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du Cros P, Greig J, Alffenaar JWC, Cross GB, Cousins C, Berry C, Khan U, Phillips PPJ, Velásquez GE, Furin J, Spigelman M, Denholm JT, Thi SS, Tiberi S, Huang GKL, Marks GB, Turkova A, Guglielmetti L, Chew KL, Nguyen HT, Ong CWM, Brigden G, Singh KP, Motta I, Lange C, Seddon JA, Nyang'wa BT, Maug AKJ, Gler MT, Dooley KE, Quelapio M, Tsogt B, Menzies D, Cox V, Upton CM, Skrahina A, McKenna L, Horsburgh CR, Dheda K, Marais BJ. Standards for clinical trials for treating TB. Int J Tuberc Lung Dis 2023; 27:885-898. [PMID: 38042969 PMCID: PMC10719894 DOI: 10.5588/ijtld.23.0341] [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: 07/25/2023] [Accepted: 08/21/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND: The value, speed of completion and robustness of the evidence generated by TB treatment trials could be improved by implementing standards for best practice.METHODS: A global panel of experts participated in a Delphi process, using a 7-point Likert scale to score and revise draft standards until consensus was reached.RESULTS: Eleven standards were defined: Standard 1, high quality data on TB regimens are essential to inform clinical and programmatic management; Standard 2, the research questions addressed by TB trials should be relevant to affected communities, who should be included in all trial stages; Standard 3, trials should make every effort to be as inclusive as possible; Standard 4, the most efficient trial designs should be considered to improve the evidence base as quickly and cost effectively as possible, without compromising quality; Standard 5, trial governance should be in line with accepted good clinical practice; Standard 6, trials should investigate and report strategies that promote optimal engagement in care; Standard 7, where possible, TB trials should include pharmacokinetic and pharmacodynamic components; Standard 8, outcomes should include frequency of disease recurrence and post-treatment sequelae; Standard 9, TB trials should aim to harmonise key outcomes and data structures across studies; Standard 10, TB trials should include biobanking; Standard 11, treatment trials should invest in capacity strengthening of local trial and TB programme staff.CONCLUSION: These standards should improve the efficiency and effectiveness of evidence generation, as well as the translation of research into policy and practice.
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Affiliation(s)
- P du Cros
- Burnet Institute, Melbourne, VIC, Monash Infectious Diseases, Monash Health, Melbourne, VIC, Australia
| | - J Greig
- Burnet Institute, Melbourne, VIC, Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | - J-W C Alffenaar
- Sydney Infectious Diseases Institute (Sydney ID), and, School of Pharmacy, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Westmead Hospital, Sydney, NSW
| | - G B Cross
- Burnet Institute, Melbourne, VIC, Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - C Cousins
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - C Berry
- Médecins Sans Frontières (MSF), Manson Unit, London, UK
| | - U Khan
- Interactive Research and Development Global, Singapore City, Singapore
| | - P P J Phillips
- UCSF Center for Tuberculosis, Division of Pulmonary and Critical Care Medicine, and
| | - G E Velásquez
- UCSF Center for Tuberculosis, Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA
| | - J Furin
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA
| | - M Spigelman
- Global Alliance for TB Drug Development, New York, NY, USA
| | - J T Denholm
- Victorian Tuberculosis Program, Melbourne Health, Melbourne, VIC, Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia
| | - S S Thi
- Eswatini National TB Control Program, Mbabane, Kingdom of Eswatini
| | - S Tiberi
- Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, GlaxoSmithKline, London, UK
| | - G K L Huang
- Burnet Institute, Melbourne, VIC, Northern Health Infectious Diseases, Northern Health, Melbourne, VIC
| | - G B Marks
- School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - A Turkova
- Medical Research Council Clinical Trials Unit at University College London, London, UK
| | - L Guglielmetti
- Médecins Sans Frontières (MSF), Paris, Sorbonne Université, Institut national de la santé et de la recherche médicale, Unité 1135, Centre d'Immunologie et des Maladies Infectieuses, Paris, Assistance Publique Hôpitaux de Paris (APHP), Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries, Paris, France
| | - K L Chew
- Department of Laboratory Medicine, National University Hospital, Singapore City, Singapore
| | - H T Nguyen
- Research Department, Friends for International TB Relief, Ha Noi, Vietnam
| | - C W M Ong
- Infectious Diseases Translational Research Programme, Department of Medicine, National University of Singapore, Singapore City, Division of Infectious Diseases, Department of Medicine, National University Hospital, Singapore City, Institute of Healthcare Innovation & Technology, National University of Singapore, Singapore City, Singapore
| | - G Brigden
- The Global Fund, Geneva, Switzerland
| | - K P Singh
- Department of Infectious Diseases, Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC, Australia, Victorian Infectious Disease Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - C Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, German Center for Infection Research (DZIF), TTU-TB, Borstel, Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - J A Seddon
- Department of Infectious Disease, Imperial College London, London, UK, Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - B-T Nyang'wa
- Public Health Department, Operational Center Amsterdam (OCA), MSF, Amsterdam, The Netherlands
| | - A K J Maug
- Damien Foundation Bangladesh, Dhaka, Bangladesh
| | - M T Gler
- De La Salle Medical and Health Sciences Institute, Dasmariñas, the Philippines
| | - K E Dooley
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA
| | - M Quelapio
- Tropical Disease Foundation, Makati City, Manila, the Philippines, KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - B Tsogt
- Mongolian Anti-TB Coalition, Ulaanbaatar, Mongolia
| | - D Menzies
- Respiratory Epidemiology and Clinical Research Unit, Montreal Chest Institute & McGill International TB Centre, Montreal, QC, Canada
| | - V Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town
| | - C M Upton
- TASK Applied Science, Cape Town, South Africa
| | - A Skrahina
- The Republican Scientific and Practical Center for Pulmonology and TB, Minsk, Belarus
| | - L McKenna
- Treatment Action Group, New York, NY
| | - C R Horsburgh
- Departments of Global Health, Epidemiology, Biostatistics and Medicine, Schools of Public Health and Medicine, Boston University, Boston MA, USA
| | - K Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa, Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene & Tropical Medicine, London, UK
| | - B J Marais
- Sydney Infectious Diseases Institute (Sydney ID), and, The Children's Hospital at Westmead, Sydney, NSW, WHO Collaborating Centre in Tuberculosis, The University of Sydney, Sydney, NSW, Australia
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Cavazos A, Iskander GM, Cox V, Cheng H, Ejezie CL, Perez S, Nguyen J, Beddar S, Liao Z, Yeboa DN. Protocol in a Day: An Educational Institutional Workshop for Protocol Development. Int J Radiat Oncol Biol Phys 2023; 117:e557-e558. [PMID: 37785710 DOI: 10.1016/j.ijrobp.2023.06.1871] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) The Protocol-in-a-Day (PIAD) workshop was developed to support junior faculty and residents with clinical trial protocol design, with the main goal of providing initial feedback during development to reduce time for review and approval from institutional oversight committees. Our objectives are to mentor and educate participants and to evaluate the time to institutional approval by oversight committees. MATERIALS/METHODS PIAD provided concurrent educational feedback on 6 key elements of trial design. These included: (1) regulatory aspects; (2) institutional scientific review committee (SRC) and institutional review board (IRB); (3) clinical research and data coordination (including nursing); (4) statistics; (5) correlatives including imaging, biospecimens, and health services research/patient-reported outcomes; and (6) operations. The average number of days from submission to IRB approval or study activation for PIAD protocols was compared to other protocols submitted between January 2018 - January 2022 within the Division of Radiation Oncology. Participants were also given a 15-question survey to assess their perspective of the impact of the workshop. RESULTS A total of 25 protocols went through the PIAD workshop between January 2018-January 2022. Of the 25 protocols, 7 (28%) were excluded from this study due to not being submitted possibly after participants benefited from education on the limitations of their design. Eighteen protocols were included in our final analyses. These protocols included phase II (n = 11), phase 1 (n = 5), and phase III (n = 2). At the time of this report, all protocols (n = 18) have received IRB approval and have been activated. Protocol elements that could impact study activation included protocols requiring investigational new drug (IND) approval (n = 8) and multicenter studies (n = 1). Analyzing the time of submission to request for activation showed a decrease in time for protocols that went through PIAD vs those that did not [PIAD protocols, 254 days vs All other protocols, 262 days]. Likewise, those who attended PIAD had a lower average time from submission to IRB Approval [ PIAD protocols, 40 days vs All other protocols, 59 days]. All participants (100%) of the PIAD workshop responded that the educational program "improved the overall quality of the study design." The most commonly cited changes were protocol language (n = 17), statistics (n = 15), consent language (n = 8), and study design (n = 8). Aspects participants identified as the most educational included mentorship from regulatory, clinical research finance, and IRB review. CONCLUSION PIAD from participant surveys provided high educational value in the areas of improving trial quality, language and statistical design. When analyzing the average time, from 'submission to IRB initial approval' and 'submission to activation', PIAD protocols had a shorter time for approval, and thus suggests PIAD is effective in improving the overall design of protocols.
