNA (as a measurement of fungal abundance) in the samples. Canonical correspondence analysis (CCA) was used to determine the relationship of the incidence and abundance of each species with weather variables. CCA indicated that little variability in the species prevalence data was explained by the weather variables. In contrast, a greater proportion of variability in abundance data was accounted for by the weather variables. Most samples contained two or more species and statistical analysis suggested that these species tended to coexist at field sites. CCA also indicated that there were differences in the relationships of the prevalence and abundance of the six FHB species with environmental variables. Fusarium poae was associated with relatively drier and warmer conditions, whereas F. graminearum was associated with warmer/humid conditions. F. avenaceum and F. culmorum were both associated with niches of cooler/wet/humid conditions. Two Microdochium species were associated with regions of relatively cool/moderate temperatures and frequent rainfalls of short duration. The results also suggested that environmental conditions differentially affect the infection and colonization processes, and the comparative abundance of the six species.
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Affiliation(s)
- X-M Xu
- East Malling Research, New Road, East Mailling, Kent ME19 6BJ, UK.
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Tariq S, Edwards SG, Nalabanda A, Ward H, Allen E, Fenton K, Mercey D, Sethi G. Sexual health services for South Asians in London, UK: a case-control study. Int J STD AIDS 2007; 18:563-4. [PMID: 17686221 DOI: 10.1258/095646207781439676] [Citation(s) in RCA: 6] [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: 11/18/2022]
Abstract
National guidance on sexual health in England recommends service development to meet the specific needs of ethnic minority populations. Our aim was to evaluate mode of referral, number of sexually transmitted infections (STIs) diagnosed, and the offering and uptake of HIV testing in patients of South Asian ethnicity. A retrospective case-control study was undertaken in two London genito-urinary (GU) medicine clinics. There were 250 case-control pairs with approximately equal numbers of men and women. South Asians were less likely to have an STI (Odds ratio [OR] 0.66, 95% confidence interval [CI] 0.45, 0.97) or to report risk factors for HIV (OR 0.45, 95% CI 0.28, 0.71). Offering and uptake of HIV antibody testing were high in both South Asian and non-South Asian groups (OR 0.62, 95% CI 0.27, 1.51). South Asians were significantly more likely than controls to have been referred by other medical services rather than self-referred (OR 2.00, 95% CI 1.32, 3.01), which is in keeping with poorer access to GU medicine services in London.
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Affiliation(s)
- S Tariq
- Mortimer Market Centre, Camden Primary Care Trust, London, UK.
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Abstract
The commercial processing of oats is different from that of other cereals, such as wheat and maize. In northwest Europe, oats also appear to be more susceptible to contamination with HT-2 and T-2 toxins than other cereals. Mycotoxins, such as deoxynivanol and zearalenone, in cereals are already controlled by EU legislation. With regard to additional, impending legislation, this study examined HT-2 and T-2 toxins together with zearalenone, deoxynivalenol and other related toxins in a commercial oat mill and how the concentrations varied from raw oats to the final prepared oat flakes. Concentrations of each Fusarium mycotoxin fell by 90-95% during the process, with the major loss being a physical distribution occurring at the de-hulling stage. Initial studies of losses occurring at other stages, such as kilning or de-branning of prepared oat groats, suggest these to be small. The use of colour sorting after kilning showed higher concentrations of each mycotoxin in the discoloured groats. The feasibility of developing a predictive tool for the oat industry is examined.
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Affiliation(s)
- K A Scudamore
- KAS Mycotoxins, 6 Fern Drive, Taplow, Maidenhead, Berkshire, SL6 0JS, UK.
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Abstract
BACKGROUND Nevirapine has been widely used in pregnancy for its efficacy, low pill burden, bioavailability and rapid transplacental transfer. Concern about nevirapine toxicity during pregnancy has emerged over recent years. OBJECTIVES The aims of the study were to document the frequency of cutaneous and hepatic toxicity secondary to nevirapine use during pregnancy and to compare rates in women starting nevirapine during the current pregnancy with those in women who had commenced nevirapine prior to the current pregnancy. DESIGN This was a retrospective, comparative, five-centre study carried out in London, UK, in 1997-2003. METHODS All HIV-1-infected women who received nevirapine as part of combination antiretroviral therapy (ART) during pregnancy were included in the study. Data on demographics, HIV infection risk, Centers for Disease Control and Prevention (CDC) status, surrogate markers at initiation of therapy, other medications hepatitis B and C virus coinfection and clinical data relating to potential toxicity were collated and analysed. RESULTS Fifteen of 235 eligible women (6.4%) developed rash and eight (3.4%) developed hepatotoxicity, including four with coexistent rash, giving a combined incidence of 19 potential cases of nevirapine toxicity during pregnancy (8.1%). Alternative causes of rash/hepatotoxicity were suspected in seven cases and only 10 mothers (5.8%) discontinued nevirapine. Of the 170 women who commenced nevirapine during this pregnancy, 13 (7.6%) developed rash and eight (4.7%) hepatotoxicity, a combined incidence of 10%. Only two of 65 women with nevirapine exposure prior to this pregnancy developed rash (3.1%). CONCLUSIONS Nevirapine-containing ART was well tolerated in this cohort of pregnant women. Although pregnancy did not appear to increase the risk of nevirapine-associated toxicity compared to published adult data, CD(4) count may be less predictive of toxicity in pregnancy.
