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Braat S, Fielding KL, Han J, Jackson VE, Zaloumis S, Xu JXH, Moir-Meyer G, Blaauwendraad SM, Jaddoe VWV, Gaillard R, Parkin PC, Borkhoff CM, Keown-Stoneman CDG, Birken CS, Maguire JL, Bahlo M, Davidson EM, Pasricha SR. Haemoglobin thresholds to define anaemia from age 6 months to 65 years: estimates from international data sources. Lancet Haematol 2024; 11:e253-e264. [PMID: 38432242 PMCID: PMC10983828 DOI: 10.1016/s2352-3026(24)00030-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/25/2024] [Accepted: 01/25/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND Detection of anaemia is crucial for clinical medicine and public health. Current WHO anaemia definitions are based on statistical thresholds (fifth centiles) set more than 50 years ago. We sought to establish evidence for the statistical haemoglobin thresholds for anaemia that can be applied globally and inform WHO and clinical guidelines. METHODS In this analysis we identified international data sources from populations in the USA, England, Australia, China, the Netherlands, Canada, Ecuador, and Bangladesh with sufficient clinical and laboratory information collected between 1998 and 2020 to obtain a healthy reference sample. Individuals with clinical or biochemical evidence of a condition that could reduce haemoglobin concentrations were excluded. We estimated haemoglobin thresholds (ie, 5th centiles) for children aged 6-23 months, 24-59 months, 5-11 years, and 12-17 years, and adults aged 18-65 years (including during pregnancy) for individual datasets and pooled across data sources. We also collated findings from three large-scale genetic studies to summarise genetic variants affecting haemoglobin concentrations in different ancestral populations. FINDINGS We identified eight data sources comprising 18 individual datasets that were eligible for inclusion in the analysis. In pooled analyses, the haemoglobin fifth centile was 104·4 g/L (90% CI 103·5-105·3) in 924 children aged 6-23 months, 110·2 g/L (109·5-110·9) in 1874 children aged 24-59 months, and 114·4 g/L (113·6-115·2) in 1839 children aged 5-11 years. Values diverged by sex in adolescents and adults. In pooled analyses, the fifth centile was 122·2 g/L (90% CI 121·3-123·1) in 1741 female adolescents aged 12-17 years and 128·2 g/L (126·4-130·0) in 1103 male adolescents aged 12-17 years. In pooled analyses of adults aged 18-65 years, the fifth centile was 119·7 g/L (90% CI 119·1-120·3) in 3640 non-pregnant females and 134·9 g/L (134·2-135·6) in 2377 males. Fifth centiles in pregnancy were 110·3 g/L (90% CI 109·5-111·0) in the first trimester (n=772) and 105·9 g/L (104·0-107·7) in the second trimester (n=111), with insufficient data for analysis in the third trimester. There were insufficient data for adults older than 65 years. We did not identify ancestry-specific high prevalence of non-clinically relevant genetic variants that influence haemoglobin concentrations. INTERPRETATION Our results enable global harmonisation of clinical and public health haemoglobin thresholds for diagnosis of anaemia. Haemoglobin thresholds are similar between sexes until adolescence, after which males have higher thresholds than females. We did not find any evidence that thresholds should differ between people of differering ancestries. FUNDING World Health Organization and the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Sabine Braat
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Katherine L Fielding
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; Clinical Haematology, The Austin Hospital, Heidelberg, VIC, Australia
| | - Jiru Han
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Victoria E Jackson
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sophie Zaloumis
- Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Jessica Xu Hui Xu
- Methods and Implementation Support for Clinical and Health research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Gemma Moir-Meyer
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Sophia M Blaauwendraad
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Vincent W V Jaddoe
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Romy Gaillard
- Generation R Study Group, and Department of Pediatrics, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Patricia C Parkin
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Cornelia M Borkhoff
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Charles D G Keown-Stoneman
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, Canada
| | - Catherine S Birken
- Division of Pediatric Medicine and the Pediatric Outcomes Research Team, The Hospital for Sick Children, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jonathon L Maguire
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Unity Health Toronto, Toronto, ON, Canada
| | - Melanie Bahlo
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia
| | - Eliza M Davidson
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Sant-Rayn Pasricha
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia; Medical Biology, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, VIC, Australia; Diagnostic Haematology, The Royal Melbourne Hospital, Parkville, VIC, Australia; Clinical Haematology, Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Parkville, VIC, Australia.
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2
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Duncan R, Berlowitz DJ, Mullen S, Bondarenko J, Winton-Brown TT, O'Brien TJ, Zaloumis S, Braat S, Oliver G, Kanaan RA. Breathing control training for functional seizures: A multi-site, open-label pilot study. Epilepsy Behav 2024; 154:109745. [PMID: 38521027 DOI: 10.1016/j.yebeh.2024.109745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/11/2024] [Accepted: 03/12/2024] [Indexed: 03/25/2024]
Abstract
There are no well-validated treatments for functional seizures. While specialist psychotherapy is usually recommended, the evidence for its benefit is qualified, and it can be difficult to obtain. Given the association between hyperventilation and functional seizures we explored an alternative modality, breathing control training, in a multi-site open label pilot trial. Participants with functional seizures over the age of 16 received an hour of breathing training from a respiratory physiotherapist, with a half-hour booster session a month later. Seizure frequency and Nijmegen scores (a measure of hyperventilation) were reported at baseline and follow-up, 3-4 months later. Eighteen subjects were recruited, and 10 completed follow-up. Seven of these 10 had improved seizure frequency, and 3 did not (Wilcoxon signed rank test, p = 0.09), with seizure frequency correlating with Nijmegen score (Spearman's rank correlation = 0.75, p = 0.034). The intervention was well tolerated, with no adverse events reported. These preliminary results support a potentially new approach to treating functional seizures that should prove cost-effective and acceptable, though require confirmation by a randomised controlled trial.
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Affiliation(s)
- Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - David J Berlowitz
- Department of Physiotherapy, The University of Melbourne, Melbourne Australia; Institute for Breathing and Sleep, Austin Health, Heidelberg, Australia
| | - Saul Mullen
- Department of Neurology, Austin Health, Heidelberg, Australia
| | - Janet Bondarenko
- Physiotherapy, Alfred Health, Melbourne, Australia; Respiratory Research@Alfred, Monash University, Melbourne, Australia
| | - Toby T Winton-Brown
- Department of Neuroscience, Central Clinical School, Monash University, Prahran 3004, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Prahran 3004, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne Australia; MISCH (Methods and Implementation Support for Clinical Health) research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne Australia; MISCH (Methods and Implementation Support for Clinical Health) research Hub, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne Australia
| | - Georgina Oliver
- Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, Australia
| | - Richard A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, Australia.