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Affiliation(s)
- A Cavazos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - G M Iskander
- MD Anderson Cancer Center, Houston, TX; Tillman J Fertitta Family College of Medicine, Houston, TX
| | - V Cox
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - H Cheng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX; UT Southwestern Medical Center, Dallas, TX
| | - C L Ejezie
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Perez
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - J Nguyen
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - S Beddar
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Z Liao
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - D N Yeboa
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
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Mohr-Holland E, Daniels J, Reuter A, Rodriguez CA, Mitnick C, Kock Y, Cox V, Furin J, Cox H. Early mortality during rifampicin-resistant TB treatment. Int J Tuberc Lung Dis 2022; 26:150-157. [PMID: 35086627 PMCID: PMC8802559 DOI: 10.5588/ijtld.21.0494] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/30/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: Data suggest that treatment with newer TB drugs (linezolid [LZD], bedaquiline [BDQ] and delamanid [DLM]), used in Khayelitsha, South Africa, since 2012, reduces mortality due to rifampicin-resistant TB (RR-TB).METHODS: This was a retrospective cohort study to assess 6-month mortality among RR-TB patients diagnosed between 2008 and 2019.RESULTS: By 6 months, 236/2,008 (12%) patients died; 12% (78/651) among those diagnosed in 2008-2011, and respectively 8% (49/619) and 15% (109/738) with and without LZD/BDQ/DLM in 2012-2019. Multivariable analysis showed a small, non-significant mortality reduction with LZD/BDQ/DLM use compared to the 2008-2011 period (aOR 0.79, 95% CI 0.5-1.2). Inpatient treatment initiation (aOR 3.2, 95% CI 2.4-4.4), fluoroquinolone (FQ) resistance (aOR 2.7, 95% CI 1.8-4.2) and female sex (aOR 1.5, 95% CI 1.1-2.0) were also associated with mortality. When restricted to 2012-2019, use of LZD/BDQ/DLM was associated with lower mortality (aOR 0.58, 95% CI 0.39-0.87).CONCLUSIONS: While LZD/BDQ/DLM reduced 6-month mortality between 2012 and 2019, there was no significant effect overall. These findings may be due to initially restricted LZD/BDQ/DLM use for those with high-level resistance or treatment failure. Additional contributors include increased treatment initiation among individuals who would have otherwise died before treatment due to universal drug susceptibility testing from 2012, an effect that also likely contributed to higher mortality among females (survival through to care-seeking).
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Affiliation(s)
- E Mohr-Holland
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa, Southern Africa Medical Unit, MSF, Cape Town, South Africa
| | - J Daniels
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - A Reuter
- Khayelitsha Project, Médecins Sans Frontières (MSF), Cape Town, South Africa
| | - C A Rodriguez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - C Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Y Kock
- National Department of Health, Pretoria, South Africa
| | - V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - H Cox
- Division of Medical Microbiology, Department of Pathology, University of Cape Town, Cape Town, South Africa, Institute for Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
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Guglielmetti L, Ardizzoni E, Atger M, Baudin E, Berikova E, Bonnet M, Chang E, Cloez S, Coit JM, Cox V, de Jong BC, Delifer C, Do JM, Tozzi DDS, Ducher V, Ferlazzo G, Gouillou M, Khan A, Khan U, Lachenal N, LaHood AN, Lecca L, Mazmanian M, McIlleron H, Moschioni M, O’Brien K, Okunbor O, Oyewusi L, Panda S, Patil SB, Phillips PPJ, Pichon L, Rupasinghe P, Rich ML, Saluhuddin N, Seung KJ, Tamirat M, Trippa L, Cellamare M, Velásquez GE, Wasserman S, Zimetbaum PJ, Varaine F, Mitnick CD. Evaluating newly approved drugs for multidrug-resistant tuberculosis (endTB): study protocol for an adaptive, multi-country randomized controlled trial. Trials 2021; 22:651. [PMID: 34563240 PMCID: PMC8465691 DOI: 10.1186/s13063-021-05491-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 03/08/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) is expensive, labour-intensive, and associated with substantial adverse events and poor outcomes. While most MDR/RR-TB patients do not receive treatment, many who do are treated for 18 months or more. A shorter all-oral regimen is currently recommended for only a sub-set of MDR/RR-TB. Its use is only conditionally recommended because of very low-quality evidence underpinning the recommendation. Novel combinations of newer and repurposed drugs bring hope in the fight against MDR/RR-TB, but their use has not been optimized in all-oral, shorter regimens. This has greatly limited their impact on the burden of disease. There is, therefore, dire need for high-quality evidence on the performance of new, shortened, injectable-sparing regimens for MDR-TB which can be adapted to individual patients and different settings. METHODS endTB is a phase III, pragmatic, multi-country, adaptive, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of shorter treatment regimens containing new drugs for patients with fluoroquinolone-susceptible, rifampin-resistant tuberculosis. Study participants are randomized to either the control arm, based on the current standard of care for MDR/RR-TB, or to one of five 39-week multi-drug regimens containing newly approved and repurposed drugs. Study participation in all arms lasts at least 73 and up to 104 weeks post-randomization. Randomization is response-adapted using interim Bayesian analysis of efficacy endpoints. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 750 patients across 6 arms affords at least 80% power to detect the non-inferiority of at least 1 (and up to 3) experimental regimens, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per protocol populations. DISCUSSION The lack of a safe and effective regimen that can be used in all patients is a major obstacle to delivering appropriate treatment to all patients with active MDR/RR-TB. Identifying multiple shorter, safe, and effective regimens has the potential to greatly reduce the burden of this deadly disease worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02754765. Registered on 28 April 2016; the record was last updated for study protocol version 3.3, on 27 August 2019.
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Affiliation(s)
- L. Guglielmetti
- Médecins Sans Frontières, Paris, France
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie Et Des Maladies Infectieuses, Paris, France
- Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National De Référence Des Mycobactéries Et De La Résistance Des Mycobactéries Aux Antituberculeux, Paris, France
| | - E. Ardizzoni
- Institute of Tropical Medicine, Antwerp, Belgium
| | - M. Atger
- Médecins Sans Frontières, Paris, France
| | | | - E. Berikova
- Partners In Health, Astana, Kazakhstan
- National Scientific Center of Phthisiopulmonology, Almaty, Kazakhstan
| | - M. Bonnet
- Médecins Sans Frontières, Paris, France
- Institut de Recherche pour le Développement/INSERM U1175/UMI233/ Université de Montpellier, Montpellier, France
| | - E. Chang
- Médecins Sans Frontières, Toronto, Ontario Canada
| | - S. Cloez
- Médecins Sans Frontières, Paris, France
| | - J. M. Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - V. Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | | | - J. M. Do
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | | | - V. Ducher
- Médecins Sans Frontières, Paris, France
| | - G. Ferlazzo
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - A. Khan
- Interactive Research and Development, Karachi, Pakistan
| | - U. Khan
- Interactive Research and Development, Karachi, Pakistan
| | | | - A. N. LaHood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - L. Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Socios En Salud-Sucursal Peru, Lima, Peru
| | - M. Mazmanian
- Médecins Sans Frontières, Paris, France
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique, Hôpital Pitié-Salpêtrière, Paris, France
| | - H. McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - O. Okunbor
- Social & Scientific Systems-DLH, Silver Spring, MD USA
| | | | - S. Panda
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, Pune, India
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - S. B. Patil
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - P. P. J. Phillips
- University of San Francisco Center for Tuberculosis, San Francisco, CA USA
| | - L. Pichon
- Médecins Sans Frontières, Paris, France
| | | | - M. L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | - N. Saluhuddin
- Department of Infectious Diseases, Indus Hospital, Karachi, Pakistan
| | - K. J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | | | - L. Trippa
- Dana-Farber Cancer Institute, Boston, MA USA
- Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | - G. E. Velásquez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA USA
| | - S. Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - P. J. Zimetbaum
- Harvard Medical School, Boston, MA USA
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | | | - C. D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
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Cox V, McKenna L, Acquah R, Reuter A, Wasserman S, Vambe D, Ustero P, Udwadia Z, Triviño-Duran L, Tommasi M, Skrahina A, Seddon JA, Rodolfo R, Rich M, Padanilam X, Oyewusi L, Ohler L, Lungu P, Loveday M, Khan U, Khan P, Hughes J, Hewison C, Guglielmetti L, Furin J. Clinical perspectives on treatment of rifampicin-resistant/multidrug-resistant TB. Int J Tuberc Lung Dis 2021; 24:1134-1144. [PMID: 33172520 DOI: 10.5588/ijtld.20.0330] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Rapid diagnostics, newer drugs, repurposed medications, and shorter regimens have radically altered the landscape for treating rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB). There are multiple ongoing clinical trials aiming to build a robust evidence base to guide RR/MDR-TB treatment, and both observational studies and programmatic data have contributed to advancing the treatment field. In December 2019, the WHO issued their second 'Rapid Communication´ related to RR-TB management. This reiterated their prior recommendation that a majority of people with RR/MDR-TB receive all-oral treatment regimens, and now allow for specific shorter duration regimens to be used programmatically as well. Many TB programs need clinical advice as they seek to roll out such regimens in their specific setting. In this Perspective, we highlight our early experiences and lessons learned from working with National TB Programs, adult and pediatric clinicians and civil society, in optimizing treatment of RR/MDR-TB, using shorter, highly-effective, oral regimens for the majority of people with RR/MDR-TB.