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Affiliation(s)
- U Natarajan
- Department of Genitourinary Medicine, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Glynn NC, Ray R, Edwards SG, Hare MC, Parry DW, Barnett CJ, Beck JJ. Quantitative Fusarium spp. and Microdochium spp. PCR assays to evaluate seed treatments for the control of Fusarium seedling blight of wheat. J Appl Microbiol 2007; 102:1645-53. [PMID: 17578430 DOI: 10.1111/j.1365-2672.2006.03190.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [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: 11/26/2022]
Abstract
AIMS To develop sensitive quantitative PCR assays for the two groups of pathogens responsible for Fusarium seedling blight in wheat: Fusarium group (Fusarium culmorum and Fusarium graminearum) and Microdochium group (Microdochium nivale and Microdochium majus); and to use the assays to assess performance of fungicide seed treatments against each group. METHODS AND RESULTS Primers conserved between the species within each group were used to develop competitive PCR assays and used to quantify DNA of each group in wheat seed produced from inoculated field plots. Seed was used in seed treatment efficacy field experiments and the amount of DNA of each group was determined in emerged seedlings. The performance of treatments towards each group of pathogens was evaluated by comparison of the reduction in DNA in seedlings emerged from treated seed compared with untreated seed. CONCLUSIONS DNA from the two groups of pathogens causing Fusarium seedling blight of wheat can be quantified separately using the competitive PCR assays. These assays show improved sensitivity compared with those previously reported for the individual species and allowed the quantification of pathogen DNA in seed and seedlings. Significant reductions in pathogen DNA were evident for each seed treatment. SIGNIFICANCE AND IMPACT OF THE STUDY Quantification of DNA for each group allows the evaluation of seed treatment performance towards the two components of Fusarium seedling blight disease complex. The approach taken and the assays developed in this study will be of use for the study of other Fusarium disease complexes and their control. Based on the results reported here on the seedling stage of crop development, further studies that examine the control of seed-borne pathogens through fungicide seed treatments throughout the growing season are warranted.
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Affiliation(s)
- N C Glynn
- USDA-ARS, Sugarcane Field Station, Canal Point, FL 33438, USA.
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Dickson SJ, Batson S, Copas AJ, Edwards SG, Singer M, Miller RF. Survival of HIV-infected patients in the intensive care unit in the era of highly active antiretroviral therapy. Thorax 2007; 62:964-8. [PMID: 17517829 PMCID: PMC2117109 DOI: 10.1136/thx.2006.072256] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.1] [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: 11/04/2022]
Abstract
BACKGROUND Several studies have described improved outcomes for HIV-infected patients admitted to the intensive care unit (ICU) since the introduction of highly active antiretroviral therapy (HAART). A study was undertaken to examine the outcome from the ICU for HIV-infected patients and to identify prognostic factors. METHODS A retrospective study of HIV-infected adults admitted to a university affiliated hospital ICU between January 1999 and December 2005 was performed. Information was collected on patient demographics, receipt of HAART (no patient began HAART on the ICU), reason for ICU admission and hospital course. Outcomes were survival to ICU discharge and to hospital discharge. RESULTS 102 patients had 113 admissions to the ICU; HIV infection was newly diagnosed in 31 patients. Survival (first episode ICU discharge and hospital discharge) was 77% and 68%, respectively, compared with 74% and 65% for general medical patients. ICU and hospital survival was 78% and 67% in those receiving HAART, and 75% and 66% in those who were not. In univariate analysis, factors associated with survival were: haemoglobin (OR = 1.25, 95% CI 1.03 to 1.51, for an increase of 1 g/dl), CD4 count (OR = 1.59, 95% CI 0.98 to 2.58, for a 10-fold increase in cells/microl), APACHE II score (OR = 0.51, 95% CI 0.29 to 0.90, for a 10 unit increase) and mechanical ventilation (OR = 0.29, 95% CI 0.10 to 0.83). CONCLUSIONS The outcome for HIV-infected patients admitted to the ICU was good and was comparable to that in general medical patients. More than a quarter of patients had newly diagnosed HIV infection. Patients receiving HAART did not have a better outcome.