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3
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Nolan TM, Deliyannis G, Griffith M, Braat S, Allen LF, Audsley J, Chung AW, Ciula M, Gherardin NA, Giles ML, Gordon TP, Grimley SL, Horng L, Jackson DC, Juno JA, Kedzierska K, Kent SJ, Lewin SR, Littlejohn M, McQuilten HA, Mordant FL, Nguyen THO, Soo VP, Price B, Purcell DFJ, Ramanathan P, Redmond SJ, Rockman S, Ruan Z, Sasadeusz J, Simpson JA, Subbarao K, Fabb SA, Payne TJ, Takanashi A, Tan CW, Torresi J, Wang JJ, Wang LF, Al-Wassiti H, Wong CY, Zaloumis S, Pouton CW, Godfrey DI. Interim results from a phase I randomized, placebo-controlled trial of novel SARS-CoV-2 beta variant receptor-binding domain recombinant protein and mRNA vaccines as a 4th dose booster. EBioMedicine 2023; 98:104878. [PMID: 38016322 PMCID: PMC10696466 DOI: 10.1016/j.ebiom.2023.104878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/18/2023] [Accepted: 11/02/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND SARS-CoV-2 booster vaccination should ideally enhance protection against variants and minimise immune imprinting. This Phase I trial evaluated two vaccines targeting SARS-CoV-2 beta-variant receptor-binding domain (RBD): a recombinant dimeric RBD-human IgG1 Fc-fusion protein, and an mRNA encoding a membrane-anchored RBD. METHODS 76 healthy adults aged 18-64 y, previously triple vaccinated with licensed SARS-CoV-2 vaccines, were randomised to receive a 4th dose of either an adjuvanted (MF59®, CSL Seqirus) protein vaccine (5, 15 or 45 μg, N = 32), mRNA vaccine (10, 20, or 50 μg, N = 32), or placebo (saline, N = 12) at least 90 days after a 3rd boost vaccination or SARS-CoV-2 infection. Bleeds occurred on days 1 (prior to vaccination), 8, and 29. CLINICALTRIALS govNCT05272605. FINDINGS No vaccine-related serious or medically-attended adverse events occurred. The protein vaccine reactogenicity was mild, whereas the mRNA vaccine was moderately reactogenic at higher dose levels. Best anti-RBD antibody responses resulted from the higher doses of each vaccine. A similar pattern was seen with live virus neutralisation and surrogate, and pseudovirus neutralisation assays. Breadth of immune response was demonstrated against BA.5 and more recent omicron subvariants (XBB, XBB.1.5 and BQ.1.1). Binding antibody titres for both vaccines were comparable to those of a licensed bivalent mRNA vaccine. Both vaccines enhanced CD4+ and CD8+ T cell activation. INTERPRETATION There were no safety concerns and the reactogenicity profile was mild and similar to licensed SARS-CoV-2 vaccines. Both vaccines showed strong immune boosting against beta, ancestral and omicron strains. FUNDING Australian Government Medical Research Future Fund, and philanthropies Jack Ma Foundation and IFM investors.
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Affiliation(s)
- Terry M Nolan
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia.
| | - Georgia Deliyannis
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Maryanne Griffith
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Lilith F Allen
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Jennifer Audsley
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Amy W Chung
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Marcin Ciula
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Nicholas A Gherardin
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Michelle L Giles
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia
| | - Tom P Gordon
- Department of Immunology, Flinders University and SA Pathology, Flinders Medical Centre, Bedford Park, Adelaide, Australia
| | - Samantha L Grimley
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Lana Horng
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - David C Jackson
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Jennifer A Juno
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Katherine Kedzierska
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Global Station for Zoonosis Control, Global Institution for Collaborative Research and Education (GI-CoRE), Hokkaido University, Sapporo, Japan
| | - Stephen J Kent
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Sharon R Lewin
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia; Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Mason Littlejohn
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia
| | - Hayley A McQuilten
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Francesca L Mordant
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Thi H O Nguyen
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Vanessa Pac Soo
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Briony Price
- Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection & Immunity, Melbourne, Australia; Murdoch Children's Research Institute, Melbourne, Australia
| | - Damian F J Purcell
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Pradhipa Ramanathan
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Samuel J Redmond
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Steven Rockman
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; CSL Seqirus, Vaccine Innovation Unit, Parkville, Melbourne, Australia
| | - Zheng Ruan
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Joseph Sasadeusz
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; Department of Infectious Diseases, Alfred Hospital and Monash University, Melbourne, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Kanta Subbarao
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia; WHO Collaborating Centre for Reference and Research on Influenza at the Peter Doherty Institute for Infection and Immunity, Australia
| | - Stewart A Fabb
- Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Thomas J Payne
- Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Asuka Takanashi
- Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Chee Wah Tan
- Duke NUS Medical School, Programme for Emerging Infectious Diseases, Singapore
| | - Joseph Torresi
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Jing Jing Wang
- Department of Immunology, Flinders University and SA Pathology, Flinders Medical Centre, Bedford Park, Adelaide, Australia
| | - Lin-Fa Wang
- Duke NUS Medical School, Programme for Emerging Infectious Diseases, Singapore
| | | | - Chinn Yi Wong
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Colin W Pouton
- Monash Institute of Pharmaceutical Sciences, Parkville, Australia
| | - Dale I Godfrey
- Department of Microbiology & Immunology, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
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4
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Mehdipour P, Rajasekhar M, Dini S, Zaloumis S, Abreha T, Adam I, Awab GR, Baird JK, Brasil LW, Chu CS, Cui L, Daher A, do Socorro M Gomes M, Gonzalez-Ceron L, Hwang J, Karunajeewa H, Lacerda MVG, Ladeia-Andrade S, Leslie T, Ley B, Lidia K, Llanos-Cuentas A, Longley RJ, Monteiro WM, Pereira DB, Rijal KR, Saravu K, Sutanto I, Taylor WRJ, Thanh PV, Thriemer K, Vieira JLF, White NJ, Zuluaga-Idarraga LM, Guerin PJ, Price RN, Simpson JA, Commons RJ. Effect of adherence to primaquine on the risk of Plasmodium vivax recurrence: a WorldWide Antimalarial Resistance Network systematic review and individual patient data meta-analysis. Malar J 2023; 22:306. [PMID: 37817240 PMCID: PMC10563365 DOI: 10.1186/s12936-023-04725-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/25/2023] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND Imperfect adherence is a major barrier to effective primaquine radical cure of Plasmodium vivax. This study investigated the effect of reduced adherence on the risk of P. vivax recurrence. METHODS Efficacy studies of patients with uncomplicated P. vivax malaria, including a treatment arm with daily primaquine, published between January 1999 and March 2020 were identified. Individual patient data from eligible studies were pooled using standardized methodology. Adherence to primaquine was inferred from i) the percentage of supervised doses and ii) the total mg/kg dose received compared to the target total mg/kg dose per protocol. The effect of adherence to primaquine on the incidence of P. vivax recurrence between days 7 and 90 was investigated by Cox regression analysis. RESULTS Of 82 eligible studies, 32 were available including 6917 patients from 18 countries. For adherence assessed by percentage of supervised primaquine, 2790 patients (40.3%) had poor adherence (≤ 50%) and 4127 (59.7%) had complete adherence. The risk of recurrence by day 90 was 14.0% [95% confidence interval: 12.1-16.1] in patients with poor adherence compared to 5.8% [5.0-6.7] following full adherence; p = 0.014. After controlling for age, sex, baseline parasitaemia, and total primaquine dose per protocol, the rate of the first recurrence was higher following poor adherence compared to patients with full adherence (adjusted hazard ratio (AHR) = 2.3 [1.8-2.9]). When adherence was quantified by total mg/kg dose received among 3706 patients, 347 (9.4%) had poor adherence, 88 (2.4%) had moderate adherence, and 3271 (88.2%) had complete adherence to treatment. The risks of recurrence by day 90 were 8.2% [4.3-15.2] in patients with poor adherence and 4.9% [4.1-5.8] in patients with full adherence; p < 0.001. CONCLUSION Reduced adherence, including less supervision, increases the risk of vivax recurrence.