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Affiliation(s)
- V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, Soauth Africa
| | - L McKenna
- Treatment Action Group, New York, NY, USA
| | - R Acquah
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - A Reuter
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - S Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, and Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - D Vambe
- Eswatini National TB Control Programme, Manzini, Eswatini
| | - P Ustero
- Global TB Program, Baylor College of Medicine, Houston, TX, USA
| | - Z Udwadia
- Hinduja Hospital & Research Centre, Mumbai, India
| | | | - M Tommasi
- Independent Consultant, Maputo, Mozambique
| | - A Skrahina
- Republican Scientific and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - J A Seddon
- Department of Infectious Diseases, Imperial College London, UK, and Desmond Tutu TB Centre, Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg, South Africa
| | - R Rodolfo
- National Department of Health, Mahikeng, North West Province, South Africa
| | - M Rich
- Partners In Health (PIH), Boston, MA, USA
| | - X Padanilam
- National Department of Health, Johannesburg, Gauteng Province, South Africa
| | | | | | - P Lungu
- National Tuberculosis and Leprosy Programme, Ministry of Health, Lusaka, Zambia
| | - M Loveday
- Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
| | - U Khan
- Interactive Research and Development, Karachi
| | - P Khan
- Interactive Research and Development, Karachi, Pakistan, and Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - J Hughes
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | | | | | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Cox V, Guglielmetti L, Hewison C, Reuter A, Furin J. Reply to: "Human rights: finding the right balance for rifampicin-resistant TB treatment". Int J Tuberc Lung Dis 2021; 25:328-329. [PMID: 33762080 DOI: 10.5588/ijtld.21.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - A Reuter
- Médecins Sans Frontières, South Africa
| | - J Furin
- Harvard Medical School, Department of Global Health and Social Medicine, Boston, MA, USA ,
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Abstract
To improve the unsatisfactory treatment outcomes of multidrug-resistant TB (MDR-TB), it is essential we use new regimens based on newer drugs. To address challenges in the introduction of BDQ and the shorter treatment regimen (STR), the USAID has committed to support countries receiving
BDQ (through the USAID/Janssen Bedaquiline Donation Program), with targeted short-term technical assistance (TA). Six MDR-TB clinical consultants were recruited and provided TA to 17 countries between 2017 and 2019. Building on other in-country support, this short-term TA proved instrumental
in overcoming barriers, such as misconceptions about BDQ safety, inadequate clinical skills to manage patients and limited expansion plans to increase access to BDQ and the STR.
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Affiliation(s)
- I. Zabsonre
- Stop TB Partnership, UNOPS, Geneva, Switzerland
| | - S. S. Thi
- Stop TB Partnership, UNOPS, Geneva, Switzerland
| | - V. Cox
- Stop TB Partnership, UNOPS, Geneva, Switzerland
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8
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Cox V, Fuller LC, Engelman D, Steer A, Hay RJ. Estimating the global burden of scabies: what else do we need? Br J Dermatol 2020; 184:237-242. [PMID: 32358799 DOI: 10.1111/bjd.19170] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2020] [Indexed: 02/06/2023]
Abstract
Scabies is one of the most common disorders identified in any estimate of global skin disease prevalence. Furthermore, quantifying its impact on individuals and societies has been problematic. There has been a lack of clear case definitions and laboratory tests. There have been few epidemiological studies, particularly those focusing on low-income countries, variation in prevalence within high-income countries, or estimates of the effect of scabies on health beyond the skin, such as renal disease or mental wellbeing. Economic studies are also lacking. However, the new strategy of integrating surveillance for skin Neglected Tropical Diseases may well produce advancements on these issues, in addition to providing an overarching structure for health improvement and disease control.
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Affiliation(s)
- V Cox
- Royal Darwin Hospital, Darwin, Australia
| | - L C Fuller
- International Foundation for Dermatology, London, UK.,Chelsea and Westminster NHS Foundation Trust, London, UK
| | - D Engelman
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Melbourne Children's Global Health, Melbourne, Australia
| | - A Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia.,Melbourne Children's Global Health, Melbourne, Australia
| | - R J Hay
- International Foundation for Dermatology, London, UK.,St John's Institute of Dermatology, King's College London, London, UK
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9
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Cox V, Wilkinson L, Grimsrud A, Hughes J, Reuter A, Conradie F, Nel J, Boyles T. Critical changes to services for TB patients during the COVID-19 pandemic. Int J Tuberc Lung Dis 2020; 24:542-544. [PMID: 32398211 DOI: 10.5588/ijtld.20.0205] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- V Cox
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town
| | - L Wilkinson
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, International AIDS Society, Cape Town
| | | | - J Hughes
- Desmond Tutu TB Centre, Stellenbosch University, Cape Town
| | - A Reuter
- Médecins Sans Frontières, Khayelitsha
| | - F Conradie
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg
| | - J Nel
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Helen Joseph Hospital, Johannesburg, South Africa, ,
| | - T Boyles
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Helen Joseph Hospital, Johannesburg, South Africa, ,
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10
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Cox V, Cox H, Pai M, Stillo J, Citro B, Brigden G. Health care gaps in the global burden of drug-resistant tuberculosis. Int J Tuberc Lung Dis 2020; 23:125-135. [PMID: 30808447 DOI: 10.5588/ijtld.18.0866] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The drug-resistant tuberculosis (DR-TB) cascade-from estimated or incident cases to numbers successfully treated or disease-free survival-has long been characterised by sharp declines at each step in the cascade. The losses along the cascade vary across different settings, and the reasons why some countries have a higher burden of DR-TB are complex and multifactorial; broadly, weak health systems, inadequate financing and poverty all impact differential access to DR-TB care. Within a human rights framework that mandates the right to health and the right to benefit from scientific progress, the aim of this review is to focus on describing inequities in access to DR-TB care at critical points in the cascade.
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Affiliation(s)
- V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town
| | - H Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - M Pai
- McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - J Stillo
- College of Liberal Arts and Sciences, Wayne State University, Detroit, Michigan
| | - B Citro
- Northwestern Pritzker School of Law, Chicago, Illinois, USA
| | - G Brigden
- International Union Against TB and Lung Disease, Paris, France
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11
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Monedero-Recuero I, Hernando-Marrupe L, Sánchez-Montalvá A, Cox V, Tommasi M, Furin J, Chiang CY, Quelapio M, Koura KG, Trébucq A, Padanilam X, Dravniece G, Piubello A. QTc and anti-tuberculosis drugs: a perfect storm or a tempest in a teacup? Review of evidence and a risk assessment. Int J Tuberc Lung Dis 2018; 22:1411-1421. [PMID: 30366516 DOI: 10.5588/ijtld.18.0423] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SUMMARYMultidrug-resistant (MDR) and extensively drug-resistant tuberculosis (XDR-TB) are global concerns, with stagnant treatment success rates of roughly 54% and 30%, respectively. Despite adverse events associated with several DR-TB drugs, newly developed drugs and shorter regimens are bringing hope; recent concern has focused on drugs that prolong the corrected QT interval (QTc). QTc prolongation is a risk factor for torsades de pointe (TdP), a potentially lethal cardiac arrhythmia. While QTc prolongation is used in research as a surrogate marker for drug safety, the correlation between QTc and TdP is not perfect and depends on additional risk factors. The electrocardiogram (ECG) monitoring that has been recommended when new drugs are used has created alarm among clinicians and National Tuberculosis Programmes (NTPs). ECG monitoring is often challenging in high-burden settings where treatment alternatives are limited. According to a review of studies, the prevalence of sudden death directly attributable to TdP by QTc-prolonging DR-TB drugs is likely less than 1%. The risk of death from an ineffective MDR-TB/XDR-TB regimen thus far exceeds the risk of death from arrhythmia. In patients with QTc prolongation who develop cardiac events, other significant risk factors in addition to the drugs themselves are nearly always present. Clinicians and NTPs should be aware of and manage all possible circumstances that may trigger an arrhythmia (hypopotassaemia and human immunodeficiency virus infection are probably the most frequent in DR-TB patients). We present the limited but growing evidence on QTc prolongation and DR-TB management and propose a clinical approach to achieve an optimal balance between access to life-saving drugs and patient safety.
