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Trevisi L, Hernán MA, Mitnick CD, Khan U, Seung KJ, Rich ML, Bastard M, Huerga H, Melikyan N, Atwood SA, Avaliani Z, Llanos F, Manzur-ul-Alam M, Zarli K, Binegdie AB, Adnan S, Melikyan A, Gelin A, Isani AK, Vetushko D, Daugarina Z, Nkundanyirazo P, Putri FA, Vilbrun C, Khan M, Hewison C, Khan PY, Franke MF. Effectiveness of Bedaquiline Use beyond Six Months in Patients with Multidrug-Resistant Tuberculosis. Am J Respir Crit Care Med 2023; 207:1525-1532. [PMID: 36802336 PMCID: PMC10263131 DOI: 10.1164/rccm.202211-2125oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Rationale: Current recommendations for the treatment of rifampicin- and multidrug-resistant tuberculosis include bedaquiline (BDQ) used for 6 months or longer. Evidence is needed to inform the optimal duration of BDQ. Objectives: We emulated a target trial to estimate the effect of three BDQ duration treatment strategies (6, 7-11, and ⩾12 mo) on the probability of successful treatment among patients receiving a longer individualized regimen for multidrug-resistant tuberculosis. Methods: To estimate the probability of successful treatment, we implemented a three-step approach comprising cloning, censoring, and inverse probability weighting. Measurements and Main Results: The 1,468 eligible individuals received a median of 4 (interquartile range, 4-5) likely effective drugs. In 87.1% and 77.7% of participants, this included linezolid and clofazimine, respectively. The adjusted probability of successful treatment was 0.85 (95% confidence interval [CI], 0.81-0.88) for 6 months of BDQ, 0.77 (95% CI, 0.73-0.81) for 7-11 months, and 0.86 (95% CI, 0.83-0.88) for ⩾12 months. Compared with 6 months of BDQ, the ratio of treatment success was 0.91 (95% CI, 0.85-0.96) for 7-11 months and 1.01 (95% CI, 0.96-1.06) for ⩾12 months. Naive analyses that did not account for bias revealed a higher probability of successful treatment with ⩾12 months (ratio, 1.09 [95% CI, 1.05-1.14]). Conclusions: BDQ use beyond 6 months did not increase the probability of successful treatment among patients receiving longer regimens that commonly included new and repurposed drugs. When not properly accounted for, immortal person-time bias can influence estimates of the effects of treatment duration. Future analyses should explore the effect of treatment duration of BDQ and other drugs in subgroups with advanced disease and/or receiving less potent regimens.
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Affiliation(s)
- Letizia Trevisi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Miguel A. Hernán
- CAUSALab, Departments of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | - Uzma Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Kwonjune J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | - Michael L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | | | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Nara Melikyan
- Field Epidemiology Department, Epicentre, Paris, France
| | - Sidney A. Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Felix Llanos
- Unidad de Tuberculosis, Hospital Nacional Dos de Mayo, Lima, Peru
- Instituto de Investigaciones en Ciencias Biomedicas, Universidad Ricardo Palma, Lima, Peru
| | | | - Khin Zarli
- Médecins sans Frontières, Yangon, Myanmar
| | - Amsalu Bekele Binegdie
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sana Adnan
- Indus Hospital and Health Network, Karachi, Pakistan
| | | | | | - Afshan K. Isani
- National Core Research Group, Stop TB Partnership, Islamabad, Pakistan
| | - Dmitry Vetushko
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis, Minsk, Belarus
| | | | | | | | | | - Munira Khan
- Interactive Research and Development, Durban, South Africa
| | | | - Palwasha Y. Khan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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Nelson AK, Miller AC, Munoz M, Rumaldo N, Kammerer B, Vibbert M, Lundy S, Soplapuco G, Lecca L, Condeso A, Valdivia Y, Atwood SA, Shin SS. CASITA: a controlled pilot study of community-based family coaching to stimulate early child development in Lima, Peru. BMJ Paediatr Open 2018; 2:e000268. [PMID: 29862331 PMCID: PMC5976100 DOI: 10.1136/bmjpo-2018-000268] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/10/2018] [Accepted: 04/16/2018] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To determine whether the 3-month, community-based early stimulation coaching and social support intervention 'CASITA', delivered by community health workers, could improve early child development and caregiver-child interaction in a resource-limited district in Lima, Peru. DESIGN A controlled two-arm proof-of-concept study. SETTING Six neighbourhood health posts in Carabayllo, a mixed rural/urban district in Lima. Sessions were held in homes and community centres. PARTICIPANTS Children aged 6-24 months who screened positive for risk of neurodevelopmental delay (using validated developmental delay tool) and poverty (using progress out of poverty tool) were enrolled with their caregivers. Dyads with children born >21 days early were excluded. INTERVENTION 12-week parenting/support intervention plus nutritional support (n=41) or nutrition alone (n=19). OUTCOME MEASURES Development and home environment differences and mean changes from baseline to 3 months postintervention were evaluated using age-adjusted z-scores on the Extended Ages and Stages Questionnaire (EASQ) and the Home Observation Measurement of the Environment (HOME) scores, respectively. RESULTS Development in CASITA improved significantly in all EASQ domains, whereas the control group's z-scores did not improve significantly in any domain. The mean adjusted difference (MAD) in change in EASQ age-adjusted z-scores between the two study arms was 1.39 (95% CI 0.55 to 2.22); Cohen's d effect size of 0.87 (95% CI 0.23 to 1.50). Likewise, intervention significantly improved global HOME scores versus control group (MAD change of 6.33 (95% CI 2.12 to 10.55); Cohen's d of 0.85 (95% CI 0.28 to 1.41)). CONCLUSIONS An evidence-based early intervention delivered weekly during 3 months by a community health worker significantly improved children's communication, motor and personal/social development in this proof-of-concept study.
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Affiliation(s)
| | - Ann C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Betsy Kammerer
- Department of Psychiatry, Children's Hospital Boston, Boston, Massachusetts, USA
| | - Martha Vibbert
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.,SPARK Center, Boston Medical Center, Boston, Massachusetts, USA
| | - Shannon Lundy
- Division of Developmental Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.,UCSF Benioff Children's Hospital, San Francisco, California, USA
| | | | - Leonid Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Socios En Salud Sucursal, Lima, Peru
| | | | | | - Sidney A Atwood
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sonya S Shin
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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