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Freret TS, Cohen JL, Gyamfi-Bannerman C, Kaimal AJ, Lorch SA, Wright JD, Melamed A, Clapp MA. Regional Variation in Antenatal Late Preterm Steroid Use Following the ALPS Trial. JAMA Netw Open 2024; 7:e2350830. [PMID: 38194234 PMCID: PMC10777258 DOI: 10.1001/jamanetworkopen.2023.50830] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/20/2023] [Indexed: 01/10/2024] Open
Abstract
Importance The publication of the Antenatal Late Preterm Steroids (ALPS) trial in February 2016 demonstrated that antenatal administration of betamethasone in the late preterm period (between 34 to 36 weeks of gestation) for individuals with a high risk of delivery decreased neonatal respiratory morbidity. National estimates have suggested the trial did change obstetric practice, but little is known if the evidence was adopted uniformly or equitably. Objective To assess regional variation in the use of late preterm steroids after the publication of the Antenatal Late Preterm Steroids (ALPS) Trial and to understand factors associated with a region's pace of adoption. Design, Setting, and Participants This cross-sectional study used US natality data from February 2015 to October 2017 from hospital referral regions (HRRs) within the US. Inclusion criteria included live-born, nonanomalous, singleton, late preterm (34 to 36 completed weeks of gestation) neonates born to individuals without pregestational diabetes. This study was conducted from November 15, 2022, to January 13, 2023. Main Outcome and Measures HRRs were categorized as either a slower adopter or faster adopter of antenatal late preterm steroids based on the observed vs expected pace of antenatal steroid adoption in a 1-year period after the trial's dissemination. Patient and regional factors hypothesized a priori to be associated with the uptake of late preterm steroids were compared between faster and slower adopters. Comparisons were made using Student t test or Wilcoxon rank-sum test, as appropriate. A multivariable logistic regression was constructed to identify factors associated with faster adopter status in the postperiod. Results There were 666 097 late preterm births in 282 HRRs. The mean (SD) maternal age in HRRs was 27.9 (1.2) years. The median (IQR) percentage of births by race categories in HRRs for patients identifying as American Indian or Alaskan Native was 0.5% (0.2%-1.3%); Asian or Pacific Islander, 3.0% (1.7%-5.3%); Black, 12.9% (5.1%-29.1%); and White, 78.6% (66.6%-87.0%). The median percentage of births in HRRs to patients of Hispanic ethnicity was 11.2% (6.3%-27.4%). In this study, 136 HRRs (48.2%) were classified as faster adopters and 146 (51.8%) were classified as slower adopters. Faster adopters increased their steroid use by 12.1 percentage points (from 5.9% to 18.0%) compared with a 5.5 percentage point increase (from 3.7% to 9.2%) among slower adopters (P < .001). Most examined patient and regional factors were not associated with a region's pace of adoption, with the exception of the regional prevalence of prior preterm birth (adjusted odds ratio [aOR], 2.04 [95% CI, 1.48-2.82]) and the percentage of deliveries at 34 to 35 weeks of gestation (aOR, 0.68 [95% CI, 0.47-0.99]) compared with 36 weeks. Conclusions and Relevance In this cross-sectional study, there was widespread geographic variation in the adoption of antenatal steroid administration for late preterm births that largely remained unexplained by population factors. These findings should prompt further investigations to barriers to timely or equitable access to new evidence-based practices and guide future dissemination strategies with the goal of more uniform adoption.