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Affiliation(s)
- I Monedero-Recuero
- TB-HIV Department, International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | | | - V Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - M Tommasi
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - C-Y Chiang
- TB-HIV Department, International Union Against Tuberculosis and Lung Disease, Paris, France
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - M Quelapio
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - K G Koura
- TB-HIV Department, International Union Against Tuberculosis and Lung Disease, Paris, France
- Mère et enfant face aux infections tropicales, L'Institut de recherche pour le développement, University of Paris, Sorbonne Paris Cité, Paris, France
| | - A Trébucq
- TB-HIV Department, International Union Against Tuberculosis and Lung Disease, Paris, France
| | - X Padanilam
- Sizwe Tropical Disease Hospital, Johannesburg, South Africa
| | - G Dravniece
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - A Piubello
- TB-HIV Department, International Union Against Tuberculosis and Lung Disease, Paris, France
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12
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Mohr E, Daniels J, Muller O, Furin J, Chabalala B, Steele SJ, Cox V, Dolby T, Ferlazzo G, Shroufi A, Duran LT, Cox H. Missed opportunities for earlier diagnosis of rifampicin-resistant tuberculosis despite access to Xpert ® MTB/RIF. Int J Tuberc Lung Dis 2018; 21:1100-1105. [PMID: 28911352 DOI: 10.5588/ijtld.17.0372] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To assess the proportion of rifampicin-resistant tuberculosis (RR-TB) patients with potential earlier RR-TB diagnoses in Khayelitsha, South Africa. DESIGN We conducted a retrospective analysis among RR-TB patients diagnosed from 2012 to 2014. Patients were considered to have missed opportunities for earlier diagnosis if 1) they were incorrectly screened according to the Western Cape diagnostic algorithm; 2) the first specimen was not tested using Xpert® MTB/RIF; 3) no specimen was ever tested; or 4) the initial Xpert test showed a negative result, but no subsequent specimen was sent for follow-up testing in human immunodeficiency virus-positive patients. RESULTS Among 543 patients, 386 (71%) were diagnosed with Xpert and 112 (21%) had had at least one presentation at a health care facility within the 6 months before the presentation at which RR-TB was diagnosed. Overall, 95/543 (18%) patients were screened incorrectly at some point: 48 at diagnostic presentation only, 38 at previous presentation only, and 9 at both previous and diagnostic presentations. CONCLUSIONS These data show that a significant proportion of RR-TB patients might have been diagnosed earlier, and suggest that case detection could be improved if diagnostic algorithms were followed more closely. Further training and monitoring is required to ensure the greatest benefit from universal Xpert implementation.
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Affiliation(s)
- E Mohr
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - J Daniels
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - O Muller
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - J Furin
- Harvard Medical School, Boston, Massachusetts, USA
| | - B Chabalala
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | | | - V Cox
- MSF, Eshowe, University of Cape Town Center for Infectious Disease Epidemiology and Research, Cape Town
| | - T Dolby
- National Health Laboratory Service, Cape Town
| | | | | | - L T Duran
- Médecins Sans Frontières (MSF), Khayelitsha, South Africa
| | - H Cox
- Division of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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13
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Cox V, Brigden G, Crespo RH, Lessem E, Lynch S, Rich ML, Waning B, Furin J. Global programmatic use of bedaquiline and delamanid for the treatment of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2018; 22:407-412. [DOI: 10.5588/ijtld.17.0706] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- V. Cox
- Drug-Resistant TB Scale-Up Treatment Action Team, Global Drug-Resistant Tuberculosis Initiative, Stop TB Partnership, Geneva, Switzerland, Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University
of Cape Town, Cape Town, South Africa
| | - G. Brigden
- International Union Against Tuberculosis and Lung Disease, Geneva
| | - R. H. Crespo
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - E. Lessem
- Treatment Action Group, New York, New York
| | - S. Lynch
- Médecins Sans Frontières Access Campaign, New York, New York
| | - M. L. Rich
- Partners In Health, Boston, Massachusetts, Brigham and Women's Hospital, Boston, Massachusetts
| | - B. Waning
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - J. Furin
- Partners In Health, Boston, Massachusetts, Harvard Medical School, Boston, Massachusetts, USA
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14
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Cox V, Furin J. World Health Organization recommendations for multidrug-resistant tuberculosis: should different standards be applied? Int J Tuberc Lung Dis 2017; 21:1211-1213. [PMID: 29297439 DOI: 10.5588/ijtld.17.0199] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The World Health Organization uses a Grading of Recommendations Assessment, Development, and Evaluation process to make recommendations for treating multidrug-resistant tuberculosis. Even with this standardized approach, there have been discrepancies between recommendations for newer drugs such as bedaquiline and delamanid and the shorter regimen. This may be because newer drugs are novel chemical entities and may merit closer scrutiny. Here, we explore the problematic nature of this supposition, arguing that although the newer drugs have been used in fewer individuals, they may have more robust efficacy and safety data than many of the second-line drugs used in the shorter regimen.
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Affiliation(s)
- V Cox
- Center for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - J Furin
- Department of Social Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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15
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Reuter A, Tisile P, von Delft D, Cox H, Cox V, Ditiu L, Garcia-Prats A, Koenig S, Lessem E, Nathavitharana R, Seddon JA, Stillo J, von Delft A, Furin J. The devil we know: is the use of injectable agents for the treatment of MDR-TB justified? Int J Tuberc Lung Dis 2017; 21:1114-1126. [DOI: 10.5588/ijtld.17.0468] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- A. Reuter
- Médecins Sans Frontières, Khayeltisha
| | | | | | - H. Cox
- Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - V. Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - L. Ditiu
- Stop TB Partnership, Geneva, Switzerland
| | - A. Garcia-Prats
- Desmond Tutu TB Center, Stellenbosch University, Cape Town, South Africa
| | - S. Koenig
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - E. Lessem
- HIV/TB Project, Treatment Action Group, New York, New York
| | | | - J. A. Seddon
- Centre for International Health, Imperial College, London, UK
| | - J. Stillo
- College of Liberal Arts and Sciences, Wayne State University, Detroit, Michigan, USA
| | - A. von Delft
- TB Proof, Cape Town, Division of Medical Microbiology, University of Cape Town, Cape Town, South Africa
| | - J. Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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16
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Huynh DH, Boyd TA, Etzel CJ, Cox V, Kremer J, Mease P, Kavanaugh A. Persistence of low disease activity after tumour necrosis factor inhibitor (TNFi) discontinuation in patients with psoriatic arthritis. RMD Open 2017; 3:e000395. [PMID: 28123783 PMCID: PMC5255890 DOI: 10.1136/rmdopen-2016-000395] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/30/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To determine the duration of clinical benefit among patients with psoriatic arthritis (PsA) discontinuing tumour necrosis factor inhibitor (TNFi) therapy while in low disease activity (LDA), and to identify patient characteristics associated with prolonged clinical benefit. Methods We performed an observational cohort study assessing patients with PsA from the Consortium of Rheumatology Researchers of North America (CORRONA) registry who had discontinued TNFi after achieving LDA, defined as clinical disease activity index (CDAI) score ≤10 and physician's global assessment (PGA) of skin psoriasis ≤20/100. Kaplan–Meier method was used to estimate the duration of clinical benefit. Results Of the 5945 patients with PsA in CORRONA, 302 patients had discontinued TNFi (n=325) while in LDA and had follow-up data available. At time of discontinuation, mean PsA duration was 9.8 years, mean CDAI was 3.9, and mean duration of TNFi use was 1.5 years; 52.6% of patients had discontinued their first TNFi. Median time to loss of benefit was 29.2 months. 179 (55.1%) patients had persistent benefit at their previous clinic visit. An increased risk of losing clinical benefit was seen among patients with higher disease activity at discontinuation (CDAI≥3.2 vs <3.2; HR 1.43 (p=0.32)) and among smokers (HR 1.78 (p=0.027)). Conclusions Patients with PsA who achieve LDA may maintain clinical benefit after discontinuation of TNFi therapy.