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Affiliation(s)
- S J Dickson
- University College London Hospitals, London, UK
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Turner JM, Rider AT, Imrie J, Copas AJ, Edwards SG, Dodds JP, Stephenson JM. Behavioural predictors of subsequent hepatitis C diagnosis in a UK clinic sample of HIV positive men who have sex with men. Sex Transm Infect 2006; 82:298-300. [PMID: 16877578 PMCID: PMC2564713 DOI: 10.1136/sti.2005.018366] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To explore the associations between self reported high risk sexual behaviours and subsequent diagnosis with hepatitis C virus (HCV) infection. METHODS The Sex, Health and Anti-Retrovirals Project (SHARP) was a cross sectional study of sexual behaviour in HIV positive, men who have sex with men (MSM) attending a London outpatient clinic. From July 1999 to August 2000 participants completed a computer assisted self interview questionnaire (CASI) on recent sexual behaviour, recreational drug use, and detailed reporting of the last two sexual episodes involving different partners. Results were combined with routine clinic data and subsequent testing for HCV up to 21 April 2005. A new HCV diagnosis was defined as anti-HCV antibody seroconversion or positive HCV RNA following a previous negative. Incident rate ratios (IRR) were calculated using Poisson regression in Stata (version 9). Men contributed time at risk from interview until either their diagnosis or their last negative test result. RESULTS Of the 422 men who completed questionnaires, 308 (73%) had sufficient clinical and HCV testing data available for analysis. Incident HCV infection was identified in 11 men. Unprotected anal intercourse, more than 30 sex partners in the past year, higher numbers of new anal sex partners, rimming (oro-anal sex), fisting, use of sex toys, and intranasal recreational drug use were associated with HCV. In multivariate analysis only fisting remained associated with HCV (adjusted IRR 6.27, p = 0.005). CONCLUSIONS In this study of HIV positive MSM, fisting is strongly associated with HCV infection. Where individuals report high risk sexual behaviours, clinicians should offer appropriate testing for HCV infection.
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Affiliation(s)
- J M Turner
- Centre for Sexual Health and HIV Research, Mortimer Market Centre, Capper Street, London WC1E 6AU, UK.
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Ferrand RA, Elgalib A, Newsholme W, Childerhouse A, Edwards SG, Miller RF. Hypercalcaemia complicating immune reconstitution in an HIV-infected patient with disseminated tuberculosis. Int J STD AIDS 2006; 17:349-50. [PMID: 16643687 DOI: 10.1258/095646206776790169] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [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: 11/18/2022]
Abstract
An HIV positive man being treated for disseminated tuberculosis developed hypercalcaemia 17 days after starting highly active antiretroviral therapy (HAART). Hypercalcaemia resolved with stopping HAART and was thought to be due to immune reconstitution inflammatory syndrome.
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Affiliation(s)
- R A Ferrand
- Patrick Manson Unit, University College London Hospitals, London, UK
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Griffiths C, Miles K, Penny N, George B, Stephenson J, Power R, Twist P, Brough G, Edwards SG. A formative evaluation of the potential role of nurse practitioners in a central London HIV outpatient clinic. AIDS Care 2006; 18:22-6. [PMID: 16282072 DOI: 10.1080/09540120500101807] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [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: 10/25/2022]
Abstract
In-house audit demonstrated that 49% (173/352) of patients attending routine HIV outpatient care are asymptomatic and have needs that could potentially be met by other health care professionals. We therefore evaluated the potential development and acceptability of nurse practitioner roles in contributing to HIV outpatient care. Data were collected through 26 consultation observations, 25 patient interviews, 2 patient focus groups, 22 provider interviews and 8 provider focus groups. Service users were key members of the evaluation team. With increasing HIV incidence and the change in focus of doctor-patient consultations from acute to chronic disease management, there are concerns about the sustainability of easily available routine HIV outpatient appointments using the same model of care that has prevailed over the past 20 years. Nurse practitioner models of care were considered acceptable for asymptomatic patients, including those who do not have complex issues related to highly active antiretroviral therapy (HAART). Key considerations for the role include training, supervision, referral pathways, and a clear understanding of the limitations of nursing practice. There is an emphasis on the need to consider 'new ways of working' throughout the service, rather than merely substituting or transferring clinical roles between professionals. Funding pending, nurse practitioner roles are planned for implementation in late 2004. Evaluation will determine impact on service utilization, health and economic outcomes.
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Affiliation(s)
- C Griffiths
- Department of Primary Care and Population Science, Royal Free & University College Medical School, London, UK.