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Affiliation(s)
- Parinaz Mehdipour
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Megha Rajasekhar
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Saber Dini
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Tesfay Abreha
- ICAP, Columbia University Mailman School of Public Health, Addis Ababa, Ethiopia
| | - Ishag Adam
- Department of Obstetrics and Gynecology, Unaizah College of Medicine and Medical Sciences, Qassim University, Unaizah, Saudi Arabia
| | - Ghulam Rahim Awab
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Nangarhar Medical Faculty, Nangarhar University, Jalalabad, Afghanistan
| | - J Kevin Baird
- Oxford University Clinical Research Unit Indonesia, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Larissa W Brasil
- Diretoria de Ensino E Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil
- Programa de Pós‑Graduação em Medicina Tropical, Universidade Do Estado Do Amazonas, Manaus, AM, Brazil
| | - Cindy S Chu
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Liwang Cui
- Department of Internal Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - André Daher
- Fiocruz Clinical Research Platform, Vice-Presidency of Research and Biological Collections, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, Brazil
| | - Margarete do Socorro M Gomes
- Superintendência de Vigilância Em Saúde Do Estado Do Amapá - SVS/AP, Macapá, Amapá, Brazil
- Federal University of aMAPA, Universidade Federal Do Amapá - UNIFAP), Macapá, Amapá, Brazil
| | - Lilia Gonzalez-Ceron
- Regional Centre for Public Health Research, National Institute for Public Health, Tapachula, Chiapas, Mexico
| | - Jimee Hwang
- U.S. President's Malaria Initiative, Malaria Branch, U.S. Centers for Disease Control and Prevention, Atlanta, GA, USA
- Global Health Group, University of California San Francisco, San Francisco, USA
| | - Harin Karunajeewa
- Department of Medicine-Western Health, Melbourne Medical School, The University of Melbourne, St. Albans, VIC, Australia
| | - Marcus V G Lacerda
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
- Instituto Leônidas & Maria Deane, Fiocruz, Manaus, Brazil
- University of Texas Medical Branch, Galveston, USA
| | - Simone Ladeia-Andrade
- Laboratory of Parasitic Diseases, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
- Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, Nova University of Lisbon, Lisbon, Portugal
| | - Toby Leslie
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- HealthNet-TPO, Kabul, Afghanistan
| | - Benedikt Ley
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - Kartini Lidia
- Department of Pharmacology and Therapy, Faculty of Medicine and Veterinary Medicine, Universitas Nusa Cendana, Kupang, Indonesia
| | - Alejandro Llanos-Cuentas
- Unit of Leishmaniasis and Malaria, Instituto de Medicina Tropical "Alexander Von Humboldt", Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Rhea J Longley
- Mahidol Vivax Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | | | - Dhelio B Pereira
- Centro de Pesquisa Em Medicina Tropical de Rondonia (CEPEM), Porto Velho, Brazil
- Fundação Universidade Federal de Rondonia (UNIR), Porto Velho, Brazil
| | - Komal Raj Rijal
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Kathmandu, Nepal
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kavitha Saravu
- Department of Infectious Diseases, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Madhava Nagar, Manipal, Karnataka, India
- Manipal Centre for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Madhava Nagar, Manipal, Karnataka, India
| | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Walter R J Taylor
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Pham Vinh Thanh
- National Institute of Malariology, Parasitology and Entomology, Hanoi, Vietnam
| | - Kamala Thriemer
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
| | - José Luiz F Vieira
- Federal University of Pará, Universidade Federal Do Pará - UFPA), Belém, Pará, Brazil
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
| | - Lina M Zuluaga-Idarraga
- Grupo Malaria, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
- Facultad Nacional de Salud Publica, Universidad de Antioquia, Medellín, Colombia
| | - Philippe J Guerin
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK
- Infectious Diseases Data Observatory (IDDO), Oxford, UK
| | - Ric N Price
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia
- WorldWide Antimalarial Resistance Network (WWARN), Asia-Pacific Regional Centre, Darwin, NT, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
- WorldWide Antimalarial Resistance Network (WWARN), Asia-Pacific Regional Centre, Darwin, NT, Australia
| | - Robert J Commons
- Global Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, NT, Australia.
- WorldWide Antimalarial Resistance Network (WWARN), Asia-Pacific Regional Centre, Darwin, NT, Australia.
- General and Subspecialty Medicine, Grampians Health - Ballarat, Ballarat, Australia.
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Summers MJ, Chapple LAS, Bellomo R, Chapman MJ, Ferrie S, Finnis ME, French C, Hurford S, Kakho N, Karahalios A, Maiden MJ, O'Connor SN, Peake SL, Presneill JJ, Ridley EJ, Tran-Duy A, Williams PJ, Young PJ, Zaloumis S, Deane AM. Study protocol for TARGET protein: The effect of augmented administration of enteral protein to critically ill adults on clinical outcomes: A cluster randomised, cross-sectional, double cross-over, clinical trial. CRIT CARE RESUSC 2023; 25:147-154. [PMID: 37876373 PMCID: PMC10581259 DOI: 10.1016/j.ccrj.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Background It is unknown whether increasing dietary protein to 1.2-2.0 g/kg/day as recommended in international guidelines compared to current practice improves outcomes in intensive care unit (ICU) patients. The TARGET Protein trial will evaluate this. Objective To describe the study protocol for the TARGET Protein trial. Design setting and participants TARGET Protein is a cluster randomised, cross-sectional, double cross-over, pragmatic clinical trial undertaken in eight ICUs in Australia and New Zealand. Each ICU will be randomised to use one of two trial enteral formulae for three months before crossing over to the other formula, which is then repeated, with enrolment continuing at each ICU for 12 months. All patients aged ≥16 years in their index ICU admission commencing enteral nutrition will be eligible for inclusion. Eligible patients will receive the trial enteral formula to which their ICU is allocated. The two trial enteral formulae are isocaloric with a difference in protein dose: intervention 100g/1000 ml and comparator 63g/1000 ml. Staggered recruitment commenced in May 2022. Main outcomes measures The primary outcome is days free of the index hospital and alive at day 90. Secondary outcomes include days free of the index hospital at day 90 in survivors, alive at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination. Conclusion TARGET Protein aims to determine whether augmented enteral protein delivery reduces days free of the index hospital and alive at day 90. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12621001484831).