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Affiliation(s)
- D H Huynh
- Allergy and Rheumatology Clinic , La Jolla, California , USA
| | - T A Boyd
- Division of Rheumatology, Department of Medicine , Western University , London, Ontario , Canada
| | - C J Etzel
- Corrona LLC , Southborough, Massachusetts , USA
| | - V Cox
- Corrona LLC , Southborough, Massachusetts , USA
| | - J Kremer
- Corrona LLC , Southborough, Massachusetts , USA
| | - P Mease
- Swedish Medical Center and University of Washington , Seattle, Washington , USA
| | - A Kavanaugh
- Division of Rheumatology, Allergy and Immunology, University of California, San Diego, California, USA; School of Medicine, La Jolla, California, USA
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17
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Cariem R, Cox V, de Azevedo V, Hughes J, Mohr E, Durán LT, Ndjeka N, Furin J. The experience of bedaquiline implementation at a decentralised clinic in South Africa. Public Health Action 2016; 6:190-192. [PMID: 27695682 DOI: 10.5588/pha.16.0037] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 06/27/2016] [Indexed: 11/10/2022] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a serious public health problem, but the new drugs bedaquiline (BDQ) and delamanid offer hope to improve outcomes and minimise toxicity. In Khayelitsha, South Africa, patients are routinely started on BDQ in the out-patient setting. This report from the field describes BDQ use in the out-patient setting at the Nolungile Clinic. The clinic staff overall report a positive experience using the drug. Challenges have been based largely on the logistics of drug supply and delivery. BDQ can be started successfully in the out-patient setting, and can be a positive experience for both patients and providers. La tuberculose multirésistante (TB-MDR) est un problème de santé publique grave, mais les nouveaux médicaments que sont la bédaquiline (BDQ) et le délamanide apportent un espoir d'améliorer les résultats tout en réduisant la toxicité. A Khayelitsha, Afrique du Sud, les patients démarrent leur traitement par BDQ en consultation externe en routine. Ce rapport du terrain décrit l'utilisation de la BDQ à la consultation externe du dispensaire Nolungile. Dans l'ensemble, le personnel du centre de santé exprime une expérience positive du médicament. Les défis ont surtout été liés à la logistique de l'approvisionnement et de la distribution du médicament. La BDQ peut être mise en route avec succès dans le cadre d'une consultation externe et peut constituer une expérience positive pour les patients et les prestataires de soins. La tuberculosis multirresistente (TB-MDR) representa un grave problema de salud pública, pero la utilización de nuevos medicamentos como la bedaquilina (BDQ) y el delamanid ofrece perspectivas de mejores desenlaces terapéuticos y disminución de la toxicidad asociada. En Khayelitsha, Suráfrica, se inicia de manera sistemática el tratamiento ambulatorio con BDQ. En el presente informe del terreno, se describe la utilización de BDQ en tratamiento antituberculoso ambulatorio en el centro de atención Nolungile. En general, los miembros del personal del centro refirieron una experiencia positiva con la administración del medicamento. Las dificultades surgieron en gran parte con respecto a aspectos logísticos del suministro y la administración del medicamento. Es posible iniciar un tratamiento eficaz con BDQ en condiciones ambulatorias, y represente una experiencia positiva para los pacientes y los profesionales de salud.
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Affiliation(s)
- R Cariem
- Nolungile Clinic, City Health, Cape Town, South Africa
| | - V Cox
- Médecins Sans Frontières, Cape Town, South Africa
| | | | - J Hughes
- Médecins Sans Frontières, Cape Town, South Africa
| | - E Mohr
- Médecins Sans Frontières, Cape Town, South Africa
| | | | - N Ndjeka
- TB and HIV/AIDS Division, National Department of Health, Pretoria, South Africa
| | - J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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18
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Cox V, de Azevedo V, Stinson K, Wilkinson L, Rangaka M, Boyles TH. Diagnostic accuracy of tuberculin skin test self-reading by HIV patients in a low-resource setting. Int J Tuberc Lung Dis 2016; 19:1300-4. [PMID: 26467581 DOI: 10.5588/ijtld.15.0015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization recommends tuberculin skin tests (TSTs) where feasible to identify individuals most likely to benefit from isoniazid preventive therapy (IPT). The requirement for TST reading after 48-72 h by a trained nurse is a barrier to implementation and increases loss to follow-up. METHODS Patients with human immunodeficiency virus (HIV) infection were recruited from a primary care clinic in South Africa and trained by a lay counsellor to interpret their own TST. The TST was placed by a nurse, and the patient was asked to return 2 days later with their self-reading result, followed by blinded reading by a trained nurse (reference). RESULTS Of 227 patients, 210 returned for TST reading; 78% interpreted their test correctly: those interpreting it as negative were more likely to be correct (negative predictive value 93%) than those interpreting it as positive (positive predictive value 42%); 10/36 (28%) positive TST results were read as negative by the patient. CONCLUSIONS Patients with HIV in low-resource settings can be trained to interpret their own TST. Those interpreting it as positive should return to the clinic within 48-72 h for confirmatory reading and IPT initiation; those with a negative interpretation can return at their next scheduled visit and initiate IPT at that time if appropriate.
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Affiliation(s)
- V Cox
- Médecins Sans Frontières, Khayelitsha, South Africa
| | - V de Azevedo
- City of Cape Town Health Department, Khayelitsha, South Africa
| | - K Stinson
- Médecins Sans Frontières, Khayelitsha, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - L Wilkinson
- Médecins Sans Frontières, Khayelitsha, South Africa
| | - M Rangaka
- Centre for Infectious Disease Epidemiology, Department of Infection and Population Health, University College London, London, UK
| | - T H Boyles
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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19
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Boyles TH, Hughes J, Cox V, Burton R, Meintjes G, Mendelson M. False-positive Xpert ® MTB/RIF assays in previously treated patients: need for caution in interpreting results. Int J Tuberc Lung Dis 2014; 18:876-8. [DOI: 10.5588/ijtld.13.0853] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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20
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Harrold L, Etzel C, Gibofsky A, Kremer J, Pillinger M, Saag K, Schlesinger N, Terkeltaub R, Cox V, Greenberg J. OP0136 Sex Differences in Gout Characteristics: Tailoring Care for Women and Men. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.2486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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21
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Furst D, Cox V, Etzel C, Greenberg J, Collier D. AB0376 Neither RA Disease Activity nor TNFI Increase the Incidence of Lymphoma in A Large, US RA Registry: Table 1. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.2064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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22
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Patten GE, Cox V, Stinson K, Boulle AM, Wilkinson LS. Advanced HIV Disease at Antiretroviral Therapy (ART) Initiation Despite Implementation of Expanded ART Eligibility Guidelines During 2007-2012 in Khayelitsha, South Africa. Clin Infect Dis 2014; 59:456-7. [DOI: 10.1093/cid/ciu288] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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23
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Stinson K, Ford N, Cox V, Boulle A. Patients Lost to Care Are More Likely to be Viremic Than Patients Still in Care. Clin Infect Dis 2014; 58:1344-5. [DOI: 10.1093/cid/ciu072] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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24
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Huynh D, Etzel C, Cox V, Kremer J, Greenberg J, Kavanaugh A. SAT0268 Anti Citrullinated Peptide Antibody (ACPA) in Patients with Psoriatic Arthritis (PSA): Clinical Relevance. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Abstract
BACKGROUND It is unclear whether and to what extent intensive case management is more effective than standard occupational health services in reducing sickness absence in the health care sector. AIMS To evaluate a new return to work service at an English hospital trust. METHODS The new service entailed intensive case management for staff who had been absent sick for longer than 4 weeks, aiming to restore function through a goal-directed and enabling approach based on a bio-psycho-social model. Assessment of the intervention was by controlled before and after comparison with a neighbouring hospital trust at which there were no major changes in the management of sickness absence. Data on outcome measures were abstracted from electronic databases held by the two trusts. RESULTS At the intervention trust, the proportion of 4-week absences that continued beyond 8 weeks fell from 51.7% in 2008 to 49.1% in 2009 and 45.9% in 2010. The reduction from 2008 to 2010 contrasted with an increase at the control trust from 51.2% to 56.1%-a difference in change of 10.7% (95% CI 1.5-20.0%). There was also a differential improvement in mean days of absence beyond 4 weeks, but this was not statistically significant (1.6 days per absence; 95% CI -7.2 to 10.3 days). CONCLUSIONS Our findings suggest that the intervention was effective, and calculations based on an annual running cost of £57 000 suggest that it was also cost-effective. A similar intervention should now be evaluated at a larger number of hospital trusts.