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Miller RF, Allen E, Copas A, Singer M, Edwards SG. Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy. Thorax 2006; 61:716-21. [PMID: 16601092 PMCID: PMC2104703 DOI: 10.1136/thx.2005.055905] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [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: 11/04/2022]
Abstract
BACKGROUND Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU) where mortality remains high. A study was undertaken to examine the outcome from intensive care for patients with PCP and to identify prognostic factors. METHODS A retrospective cohort study was conducted of HIV infected adults admitted to a university affiliated hospital ICU between November 1990 and October 2005. Case note review collected information on demographic variables, use of prophylaxis and highly active antiretroviral therapy (HAART), and hospital course. The main outcome was 1 month mortality, either on the ICU or in hospital. RESULTS Fifty nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation. Overall mortality was 53%. No patient received HAART before or during ICU admission. Multivariate analysis showed that the factors associated with mortality were the year of diagnosis (before mid 1996 (mortality 71%) compared with later (mortality 34%; p = 0.008)), age (p = 0.016), and the need for mechanical ventilation and/or development of pneumothorax (p = 0.031). Mortality was not associated with sex, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, PaO2, A-aO2 gradient, co-pathology in bronchoscopic lavage fluid, medical co-morbidity, APACHE II score, or duration of mechanical ventilation. CONCLUSIONS Observed improved outcomes from severe PCP for patients admitted to the ICU occurred in the absence of intervention with HAART and probably reflect general improvements in ICU management of respiratory failure and ARDS rather than improvements in the management of PCP.
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Affiliation(s)
- R F Miller
- Centre for Sexual Health and HIV Research, University College London, Mortimer Market Centre, London WC1E 6AU, UK.
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Llewelyn MJ, Noursedeghi M, Dogan A, Edwards SG, Miller RF. Diagnostic utility of bone marrow sampling in HIV-infected patients since the advent of highly active antiretroviral therapy. Int J STD AIDS 2005; 16:686-90. [PMID: 16212717 DOI: 10.1258/095646205774357343] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We investigated the diagnostic value of bone marrow (BM) sampling in investigation of HIV-infected patients presenting to a major London HIV treatment centre between 1999 and 2004. One hundred and fourteen consecutive patients underwent 130 BM samplings. The majority of BM aspirates were normal or showed non-diagnostic changes; microscopy revealed lymphoma in one and mycobacterial infection in two. Subsequent culture identified mycobacterial infection in nine samples. BM trephine had a diagnostic yield of 26% in patients with fever and cytopaenia (including mycobacteriosis in 14%, lymphoma in 6%, Castleman disease in 3% and "drug effect" in 3%), a yield of 20% in patients with fever, but no cytopaenia (mycobacteriosis in each case), and a yield of 19% in patients with cytopaenia in the absence of fever (lymphoma in 5% and "drug effect" in 14%). In investigation/staging of lymphoma, the diagnostic yield was 36%. The overall yield from BM sampling was 30% in patients receiving highly active antiretroviral therapy (HAART) and 23% in those not receiving HAART. In this study, BM sampling was of most diagnostic value in HIV-infected patients where fever and cytopaenia coexisted in the absence of localizing signs of infection, and in the staging/investigation of lymphoma. BM sampling had less diagnostic value in the investigation of fever without cytopaenia or cytopaenia without fever.
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Affiliation(s)
- M J Llewelyn
- Patrick Manson Unit, University College London Hospitals (NHS) Trust, London WC1E 6AU, UK
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Miller RF, Scully M, Cohen H, Roedling S, Starke R, Edwards SG, Machin SJ. Thrombotic thrombocytopaenic purpura in HIV-infected patients. Int J STD AIDS 2005; 16:538-42. [PMID: 16105187 DOI: 10.1258/0956462054679241] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Thrombotic thrombocytopaenic purpura (TTP) results from deficiency of von Willebrand factor-cleaving protease (vWF-cp) activity. Eight HIV-infected patients presented with TTP, representing 12.5% of all TTP treated at this centre. In four patients presentation with TTP revealed underlying HIV infection, the other four patients were previously known to be HIV infected, with plasma exchange and highly active antiretroviral therapy (HAART) all recovered. Normalization of vWF-cp activity was associated with recovery. Relapse occurred in two patients who discontinued HAART against medical advice, suggesting that HIV has a causal role in this condition. Given the clear benefit from HAART in addition to plasma exchange, these data suggest that all patients presenting with TTP should undergo HIV testing.
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Affiliation(s)
- R F Miller
- Centre for Sexual Health and HIV Research, Department of Primary Care and Population Sciences, Royal Free and University College Medical School, University College London, Mortimer Market Centre, Camden PCT, London WC1E 6AU, UK
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Richens J, Edwards SG, Sadiq ST. Can the promotion of post-exposure prophylaxis following sexual exposure to HIV (PEPSE) cause harm? Sex Transm Infect 2005; 81:190-1; discussion 191-2. [PMID: 15923282 PMCID: PMC1744985 DOI: 10.1136/sti.2005.014886] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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