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Affiliation(s)
- Matthew J. Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Craig French
- Intensive Care Unit, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nima Kakho
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew J. Maiden
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Stephanie N. O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L. Peake
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Jeffrey J. Presneill
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Dietetics and Nutrition, Alfred Hospital, Melbourne, Victoria, Australia
| | - An Tran-Duy
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Patricia J. Williams
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Paul J. Young
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - TARGET Protein Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Intensive Care Unit, Sunshine Hospital, Melbourne, Victoria, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Dietetics and Nutrition, Alfred Hospital, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Braat S, Fielding K, Han J, Jackson VE, Zaloumis S, Xu JXH, Moir-Meyer G, Blaauwendraad SM, Jaddoe VWV, Gaillard R, Parkin PC, Borkhoff CM, Keown-Stoneman CDG, Birken CS, Maguire JL, Bahlo M, Davidson E, Pasricha SR. Statistical haemoglobin thresholds to define anaemia across the lifecycle. medRxiv 2023:2023.05.22.23290129. [PMID: 37292786 PMCID: PMC10246131 DOI: 10.1101/2023.05.22.23290129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Detection of anaemia is critical for clinical medicine and public health. Current WHO values that define anaemia are statistical thresholds (5 th centile) set over 50 years ago, and are presently <110g/L in children 6-59 months, <115g/L in children 5-11 years, <110g/L in pregnant women, <120g/L in children 12-14 years of age, <120g/L in non-pregnant women, and <130g/L in men. Haemoglobin is sensitive to iron and other nutrient deficiencies, medical illness and inflammation, and is impacted by genetic conditions; thus, careful exclusion of these conditions is crucial to obtain a healthy reference population. We identified data sources from which sufficient clinical and laboratory information was available to determine an apparently healthy reference sample. Individuals were excluded if they had any clinical or biochemical evidence of a condition that may diminish haemoglobin concentration. Discrete 5 th centiles were estimated along with two-sided 90% confidence intervals and estimates combined using a fixed-effect approach. Estimates for the 5 th centile of the healthy reference population in children were similar between sexes. Thresholds in children 6-23 months were 104.4g/L [90% CI 103.5, 105.3]; in children 24-59 months were 110.2g/L [109.5, 110.9]; and in children 5-11 years were 114.1g/L [113.2, 115.0]. Thresholds diverged by sex in adolescents and adults. In females and males 12-17 years, thresholds were 122.2g/L [121.3, 123.1] and 128.2 [126.4, 130.0], respectively. In adults 18-65 years, thresholds were 119.7g/L [119.1, 120.3] in non-pregnant females and 134.9g/L [134.2, 135.6] in males. Limited analyses indicated 5 th centiles in first-trimester pregnancy of 110.3g/L [109.5, 111.0] and 105.9g/L [104.0, 107.7] in the second trimester. All thresholds were robust to variations in definitions and analysis models. Using multiple datasets comprising Asian, African, and European ancestries, we did not identify novel high prevalence genetic variants that influence haemoglobin concentration, other than variants in genes known to cause important clinical disease, suggesting non-clinical genetic factors do not influence the 5 th centile between ancestries. Our results directly inform WHO guideline development and provide a platform for global harmonisation of laboratory, clinical and public health haemoglobin thresholds.
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Tan NL, Lee SW, Zaloumis S, Lamb KE, Dawson D, Teede HJ, Myles PS. Association of menstrual cycle and postoperative quality of recovery in premenopausal women: a prospective cohort study. BJA Open 2022; 4:100102. [PMID: 37588793 PMCID: PMC10430848 DOI: 10.1016/j.bjao.2022.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 10/06/2022] [Indexed: 08/18/2023]
Abstract
Background Women have poorer quality of postoperative recovery from general anaesthesia than men. This persists for at least 3 days postoperatively, and is more pronounced in premenopausal women. Studies of menstrual cycle effects on pain or postoperative nausea and vomiting report conflicting results. Our aim was to determine whether menstrual cycle phase is associated with quality of recovery after surgery in premenopausal women. Methods Eligible women aged 18-45 yr undergoing wisdom teeth extraction or laparoscopic cholecystectomy under general anaesthesia with volatile agents were recruited from Epworth HealthCare Richmond in Melbourne, Australia from 2019 to 2021. Menstrual history and progesterone levels were used to determine cycle phase (luteal or non-luteal). Linear mixed and generalised linear regression models were fitted to examine differences in Quality of Recovery-15 (QoR-15) score on postoperative days 1 (primary outcome) and 3, and secondary outcomes (pain, analgesic effectiveness, postoperative nausea and vomiting, prolonged hospital admission), between groups, adjusting for confounders. Results A total of 177 women were recruited (74 luteal, 103 non-luteal). Six (3%) underwent laparoscopic cholecystectomy. Estimated mean differences (95% confidence interval; P-value) in adjusted QoR-15 scores between luteal and non-luteal groups were -0.05 (-5.86 to 5.76; P=0.986) and 1.40 (-4.41 to 7.21; P=0.636) on postoperative days 1 and 3, respectively. Secondary outcomes were not different between groups. Conclusions There was no significant difference in postoperative QoR-15 score or other outcomes between women in the luteal and non-luteal phases of their cycle. Women can be reassured that cycle phase does not impact postoperative quality of recovery when undergoing minor surgery under general anaesthesia. Clinical trial registration ACTRN12618000240246.
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Affiliation(s)
- Nicole L.T. Tan
- Critical Care Institute, Epworth HealthCare, Melbourne, Australia
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia
| | - Sze Wey Lee
- Women's and Children's Clinical Institute, Epworth HealthCare, Melbourne, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Australia
| | - Karen E. Lamb
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Australia
| | - Dianne Dawson
- Research Governance Unit, Epworth HealthCare, Melbourne, Australia
| | - Helena J. Teede
- Monash Centre for Health Research and Implementation, Monash University, Melbourne, Australia
| | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Australia
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8
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Simpson J, Dini S, Zaloumis S, Price D, McCarthy J, Cherkaoui M, Kummel A, Gobeau N. 977Mechanistic within-host modelling to fast-track the selection of new antimalarial combination therapies. Int J Epidemiol 2021. [DOI: 10.1093/ije/dyab168.602] [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: 11/13/2022] Open
Abstract
Abstract
Background
The efficacy of artemisinin-based combination therapies (ACTs), currently the first-line antimalarial treatments, is declining due to the emergence of resistance of malaria parasites to these drugs. This has led drug development initiatives to search for novel combination therapies to replace the failing ACTs. We developed a biologically informed within-host model, validated against data from volunteer infection studies, to guide critical drug development decisions.