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Affiliation(s)
- J Smedley
- Occupational Health Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK.
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Jones CA, Cox V, Jhangri GS, Suarez-Almazor ME. Delineating the impact of obesity and its relationship on recovery after total joint arthroplasties. Osteoarthritis Cartilage 2012; 20:511-8. [PMID: 22395039 DOI: 10.1016/j.joca.2012.02.637] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 02/17/2012] [Accepted: 02/27/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The primary aim of this study was to determine the impact of obesity in predicting short and long-term pain relief and functional recovery in total joint arthroplasty (TJA) either as an independent risk factor or a factor mediated by two chronic conditions associated with obesity-cardiac disease and diabetes mellitus. METHOD A prospective observational study of 520 patients with primary joint arthroplasties. Pain and functional outcomes were evaluated with the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index within a month of surgery and then 6 months and 3 years post-operatively. Obesity, cardiac disease and diabetes mellitus were examined as potential risk factors for poor recovery. Patients were classified into four groups based on body mass index (BMI): (normal<25.0 kg/m(2); overweight 25.0-29.9 kg/m(2); obese Class 1 30.0-34.9 kg/m(2); severe obese Class 2&3 35.0 ≥ kg/m(2)). Linear mixed models for each joint type (hip and knee arthroplasty) were developed to examine the pattern of recovery and the effect of obesity. RESULTS Ninety-nine (19%) patients were severely obese, 127 (24%) had cardiac disease and 58 (11%) had diabetes mellitus. Baseline pain and functional scores were similar regardless of BMI classification. Severe obesity was a significant risk factor for worse pain and functional recovery at 6 months but no longer at 3 years following total hip and knee arthroplasty. Cardiac disease predicted a slower recovery after hip arthroplasty. No significant interactions existed between obesity and cardiac disease or diabetes mellitus. DISCUSSION Severe obesity is an independent risk factor for slow recovery over 3 years for both hip and knee arthroplasties.
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Affiliation(s)
- C A Jones
- School of Public Health, University of Alberta, Edmonton, AB, Canada T6G 2G4.
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Cox V, Richardson J, Nelson A, Cunnington M, Wong D, Bertaso A, Teo K, Worthley M, Worthley S. Cardiac Magnetic Resonance Imaging Assessment of Coronary Sinus Morphology in Atrial Septal Defect Patients. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.05.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Cox V, Nelson A, Richardson J, Wong D, Bertaso A, Williams K, Worthley S, Worthley M. The Heterogeneous Nature of Conduit Vessel Endothelial Function: A Study in the Brachial and Carotid Vasculature. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.05.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Cox V, Richardson J, Nelson A, Cunnington M, Wong D, Bertaso A, Teo K, Worthley M, Worthley S. Cardiac Magnetic Resonance Derived Relative Atrial Index Accurately Identifies Secundum Atrial Septal Defects. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.05.467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Cox V, Nelson A, Richardson J, Wong D, Bertaso A, Williams K, Worthley S, Worthley M. The Systemic and Reproducible Nature of Endothelial-Independent Macrovascular Vasodilation. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Koschade B, Young J, Richardson J, Bertaso A, Cox V, Wong D, Cunnington M, Nelson A, Tayeb H, Williams K, Brown M, Worthley M, Teo K, Worthley S. Safety of Adenosine Stress Perfusion Cardiac Magnetic Resonance. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Young J, Koschade B, Richardson J, Bertaso A, Cox V, Wong D, Cunnington M, Nelson A, Tayeb H, Maia M, Williams K, Worthley M, Teo K, Worthley S. Is Standard Dose Adenosine Infusion Sufficient to Establish Maximal Hyperaemia During Adenosine Stress Perfusion Cardiac Magnetic Resonance? Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Williams K, Richardson J, Bertaso A, Wong D, Young J, Koschade B, Cunnington M, Nelson A, Tayeb H, Cox V, Molaee P, Brown M, Worthley M, Teo K, Worthley S. Cardiac Magnetic Resonance: Clinical Experience in a High Volume Centre. Heart Lung Circ 2011. [DOI: 10.1016/j.hlc.2011.05.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Ford ME, Kallen M, Richardson P, Matthiesen E, Cox V, Teng EJ, Cook KF, Petersen NJ. Effect of social support on informed consent in older adults with Parkinson disease and their caregivers. J Med Ethics 2008; 34:41-47. [PMID: 18156521 DOI: 10.1136/jme.2006.018192] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE To evaluate the effects of social support on comprehension and recall of consent form information in a study of Parkinson disease patients and their caregivers. DESIGN AND METHODS Comparison of comprehension and recall outcomes among participants who read and signed the consent form accompanied by a family member/friend versus those of participants who read and signed the consent form unaccompanied. Comprehension and recall of consent form information were measured at one week and one month respectively, using Part A of the Quality of Informed Consent Questionnaire (QuIC). RESULTS The mean age of the sample of 143 participants was 71 years (SD = 8.6 years). Analysis of covariance was used to compare QuIC scores between the intervention group (n = 70) and control group (n = 73). In the 1-week model, no statistically significant intervention effect was found (p = 0.860). However, the intervention status by patient status interaction was statistically significant (p = 0.012). In the 1-month model, no statistically significant intervention effect was found (p = 0.480). Again, however, the intervention status by patient status interaction was statistically significant (p = 0.040). At both time periods, intervention group patients scored higher (better) on the QuIC than did intervention group caregivers, and control group patients scored lower (worse) on the QuIC than did control group caregivers. IMPLICATIONS Social support played a significant role in enhancing comprehension and recall of consent form information among patients.
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Affiliation(s)
- M E Ford
- Department of Biostatistics, Bioinformatics, and Epidemiology, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Houghton LA, Cremonini F, Camilleri M, Busciglio I, Fell C, Cox V, Alpers DH, Dewit OE, Dukes GE, Gray E, Lea R, Zinsmeister AR, Whorwell PJ. Effect of the NK(3) receptor antagonist, talnetant, on rectal sensory function and compliance in healthy humans. Neurogastroenterol Motil 2007; 19:732-43. [PMID: 17727393 DOI: 10.1111/j.1365-2982.2007.00934.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Visceral hypersensitivity is important in the pathophysiology of irritable bowel syndrome and thus a target for modulation in drug development. Neurokinin (NK) receptors, including NK(3) receptors, are expressed in the motor and sensory systems of the digestive tract. The aim of this study was to compare the effects of two different doses (25 and 100 mg) of the NK(3) receptor antagonist, talnetant (SB223412) with placebo on rectal sensory function and compliance in healthy volunteers studied at two centres. Rectal barostat tests were performed on 102 healthy volunteers, randomized to receive either oral talnetant 25 or 100 mg or placebo over 14-17 days. Studies were performed on three occasions: day 1 immediately prior to 1st dose, day 1 4 h postdose, and after 14- to17-day therapy. Compliance, and pressure thresholds for first sensation, urgency, discomfort and pain were measured using ascending method of limits, and sensory intensity ratings for gas, urgency, discomfort and pain determined during four random phasic distensions (12, 24, 36 and 48 mmHg). Talnetant had no effect on rectal compliance, sensory thresholds or intensity ratings compared with placebo. In general, the results obtained at the two centres differed minimally, with intensity scores at one centre consistently somewhat lower. At the doses tested, talnetant has no effect on rectal compliance or distension-induced rectal sensation in healthy participants.
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Affiliation(s)
- L A Houghton
- Neurogastroenterology Unit, Wythenshawe Hospital, Academic Division of Medicine and Surgery, University of Manchester, Manchester, UK
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Asaad K, Khan A, Sillitoe A, Cox V, Rawlins J. The Bradford burns chart part 1: Adults. Burns 2007. [DOI: 10.1016/j.burns.2006.10.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Cremonini F, Houghton LA, Camilleri M, Ferber I, Fell C, Cox V, Castillo EJ, Alpers DH, Dewit OE, Gray E, Lea R, Zinsmeister AR, Whorwell PJ. Barostat testing of rectal sensation and compliance in humans: comparison of results across two centres and overall reproducibility. Neurogastroenterol Motil 2005; 17:810-20. [PMID: 16336496 DOI: 10.1111/j.1365-2982.2005.00709.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
We assessed reproducibility of measurements of rectal compliance and sensation in health in studies conducted at two centres. We estimated samples size necessary to show clinically meaningful changes in future studies. We performed rectal barostat tests three times (day 1, day 1 after 4 h and 14-17 days later) in 34 healthy participants. We measured compliance and pressure thresholds for first sensation, urgency, discomfort and pain using ascending method of limits and symptom ratings for gas, urgency, discomfort and pain during four phasic distensions (12, 24, 36 and 48 mmHg) in random order. Results obtained at the two centres differed minimally. Reproducibility of sensory end points varies with type of sensation, pressure level and method of distension. Pressure threshold for pain and sensory ratings for non-painful sensations at 36 and 48 mmHg distension were most reproducible in the two centres. Sample size calculations suggested that crossover design is preferable in therapeutic trials: for each dose of medication tested, a sample of 21 should be sufficient to demonstrate 30% changes in all sensory thresholds and almost all sensory ratings. We conclude that reproducibility varies with sensation type, pressure level and distension method, but in a two-centre study, differences in observed results of sensation are minimal and pressure threshold for pain and sensory ratings at 36-48 mmHg of distension are reproducible.
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Affiliation(s)
- F Cremonini
- Clinical Enteric Neuroscience Translational and Epidemiological Research (C.E.N.T.E.R.) Program, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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Syddall HE, Sayer AA, Simmonds SJ, Osmond C, Cox V, Dennison EM, Barker DJP, Cooper C. Birth weight, infant weight gain, and cause-specific mortality: the Hertfordshire Cohort Study. Am J Epidemiol 2005; 161:1074-80. [PMID: 15901628 DOI: 10.1093/aje/kwi137] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Low birth weight, a marker of adverse intrauterine circumstances, is known to be associated with a range of disease outcomes in later life, including coronary heart disease, hypertension, type 2 diabetes, and osteoporosis. However, it may also decrease the risk of other common conditions, most notably neoplastic disease. The authors describe the associations between birth weight, infant weight gain, and a range of mortality outcomes in the Hertfordshire Cohort. This study included 37,615 men and women born in Hertfordshire, United Kingdom, in 1911-1939; 7,916 had died by the end of 1999. For men, lower birth weight was associated with increased risk of mortality from circulatory disease (hazard ratio per standard deviation decrease in birth weight = 1.08, 95% confidence interval: 1.04, 1.11) and from accidental falls but with decreased risk of mortality from cancer (hazard ratio per standard deviation decrease in birth weight = 0.94, 95% confidence interval: 0.90, 0.98). For women, lower birth weight was associated with a significantly (p < 0.05) increased risk of mortality from circulatory and musculoskeletal disease, pneumonia, injury, and diabetes. Overall, a one-standard-deviation increase in birth weight reduced all-cause mortality risk by age 75 years by 0.86% for both men and women.
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Affiliation(s)
- H E Syddall
- Medical Research Council Epidemiology Resource Centre, University of Southampton, Southampton General Hospital, Southampton, United Kingdom
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Poole J, Sayer AA, Cox V, Cooper C, Kuh D, Hardy R, Wadsworth M. Birth weight, osteoarthritis of the hand, and cardiovascular disease in men. Ann Rheum Dis 2003; 62:1029; author reply 1029. [PMID: 12972497 PMCID: PMC1754329 DOI: 10.1136/ard.62.10.1029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Sayer AA, Poole J, Cox V, Kuh D, Hardy R, Wadsworth M, Cooper C. Weight from birth to 53 years: a longitudinal study of the influence on clinical hand osteoarthritis. Arthritis Rheum 2003; 48:1030-3. [PMID: 12687545 DOI: 10.1002/art.10862] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To determine the influence of body weight throughout the life course on the development of clinical hand osteoarthritis (OA). METHODS A British national survey was used to perform a prospective cohort study of 1,467 men and 1,519 women born in 1946. Weight was measured at birth and at subsequent followup visits through childhood and adulthood. The main outcome measure was the odds ratio for the presence of hand OA at the age of 53 years. RESULTS Two hundred eighty men (19%) and 458 women (30%) had OA in at least 1 hand joint. Hand OA was significantly associated with increased weight at ages 26 years, 43 years, and 53 years and with decreased weight at birth in men. Birth weight and adult weight showed independent effects, such that men with the highest risk for OA represented those who had been heaviest at age 53 years and lightest at birth. These findings were not explained by grip strength. There was no significant relationship between weight and hand OA in women. CONCLUSION The results of this study show that increased adult weight is associated with, and may precede, development of hand OA in men. An association between hand OA and weight was not observed in women. The relationship between hand OA and decreased birth weight is a new finding and may reflect the persisting influence of prenatal environmental factors on adult joint structure and function.
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Sallomi DF, Cox V, Ementon R, Howlett DC, Kempson D, Bradford L, Darling J, Macleod A, Patel N, Sulke AN. P16. Comparison between contrast ventriculography and cardiac gated SPECT in the evaluation of cardiac ejection fraction and ventricular volumes. Nucl Med Commun 2001. [DOI: 10.1097/00006231-200104000-00092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Pregnant women attracted twice the number of Anopheles gambiae complex--the predominant African malaria-carrying mosquito--than did their non-pregnant counterparts. We postulate that physiological and behavioural changes that occur during pregnancy are responsible for increased attractiveness, which could be important in intervention strategies aimed at protecting this high-risk group against malaria.
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Abstract
In pregnancy, the additional demands for Fe are thought to be met principally through increased maternal dietary Fe absorption and by mobilization of maternal Fe stores. In a general population sample of 576 women we examined the maternal and dietary characteristics which influenced Fe stores (assessed by serum ferritin concentration) in early pregnancy. The effects of these characteristics on two measures of functional Fe status (mean cell volume and haemoglobin concentration) were also considered. Serum ferritin concentrations were lower in multiparous women (P < 0.0001) and in those with a lower BMI (P = 0.01), and rose with increasing alcohol intake (P < 0.0001). Ferritin concentrations fell with increasing Ca intake (P < 0.0001); the proportion of women with serum ferritin values < or = 12 micrograms/l rose from 14% of the women in the lowest quarter of Ca intake to 29% of the women in the highest quarter. Mean cell volume and haemoglobin concentration were not related to Ca intake in early pregnancy. Although Ca added to test-meals reduces Fe absorption, long-term Ca supplementation has not been shown to lower plasma ferritin concentration, suggesting that high habitual Ca intakes would be unlikely to influence Fe status in non-pregnant individuals. Our findings show that in early pregnancy there is an association between high dietary Ca intake and lower Fe stores. This effect of Ca on one aspect of Fe status may result from its influence on Fe bioavailability.
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Affiliation(s)
- S Robinson
- Medical Research Council Environmental Epidemiology Unit, (University of Southampton), Southampton General Hospital, UK.
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Abstract
Recent research in Europe and the USA has shown that adults who had a low birthweight or who were thin at birth with a low ponderal index (birthweight/length3) tend to be insulin resistant and have an increased risk of developing Type 2 diabetes mellitus. Low birthweight and Type 2 diabetes are common in India. We have studied glucose and insulin metabolism in 506 men and women (aged 39-60 years) born in a hospital in Mysore, South India, which kept detailed obstetric records from 1934. The prevalence of Type 2 diabetes was 15%. In contrast to Western populations, higher rates were found in men and women who were short at birth (p = 0.07) and had a high ponderal index (p = 0.05). Their mothers tended to be heavier than average during pregnancy (p = 0.004). Higher ponderal index at birth was also associated with a lower 30 minute insulin increment (p = 0.009), a marker of reduced beta cell function. We speculate that the rise in Type 2 diabetes in Indian urban populations may have been triggered by mild obesity in mothers, leading to glucose intolerance during pregnancy, macrosomic changes in the fetus, and insulin deficiency in adult life.
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Affiliation(s)
- C H Fall
- MRC Environmental Epidemiology Unit, Southampton General Hospital, UK
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Abstract
BACKGROUND Coronary heart disease is predicted to become the commonest cause of death in india within 15 years People from India living overseas already have high rates of the disease that are not explained by known coronary risk factors. Small size at birth is a newly described risk factor for coronary heart disease, but associations between size at birth and the disease have not been examined in India. METHODS We studied 517 men and women who were born between 1934 and 1954 in a mission hospital in Mysore, South India, and who still lived near to the hospital. We related the prevalence of coronary heart disease, defined by standard criteria, to their birth size. FINDINGS 25 (9%) men and 27 (11%) women had coronary heart disease. Low birthweight, short birth length, and small head circumference at birth were associated with a raised prevalence of the disease. Prevalence fell from 11% in people whose birthweights were 5.5 lb (2.5 kg) or less to 3% in those whose birthweights were more than 7 lb (3.1 kg), p for trend = 0.09. The trends were stronger and statistically significant among people aged 45 years and over (p = 0.03 for birthweight, 0.04 for length, and 0.02 for head circumference). High rates of disease were also found in those whose mothers had a low body weight during pregnancy. The highest prevalence of the disease (20%) was in people who weighted 5.5 lb (2.5 kg) or less at birth and whose mothers weighted less than 100 lb (45 kg) in pregnancy. These associations were largely independent of known coronary risk factors. INTERPRETATION In India, as in the UK, coronary heart disease is associated with small size at birth, suggesting that its pathogenesis is influenced by events in utero. The association with low maternal bodyweight is further evidence that the disease originates through fetal undernutrition. Prevention of the rising epidemic of the disease in India may require improvements in the nutrition and health of young women.