Methods
A within-host model was developed, linking drug concentrations of two novel antimalarial drugs, OZ439 and DSM265, to their combined killing action and accounting for differential killing of these compounds against stages of the parasite’s lifecycle. Data collected from malaria-infected volunteers treated with OZ439–DSM265 were used to estimate the model parameters in a hierarchical Bayesian framework. Posterior-predictive simulations of the model were used to determine the dosing regimen required to cure >90% patients.
Results
The results showed that 800 mg of OZ439 combined with 450 mg of DSM265, which are within the safe and tolerable dose range, can provide day 42 cure rates >90%, despite the estimated antagonistic interaction between the drugs. The importance of accommodating parasite age specificity of drug action was demonstrated.
Conclusions
The dosing regimens for the combination of OZ439-DSM265 determined from our data-informed in silico model suggest this compound may be a suitable candidate to replace failing ACTs.
Key messages
Assessing various scenarios within a simulation framework allows discovery of robust dosing regimens, accelerating the drug development process and ensuring efficient allocation of resources for phase 2 and 3 clinical trials.
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Affiliation(s)
| | - Saber Dini
- University of Melbourne, Melbourne, Australia
| | | | - David Price
- University of Melbourne, Melbourne, Australia
| | - James McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
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9
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Ome-Kaius M, Kattenberg JH, Zaloumis S, Siba M, Kiniboro B, Jally S, Razook Z, Mantila D, Sui D, Ginny J, Rosanas-Urgell A, Karl S, Obadia T, Barry A, Rogerson SJ, Laman M, Tisch D, Felger I, Kazura JW, Mueller I, Robinson LJ. Differential impact of malaria control interventions on P. falciparum and P. vivax infections in young Papua New Guinean children. BMC Med 2019; 17:220. [PMID: 31813381 PMCID: PMC6900859 DOI: 10.1186/s12916-019-1456-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 08/18/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION As malaria transmission declines, understanding the differential impact of intensified control on Plasmodium falciparum relative to Plasmodium vivax and identifying key drivers of ongoing transmission is essential to guide future interventions. METHODS Three longitudinal child cohorts were conducted in Papua New Guinea before (2006/2007), during (2008) and after scale-up of control interventions (2013). In each cohort, children aged 1-5 years were actively monitored for infection and illness. Incidence of malaria episodes, molecular force of blood-stage infections (molFOB) and population-averaged prevalence of infections were compared across the cohorts to investigate the impact of intensified control in young children and the key risk factors for malaria infection and illness in 2013. RESULTS Between 2006 and 2008, P. falciparum infection prevalence, molFOB, and clinical malaria episodes reduced by 47%, 59% and 69%, respectively, and a further 49%, 29% and 75% from 2008 to 2013 (prevalence 41.6% to 22.1% to 11.2%; molFOB: 3.4 to 1.4 to 1.0 clones/child/year; clinical episodes incidence rate (IR) 2.6 to 0.8 to IR 0.2 episodes/child/year). P. vivax clinical episodes declined at rates comparable to P. falciparum between 2006, 2008 and 2013 (IR 2.5 to 1.1 to 0.2), while P. vivax molFOB (2006, 9.8; 2008, 12.1) and prevalence (2006, 59.6%; 2008, 65.0%) remained high in 2008. However, in 2013, P. vivax molFOB (1.2) and prevalence (19.7%) had also substantially declined. In 2013, 89% of P. falciparum and 93% of P. vivax infections were asymptomatic, 62% and 47%, respectively, were sub-microscopic. Area of residence was the major determinant of malaria infection and illness. CONCLUSION Intensified vector control and routine case management had a differential impact on rates of P. falciparum and P. vivax infections but not clinical malaria episodes in young children. This suggests comparable reductions in new mosquito-derived infections but a delayed impact on P. vivax relapsing infections due to a previously acquired reservoir of hypnozoites. This demonstrates the need to strengthen implementation of P. vivax radical cure to maximise impact of control in co-endemic areas. The high heterogeneity of malaria in 2013 highlights the importance of surveillance and targeted interventions to accelerate towards elimination.
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Affiliation(s)
- Maria Ome-Kaius
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Johanna Helena Kattenberg
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Institute of Tropical Medicine, Antwerp, Belgium
| | - Sophie Zaloumis
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Matthew Siba
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Benson Kiniboro
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Shadrach Jally
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Zahra Razook
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Daisy Mantila
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Desmond Sui
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | - Jason Ginny
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | - Stephan Karl
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea.,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | | | - Alyssa Barry
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Stephen J Rogerson
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Moses Laman
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
| | | | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | - Ivo Mueller
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia.,Department of Medical Biology, University of Melbourne, Melbourne, Australia.,Institut Pasteur, Paris, France
| | - Leanne J Robinson
- Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea. .,Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia. .,Department of Medical Biology, University of Melbourne, Melbourne, Australia. .,Burnet Institute, Melbourne, Australia.
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Cao P, Collins KA, Zaloumis S, Wattanakul T, Tarning J, Simpson JA, McCarthy J, McCaw JM. Modeling the dynamics of Plasmodium falciparum gametocytes in humans during malaria infection. eLife 2019; 8:49058. [PMID: 31658944 PMCID: PMC6819085 DOI: 10.7554/elife.49058] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Accepted: 10/15/2019] [Indexed: 12/25/2022] Open
Abstract
Renewed efforts to eliminate malaria have highlighted the potential to interrupt human-to-mosquito transmission — a process mediated by gametocyte kinetics in human hosts. Here we study the in vivo dynamics of Plasmodium falciparum gametocytes by establishing a framework which incorporates improved measurements of parasitemia, a novel gametocyte dynamics model and model fitting using Bayesian hierarchical inference. We found that the model provides an excellent fit to the clinical data from 17 volunteers infected with P. falciparum (3D7 strain) and reliably predicts observed gametocytemia. We estimated the sexual commitment rate and gametocyte sequestration time to be 0.54% (95% credible interval: 0.30–1.00%) per asexual replication cycle and 8.39 (6.54–10.59) days respectively. We used the data-calibrated model to investigate human-to-mosquito transmissibility, providing a method to link within-human host infection kinetics to epidemiological-scale infection and transmission patterns.