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Affiliation(s)
- C E Stein
- Medical Research Council Environmental Epidemlology Unit, Southampton General Hospital
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Osborne CA, Bartges JW, Polzin DJ, Lulich JP, Johnston GR, Cox V. Percutaneous needle biopsy of the kidney. Indications, applications, technique, and complications. Vet Clin North Am Small Anim Pract 1996; 26:1461-504. [PMID: 8911028 DOI: 10.1016/s0195-5616(96)50137-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
During the past three decades, percutaneous renal biopsy has evolved as a valuable method of clinical evaluation of patients with various forms of glomerular proteinuria and primary renal failure. The advent of automated core biopsy needles and ultrasound guidance has substantially improved the safety of needle biopsy techniques and almost eliminated the need for surgical wedge biopsy.
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Affiliation(s)
- C A Osborne
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St. Paul, USA
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Robinson S, Godfrey K, Osmond C, Cox V, Barker D. Evaluation of a food frequency questionnaire used to assess nutrient intakes in pregnant women. Eur J Clin Nutr 1996; 50:302-8. [PMID: 8735311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To compare nutrient intakes assessed by food frequency questionnaire (FFQ) with those determined from food diaries. DESIGN A 100-item FFQ was administered to women at 15 weeks of pregnancy. Food diaries were kept for a 4-day period at 16 weeks of pregnancy. SETTING Community-based study of a general population sample of pregnant women booked for delivery at the Princess Anne Maternity Hospital, Southampton, UK. SUBJECTS 603 women were recruited. Complete dietary data were provided by 569 women. RESULTS Nutrient intakes determined by FFQ were greater than those from food diaries. Spearman rank correlation coefficients for macronutrients ranged from 0.27 (protein and starch) to 0.37 (fat). Stronger correlations for energy, fat and carbohydrate were seen in women who did not experience nausea, suggesting that the level of agreement observed between the FFQ and food diary in the whole group may be an underestimate of the true agreement. The percentage of individuals classified to the same quarter of the distribution of nutrient intake by the FFQ and diaries ranged from 30% (starch) to 41% (calcium), with between 4% (riboflavin) and 8% (energy, protein and vitamin E) classified to the opposite quarters. Using serum vitamin C as an independent biomarker of intake, the percentage of individuals classified to the correct quarter of intake was similar for the FFQ and diary (34% and 37%), with 8% (FFQ) and 6% (diary) misclassified to the opposite quarter. CONCLUSION The FFQ appears to give meaningful estimates of nutrient intake in early pregnancy which can be used to rank individuals within the distribution.
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Affiliation(s)
- S Robinson
- Medical Research Council Environmental Epidemiology Unit, (University of Southampton), Southampton General Hospital, UK
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Abstract
OBJECTIVE To assess how nutrient intakes of mothers in early and late pregnancy influence placental and fetal growth. DESIGN Prospective observational study. SETTING Princess Anne Maternity Hospital, Southampton. SUBJECTS 538 mothers who delivered at term. MAIN OUTCOME MEASURES Placental and birth weights adjusted for the infant's sex and duration of gestation. RESULTS Mothers who had high carbohydrate intakes in early pregnancy had babies with lower placental and birth weights. Low maternal intakes of dairy and meat protein in late pregnancy were also associated with lower placental and birth weights. Placental weight fell by 49 g(95% confidence interval 16 g to 81 g; P=0.002) for each log g increase in intake of carbohydrate in early pregnancy and by 1.4 g (0.4 g to 2.4 g; P=0.005) for each g decrease in intake of dairy protein in late pregnancy. Birth weight fell by 165 g (49 g to 282 g; P=0.005) for each log g increase in carbohydrate intake in early pregnancy and by 3.1 g (0.3 g to 6.0 g; P=0.03) for each g decrease in meat protein intake in late pregnancy. These associations were independent of the mother's height and body mass index and of strong relations between the mother's birth weight and the placental and birth weights of her offspring. CONCLUSION These findings suggest that a high carbohydrate intake in early pregnancy suppresses placental growth, especially if combined with a low dairy protein intake in late pregnancy. Such an effect could have long term consequences for the offspring's risk of cardiovascular disease.
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Affiliation(s)
- K Godfrey
- Medical Research Council Environmental Epidemiology Unit (University of Southampton), Southampton General Hospital, UK
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Godfrey KM, Forrester T, Barker DJ, Jackson AA, Landman JP, Hall JS, Cox V, Osmond C. Maternal nutritional status in pregnancy and blood pressure in childhood. Br J Obstet Gynaecol 1994; 101:398-403. [PMID: 8018610 DOI: 10.1111/j.1471-0528.1994.tb11911.x] [Citation(s) in RCA: 156] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To examine the relation between indices of maternal nutrition during pregnancy, including haemoglobin concentration, skinfold thickness and body weight, and the child's blood pressure at 10 to 12 years of age. DESIGN Follow up study of children whose mothers had haemoglobin estimations, weights and skinfold thicknesses recorded during pregnancy. SETTING Kingston, Jamaica. SUBJECTS Seventy-seven children whose mothers took part in a prospective study of nutrition during pregnancy in relation to fetal growth. MAIN OUTCOME MEASURE Blood pressure at 10 to 12 years of age. RESULTS The child's mean systolic pressure adjusted for current weight rose by 2.6 mmHg (95% CI 0.5-4.6, P = 0.01) for each 1 g/dl fall in the mother's lowest haemoglobin during pregnancy. Mothers with a lower haemoglobin had thinner skinfold thicknesses, especially over the triceps (P = 0.005). In multiple regression analyses, taking account of the child's sex and current weight, there was a strong association between thin maternal triceps skinfold thickness at 15 weeks of gestation and raised blood pressure in the offspring. Taking account of the mother's triceps skinfold thickness abolished the relation between lower haemoglobin and raised blood pressure in the child. Lower weight gain between 15 and 35 weeks of gestation was independently associated with raised children's blood pressure. Systolic pressure rose by 10.7 mmHg (95% CI 5.7 to 15.6, P = 0.0001) for each log mm decrease in the mother's triceps skinfold thickness, and by 0.6 mmHg (95% CI 0.1 to 1.0, P = 0.02) for each 1 kg decrease in the mother's weight gain during pregnancy. CONCLUSIONS These results parallel animal experiments suggesting that impaired maternal nutrition may underlie the programming of adult hypertension during fetal life.
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Affiliation(s)
- K M Godfrey
- MRC Environmental Epidemiology Unit (Southampton University), Southampton General Hospital, UK
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Fries MH, Kuller JA, Norton ME, Yankowitz J, Kobori J, Good WV, Ferriero D, Cox V, Donlin SS, Golabi M. Facial features of infants exposed prenatally to cocaine. Teratology 1993; 48:413-20. [PMID: 8303611 DOI: 10.1002/tera.1420480505] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Thirty two infants referred for in-patient genetics evaluation at the University of California at San Francisco, 1987-1992, were found to have a history of maternal cocaine use. Genetics reports and medical records were reviewed on all these infants to identify features distinctive for cocaine exposure. Among these 32 cases, 14 infants were exposed only to cocaine; 18 were exposed to alcohol and cocaine. The infants evaluated displayed a distinctive phenotype, consisting of neurologic irritability, large fontanels, prominent glabella, marked periorbital and eyelid edema, low nasal bridge with transverse crease, short nose, lateral soft tissue nasal buildup, and small toenails. Features consistent with the fetal alcohol syndrome appeared distinct and coexistent with the other described facial findings. Other severe abnormalities included cleft lip/palate, atypical facial cleft, abnormal BSER, intraventricular hemorrhages, arthrogryposes, and genitourinary abnormalities. Forty percent of the infants were born prematurely; 28% were small for gestational age; 43% showed head circumference values less than the 10th percentile. We conclude that these findings may be distinctive for a diagnosis of fetal cocaine syndrome; such findings should be further established by a future blinded prospective study of mothers and neonates.
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Affiliation(s)
- M H Fries
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California at San Francisco
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