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Affiliation(s)
- Pengxing Cao
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Australia
| | - Katharine A Collins
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, Netherlands
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Thanaporn Wattanakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - James McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - James M McCaw
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Epidemiology, Peter Doherty Institute for Infection and Immunity, Parkville, Australia
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11
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Dini S, Zaloumis S, Cao P, Price RN, Fowkes FJI, van der Pluijm RW, McCaw JM, Simpson JA. Investigating the Efficacy of Triple Artemisinin-Based Combination Therapies for Treating Plasmodium falciparum Malaria Patients Using Mathematical Modeling. Antimicrob Agents Chemother 2018; 62:e01068-18. [PMID: 30150462 PMCID: PMC6201091 DOI: 10.1128/aac.01068-18] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 08/07/2018] [Indexed: 01/13/2023] Open
Abstract
The first line treatment for uncomplicated falciparum malaria is artemisinin-based combination therapy (ACT), which consists of an artemisinin derivative coadministered with a longer-acting partner drug. However, the spread of Plasmodium falciparum resistant to both artemisinin and its partner drugs poses a major global threat to malaria control activities. Novel strategies are needed to retard and reverse the spread of these resistant parasites. One such strategy is triple artemisinin-based combination therapy (TACT). We developed a mechanistic within-host mathematical model to investigate the efficacy of a TACT (dihydroartemisinin-piperaquine-mefloquine [DHA-PPQ-MQ]) for use in South-East Asia, where DHA and PPQ resistance are now increasingly prevalent. Comprehensive model simulations were used to explore the degree to which the underlying resistance influences the parasitological outcomes. The effect of MQ dosing on the efficacy of TACT was quantified at various degrees of DHA and PPQ resistance. To incorporate interactions between drugs, a novel model is presented for the combined effect of DHA-PPQ-MQ, which illustrates how the interactions can influence treatment efficacy. When combined with a standard regimen of DHA and PPQ, the administration of three 6.7-mg/kg doses of MQ was sufficient to achieve parasitological efficacy greater than that currently recommended by World Health Organization (WHO) guidelines. As a result, three 8.3-mg/kg doses of MQ, the current WHO-recommended dosing regimen for MQ, combined with DHA-PPQ, has the potential to produce high cure rates in regions where resistance to DHA-PPQ has emerged.
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Affiliation(s)
- Saber Dini
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Pengxing Cao
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Australia
| | - Ric N Price
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Casuarina, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Freya J I Fowkes
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Burnet Institute, Disease Elimination Program, Public Health, Melbourne, Australia
- Department of Epidemiology and Preventative Medicine and Department of Infectious Diseases, Monash University, Melbourne, Australia
| | - Rob W van der Pluijm
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - James M McCaw
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- School of Mathematics and Statistics, University of Melbourne, Melbourne, Australia
- Peter Doherty Institute for Infection and Immunity, The Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
- Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
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Cao P, Klonis N, Zaloumis S, Khoury DS, Cromer D, Davenport MP, Tilley L, Simpson JA, McCaw JM. A mechanistic model quantifies artemisinin-induced parasite growth retardation in blood-stage Plasmodium falciparum infection. J Theor Biol 2017; 430:117-127. [PMID: 28728995 DOI: 10.1016/j.jtbi.2017.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 07/13/2017] [Accepted: 07/17/2017] [Indexed: 11/16/2022]
Abstract
Falciparum malaria is a major parasitic disease causing widespread morbidity and mortality globally. Artemisinin derivatives-the most effective and widely-used antimalarials that have helped reduce the burden of malaria by 60% in some areas over the past decade-have recently been found to induce growth retardation of blood-stage Plasmodium falciparum when applied at clinically relevant concentrations. To date, no model has been designed to quantify the growth retardation effect and to predict the influence of this property on in vivo parasite killing. Here we introduce a mechanistic model of parasite growth from the ring to trophozoite stage of the parasite's life cycle, and by modelling the level of staining with an RNA-binding dye, we demonstrate that the model is able to reproduce fluorescence distribution data from in vitro experiments using the laboratory 3D7 strain. We quantify the dependence of growth retardation on drug concentration and identify the concentration threshold above which growth retardation is evident. We estimate that the parasite life cycle is prolonged by up to 10 hours. We illustrate that even such a relatively short delay in growth may significantly influence in vivo parasite dynamics, demonstrating the importance of considering growth retardation in the design of optimal artemisinin-based dosing regimens.
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Affiliation(s)
- Pengxing Cao
- School of Mathematics and Statistics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nectarios Klonis
- Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - David S Khoury
- Infection Analytics Program, Kirby Institute, UNSW Australia, Kensington, New South Wales, Australia
| | - Deborah Cromer
- Infection Analytics Program, Kirby Institute, UNSW Australia, Kensington, New South Wales, Australia
| | - Miles P Davenport
- Infection Analytics Program, Kirby Institute, UNSW Australia, Kensington, New South Wales, Australia
| | - Leann Tilley
- Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, University of Melbourne, Melbourne, Victoria, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - James M McCaw
- School of Mathematics and Statistics, The University of Melbourne, Melbourne, Victoria, Australia; Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia; Modelling and Simulation, Infection and Immunity Theme, Murdoch Childrens Research Institute, The Royal Children's Hospital, Parkville, Victoria, Australia.
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Patel K, Simpson JA, Batty KT, Zaloumis S, Kirkpatrick CM. Modelling the time course of antimalarial parasite killing: a tour of animal and human models, translation and challenges. Br J Clin Pharmacol 2015; 79:97-107. [PMID: 24251882 DOI: 10.1111/bcp.12288] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 10/31/2013] [Indexed: 01/06/2023] Open
Abstract
Malaria remains a global public health concern and current treatment options are suboptimal in some clinical settings. For effective chemotherapy, antimalarial drug concentrations must be sufficient to remove completely all of the parasites in the infected host. Optimized dosing therefore requires a detailed understanding of the time course of antimalarial response, whilst simultaneously considering the parasite life cycle and host immune elimination. Recently, the World Health Organization (WHO) has recommended the development of mathematical models for understanding better antimalarial drug resistance and management. Other international groups have also suggested that mechanistic pharmacokinetic (PK) and pharmacodynamic (PD) models can support the rationalization of antimalarial dosing strategies. At present, artemisinin-based combination therapy (ACT) is recommended as first line treatment of falciparum malaria for all patient groups. This review summarizes the PK-PD characterization of artemisinin derivatives and other partner drugs from both preclinical studies and human clinical trials. We outline the continuous and discrete time models that have been proposed to describe antimalarial activity on specific stages of the parasite life cycle. The translation of PK-PD predictions from animals to humans is considered, because preclinical studies can provide rich data for detailed mechanism-based modelling. While similar sampling techniques are limited in clinical studies, PK-PD models can be used to optimize the design of experiments to improve estimation of the parameters of interest. Ultimately, we propose that fully developed mechanistic models can simulate and rationalize ACT or other treatment strategies in antimalarial chemotherapy.
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Affiliation(s)
- Kashyap Patel
- Centre for Medicine Use and Safety, Monash University, Melbourne, VIC, Australia
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Lodge CJ, Lowe AJ, Allen KJ, Zaloumis S, Gurrin LC, Matheson MC, Axelrad C, Welsh L, Bennett CM, Hopper J, Thomas PS, Hill DJ, Hosking CS, Svanes C, Abramson MJ, Dharmage SC. Childhood wheeze phenotypes show less than expected growth in FEV1 across adolescence. Am J Respir Crit Care Med 2014; 189:1351-8. [PMID: 24796409 DOI: 10.1164/rccm.201308-1487oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
RATIONALE Better characterization of childhood wheeze phenotypes using newer statistical methods provides a basis for addressing the heterogeneity of childhood asthma. Outcomes of these phenotypes beyond childhood are unknown. OBJECTIVES To determine if adolescent respiratory symptoms, lung function, and changes in lung function over adolescence differ by childhood wheeze phenotypes defined through latent class analysis. METHODS A prospective birth cohort (Melbourne Atopy Cohort Study) followed 620 high allergy-risk children, recording respiratory symptoms and spirometry at 12 and 18 years. Regression analyses identified relationships between wheeze phenotypes (never/infrequent, early transient, early persistent, intermediate onset, and late onset) and lung function, change in lung function (12-18 yr), respiratory symptoms, and asthma. The baseline classification was never/infrequent wheeze. MEASUREMENTS AND MAIN RESULTS Deficits in expected growth of lung function, measured by change in prebronchodilator FEV1 between 12 and 18 years, were found for early persistent (reduced 290 ml; 95% confidence interval [CI], 82-498), intermediate-onset (reduced 210 ml; 95% CI, 62-359), and late-onset wheeze (reduced 255 ml; 95% CI, 69-442). Intermediate-onset wheezers had persistent FEV1 deficit after bronchodilator at 18 years (reduced 198 ml; 46,350). Current asthma risk was increased for all phenotypes except early transient, which was also not associated with lung function deficits at 12 or 18 years. CONCLUSIONS Persistent wheeze phenotypes in childhood were associated with reduced growth in prebronchodilator FEV1 over adolescence. Intermediate-onset wheezers showed irreversible airflow limitation by 18 years. Conversely, early transient wheeze was a benign condition with no sequelae for respiratory health by age 18.
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Affiliation(s)
- Caroline J Lodge
- 1 Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Melbourne, Australia
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15
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Simpson JA, Zaloumis S, DeLivera AM, Price RN, McCaw JM. Making the most of clinical data: reviewing the role of pharmacokinetic-pharmacodynamic models of anti-malarial drugs. AAPS J 2014; 16:962-74. [PMID: 25056904 DOI: 10.1208/s12248-014-9647-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/02/2014] [Indexed: 12/20/2022]
Abstract
Mechanistic within-host models integrating blood anti-malarial drug concentrations with the parasite-time profile provide a valuable decision tool for determining dosing regimens for anti-malarial treatments, as well as a formative component of population-level drug resistance models. We reviewed published anti-malarial pharmacokinetic-pharmacodynamic models to identify the challenges for these complex models where parameter estimation from clinical field data is limited. The inclusion of key pharmacodynamic processes in the mechanistic structure adopted varies considerably. These include the life cycle of the parasite within the red blood cell, the action of the anti-malarial on a specific stage of the life cycle, and the reduction in parasite growth associated with immunity. With regard to estimation of the pharmacodynamic parameters, the majority of studies simply compared descriptive summaries of the simulated outputs to published observations of host and parasite responses from clinical studies. Few studies formally estimated the pharmacodynamic parameters within a rigorous statistical framework using observed individual patient data. We recommend three steps in the development and evaluation of these models. Firstly, exploration through simulation to assess how the different parameters influence the parasite dynamics. Secondly, application of a simulation-estimation approach to determine whether the model parameters can be estimated with reasonable precision based on sampling designs that mimic clinical efficacy studies. Thirdly, fitting the mechanistic model to the clinical data within a Bayesian framework. We propose that authors present the model both schematically and in equation form and give a detailed description of each parameter, including a biological interpretation of the parameter estimates.
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Affiliation(s)
- Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia,
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De Livera AM, Zaloumis S, Simpson JA. Models for the analysis of repeated continuous outcome measures in clinical trials. Respirology 2013; 19:155-161. [PMID: 24268035 DOI: 10.1111/resp.12217] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 09/26/2013] [Indexed: 11/28/2022]
Abstract
Repeated continuous outcome measures are common in clinical trials. In this tutorial style paper, using data collected from a trial evaluating an intervention for managing asthma and chronic obstructive pulmonary disease, we demonstrate ways of statistically analysing such data to answer frequently encountered clinical research questions. We illustrate the use of linear mixed effects modelling in doing so and discuss its advantages over several other commonly used approaches. The methods described in this paper can easily be carried out using standard statistical software.
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Affiliation(s)
- Alysha M De Livera
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Centre for Biostatistics (ViCBiostat), Melbourne, Victoria, Australia
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Centre for Biostatistics (ViCBiostat), Melbourne, Victoria, Australia
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Victorian Centre for Biostatistics (ViCBiostat), Melbourne, Victoria, Australia
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Simpson JA, Jamsen KM, Anderson TJC, Zaloumis S, Nair S, Woodrow C, White NJ, Nosten F, Price RN. Nonlinear mixed-effects modelling of in vitro drug susceptibility and molecular correlates of multidrug resistant Plasmodium falciparum. PLoS One 2013; 8:e69505. [PMID: 23894496 PMCID: PMC3722116 DOI: 10.1371/journal.pone.0069505] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 06/10/2013] [Indexed: 11/19/2022] Open
Abstract
The analysis of in vitro anti-malarial drug susceptibility testing is vulnerable to the effects of different statistical approaches and selection biases. These confounding factors were assessed with respect to pfmdr1 gene mutation and amplification in 490 clinical isolates. Two statistical approaches for estimating the drug concentration associated with 50% effect (EC50) were compared: the commonly used standard two-stage (STS) method, and nonlinear mixed-effects modelling. The in vitro concentration-effect relationships for, chloroquine, mefloquine, lumefantrine and artesunate, were derived from clinical isolates obtained from patients on the western border of Thailand. All isolates were genotyped for polymorphisms in the pfmdr1 gene. The EC50 estimates were similar for the two statistical approaches but 15–28% of isolates in the STS method had a high coefficient of variation (>15%) for individual estimates of EC50 and these isolates had EC50 values that were 32 to 66% higher than isolates derived with more precision. In total 41% (202/490) of isolates had amplification of pfmdr1 and single nucleotide polymorphisms were found in 50 (10%). Pfmdr1 amplification was associated with an increase in EC50 for mefloquine (139% relative increase in EC50 for 2 copies, 188% for 3+ copies), lumefantrine (82% and 75% for 2 and 3+ copies respectively) and artesunate (63% and 127% for 2 and 3+ copies respectively). In contrast pfmdr1 mutation at codons 86 or 1042 were associated with an increase in chloroquine EC50 (44–48%). Sample size calculations showed that to demonstrate an EC50 shift of 50% or more with 80% power if the prevalence was 10% would require 430 isolates and 245 isolates if the prevalence was 20%. In conclusion, although nonlinear mixed-effects modelling did not demonstrate any major advantage for determining estimates of anti-malarial drug susceptibility, the method includes all isolates, thereby, potentially improving confirmation of candidate molecular markers of anti-malarial drug susceptibility.
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Affiliation(s)
- Julie A Simpson
- Centre for Molecular, Environmental, Genetic & Analytic Epidemiology, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
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Affiliation(s)
- A. J. Lowe
- Melbourne School of Population and Global Health; The University of Melbourne; Melbourne Australia
- Murdoch Childrens Research Institute; Melbourne Australia
| | - S. Zaloumis
- Melbourne School of Population and Global Health; The University of Melbourne; Melbourne Australia
| | - S. C. Dharmage
- Melbourne School of Population and Global Health; The University of Melbourne; Melbourne Australia
- Murdoch Childrens Research Institute; Melbourne Australia
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Zaloumis S, Humberstone A, Charman SA, Price RN, Moehrle J, Gamo-Benito J, McCaw J, Jamsen KM, Smith K, Simpson JA. Assessing the utility of an anti-malarial pharmacokinetic-pharmacodynamic model for aiding drug clinical development. Malar J 2012; 11:303. [PMID: 22931058 PMCID: PMC3546862 DOI: 10.1186/1475-2875-11-303] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 08/01/2012] [Indexed: 01/01/2023] Open
Abstract
Background Mechanistic within-host models relating blood anti-malarial drug concentrations with the parasite-time profile help in assessing dosing schedules and partner drugs for new anti-malarial treatments. A comprehensive simulation study to assess the utility of a stage-specific pharmacokinetic-pharmacodynamic (PK-PD) model for predicting within-host parasite response was performed. Methods Three anti-malarial combination therapies were selected: artesunate-mefloquine, dihydroartemisinin-piperaquine, and artemether-lumefantrine. The PK-PD model included parameters to represent the concentration-time profiles of both drugs, the initial parasite burden and distribution across the parasite life cycle, and the parasite multiplication factor due to asexual reproduction. The model also included the maximal killing rate of each drug, and the blood drug concentration associated with half of that killing effect (in vivo EC50), derived from the in vitro IC50, the extent of binding to 0.5% Albumax present in the in vitro testing media, and the drugs plasma protein binding and whole blood to plasma partitioning ratio. All stochastic simulations were performed using a Latin-Hypercube-Sampling approach. Results The simulations demonstrated that the proportion of patients cured was highly sensitive to the in vivo EC50 and the maximal killing rate of the partner drug co-administered with the artemisinin derivative. The in vivo EC50 values that corresponded to on average 95% of patients cured were much higher than the adjusted values derived from the in vitro IC50. The proportion clinically cured was not strongly influenced by changes in the parameters defining the age distribution of the initial parasite burden (mean age of 4 to 16 hours) and the parasite multiplication factor every life cycle (ranging from 8 to 12 fold/cycle). The median parasite clearance times, however, lengthened as the standard deviation of the initial parasite burden increased (i.e. the infection became more asynchronous). Conclusions This simulation study demonstrates that the PD effect predicted from in vitro growth inhibition assays does not accord well with the PD effect of the anti-malarials observed within the patient. This simulation-based PK-PD modelling approach should not be considered as a replacement to conducting clinical trials but instead as a decision tool to improve the design of a clinical trial during drug development.
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Affiliation(s)
- Sophie Zaloumis
- Centre for Molecular, Environmental, Genetic & Analytic Epidemiology, Melbourne School of Population Health, University of Melbourne, Level 3, 207 Bouverie St, Carlton, VIC 3053, Australia.
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Yip L, Zaloumis S, Irwin D, Severi G, Hopper J, Giles G, Harrap S, Sinclair R, Ellis J. Association analysis of oestrogen receptor beta gene (ESR2) polymorphisms with female pattern hair loss. Br J Dermatol 2012; 166:1131-4. [PMID: 22014031 DOI: 10.1111/j.1365-2133.2011.10702.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Webster RJ, Carter KW, Warrington NM, Loh AM, Zaloumis S, Kuijpers TW, Palmer LJ, Burgner DP. Hospitalisation with infection, asthma and allergy in Kawasaki disease patients and their families: genealogical analysis using linked population data. PLoS One 2011; 6:e28004. [PMID: 22140498 PMCID: PMC3225371 DOI: 10.1371/journal.pone.0028004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 10/29/2011] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Kawasaki disease results from an abnormal immunological response to one or more infectious triggers. We hypothesised that heritable differences in immune responses in Kawasaki disease-affected children and their families would result in different epidemiological patterns of other immune-related conditions. We investigated whether hospitalisation for infection and asthma/allergy were different in Kawasaki disease-affected children and their relatives. METHODS/MAJOR FINDINGS We used Western Australian population-linked health data from live births (1970-2006) to compare patterns of hospital admissions in Kawasaki disease cases, age- and sex-matched controls, and their relatives. There were 295 Kawasaki disease cases and 598 age- and sex-matched controls, with 1,636 and 3,780 relatives, respectively. Compared to controls, cases were more likely to have been admitted at least once with an infection (cases, 150 admissions (50.8%) vs controls, 210 admissions (35.1%); odds ratio (OR) = 1.9, 95% confidence interval (CI) 1.4-2.6, P = 7.2×10⁻⁶), and with asthma/allergy (cases, 49 admissions (16.6%) vs controls, 42 admissions (7.0%); OR = 2.6, 95% CI 1.7-4.2, P = 1.3×10⁻⁵). Cases also had more admissions per person with infection (cases, median 2 admissions, 95% CI 1-5, vs controls, median 1 admission, 95% CI 1-4, P = 1.09×10⁻⁵). The risk of admission with infection was higher in the first degree relatives of Kawasaki disease cases compared to those of controls, but the differences were not significant. CONCLUSION Differences in the immune phenotype of children who develop Kawasaki disease may influence the severity of other immune-related conditions, with some similar patterns observed in relatives. These data suggest the influence of shared heritable factors in these families.
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Affiliation(s)
- Rebecca J. Webster
- Centre for Genetic Epidemiology and Biostatistics, University of Western Australia, Perth, Australia
| | - Kim W. Carter
- Division of Bioinformatics and Biostatistics, Telethon Institute for Child Health Research, UWA Centre for Child Health Research, University of Western Australia, Perth, Australia
| | - Nicole M. Warrington
- School of Women's and Infants' Health, University of Western Australia, Perth, Australia
| | - Angeline M. Loh
- Centre for Genetic Epidemiology and Biostatistics, University of Western Australia, Perth, Australia
| | - Sophie Zaloumis
- Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, University of Melbourne, Melbourne, Australia
| | - Taco W. Kuijpers
- Department of Pediatric Hematology, Immunology and Infectious Diseases, Emma Children's Hospital, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Lyle J. Palmer
- Centre for Genetic Epidemiology and Biostatistics, University of Western Australia, Perth, Australia
| | - David P. Burgner
- School of Pediatrics and Child Health, University of Western Australia, Perth, Australia
- Murdoch Childrens Research Institute, Royal Children's Hospital, Parkville, Australia
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Yip L, Zaloumis S, Irwin D, Severi G, Hopper J, Giles G, Harrap S, Sinclair R, Ellis J. Gene-wide association study between the aromatase gene (CYP19A1) and female pattern hair loss. Br J Dermatol 2009; 161:289-94. [DOI: 10.1111/j.1365-2133.2009.09186.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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