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Affiliation(s)
- Taylor S. Freret
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Cynthia Gyamfi-Bannerman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California at San Diego, La Jolla
| | - Anjali J. Kaimal
- Department of Obstetrics and Gynecology, University of South Florida, Tampa
| | - Scott A. Lorch
- Division of Neonatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jason D. Wright
- Department of Obstetrics and Gynecology, Columbia University, New York, New York
| | - Alexander Melamed
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston
| | - Mark A. Clapp
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital, Boston
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Pellacani G, Schlesinger T, Bhatia N, Berman B, Lebwohl M, Cohen JL, Patel GK, Kunstfeld R, Hadshiew I, Lear JT. Efficacy and safety of tirbanibulin 1% ointment in actinic keratoses: Data from two phase-III trials and the real-life clinical practice presented at the European Academy of Dermatology and Venereology Congress 2022. J Eur Acad Dermatol Venereol 2024; 38 Suppl 1:3-15. [PMID: 38116638 DOI: 10.1111/jdv.19636] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 11/10/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND The 31st European Academy of Dermatology and Venereology (EADV) Congress took place between 7th and 10th of September 2022 in Milan, Italy. OBJECTIVES We report presented clinical data on the efficacy/effectiveness, safety and tolerability of tirbanibulin 1% ointment that has recently been licensed for actinic keratosis (AK) of the face or scalp in adults. METHODS Summary of presentations given at the EADV Congress. RESULTS Prof. Pellacani presented two post hoc analyses from two phase-III trials with AK patients (NCT03285477 [N = 351] and NCT03285490 [N = 351]): A descriptive analysis of medical history, concomitant medications, and safety results confirming a favourable profile for tirbanibulin showing that number of baseline AK lesions was not correlated to severity of local skin reactions. The latter analysis showed that cases of tirbanibulin application site pain or pruritus were few, and most were found to be mild. Prof. Kunstfeld reported six real-life clinical cases in Austria showing good tirbanibulin effectiveness, safety and tolerability for the treatment of new or recurring AK lesions. Results demonstrated that after 2- to 4-month follow-up, tirbanibulin was well tolerated and effective in AK patients. Presentations by Dr. Patel confirmed good outcomes and tolerability of tirbanibulin in Olsen grade 1-2 AK (N = 12) and porokeratosis patients (N = 4) treated once daily for 5 consecutive days in the United Kingdom. Furthermore, real-world experience in solid organ transplant recipients (N = 2) demonstrated effectiveness of tirbanibulin in skin field cancerization treatment. A symposium sponsored by Almirall was conducted during the congress in which Dr. Hadshiew and Dr. Lear brought together their clinical experience in Germany and the United Kingdom respectively. Interesting clinical cases of 5 consecutive days of tirbanibulin treatment compared to other treatments were discussed with attendees, as well as current treatment needs of AK patients. CONCLUSIONS This article provides an overview of presentations and symposium discussions, summarizing key phase-III results and real-life clinical experience with tirbanibulin shared by dermatologists across Europe.
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Affiliation(s)
- G Pellacani
- Department of Clinical Internal, Anesthesiological, and Cardiovascular Sciences, La Sapienza University, Rome, Italy
| | - T Schlesinger
- Clinical Research Center of the Carolinas, Charleston, South Carolina, USA
| | - N Bhatia
- Therapeutics Clinical Research, San Diego, California, USA
| | - B Berman
- Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - M Lebwohl
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J L Cohen
- Department of Dermatology, University of California, Irvine, California, USA
- AboutSkin Dermatology and DermSurgery, Greenwood Village, Colorado, USA
| | - G K Patel
- Welsh Institute of Dermatology, University Hospital Wales, Cardiff, UK
| | - R Kunstfeld
- Dermatology Department, Medical University Vienna, Vienna, Austria
| | | | - J T Lear
- Mid Cheshire Hospitals NHS Foundation Trust, Crewe, UK
- MAHSC, Manchester University, Manchester, UK
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Li Z, Wang H, Chen S, Kong Y, Xie L, Zhang X, Lu C, Subramanian SV, Cohen JL, Atun R. The association of a disability-targeted cash transfer programme with disability status and health-care access: a quasi-experimental study using a nationwide cohort of 4·3 million Chinese adults living with severe disabilities. Lancet Public Health 2023; 8:e933-e942. [PMID: 38000888 DOI: 10.1016/s2468-2667(23)00215-3] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Cash transfer is a crucial policy tool to address inequality. The objective of this study was to investigate the association between China's disability-targeted cash transfer programme and disability status, as well as equitable access to rehabilitation and medical services. METHODS For this quasi-experimental study, we drew data from the nationwide administrative cohort of individuals with disabilities between Jan 1, 2015, and Dec 31, 2019. Individuals were enrolled in the cohort if they were aged 18 years or older, had severe disabilities as defined by the Chinese Government, and had available cash transfer information for at least 4 consecutive years, without having started receiving cash transfer benefits at the time of enrolment. We used a quasi-experimental design with propensity score matching to estimate the effects of cash transfers on disability status, access to rehabilitation services, and access to medical treatment. The primary outcomes were development of new disability and reduction of existing disabilities. Secondary outcomes were use of rehabilitation services, financial barriers as a major obstacle to accessing rehabilitation services, use of medical services by individuals who had an illness in the previous 2 weeks, and financial barriers as a major obstacle to accessing medical services. FINDINGS From an initial pool of 51 356 125 individuals with disabilities registered in the administrative system, 2 686 024 individuals were eligible for analysis, of whom 2 165 335 (80·6%) were cash transfer beneficiaries and 520 689 (19·4%) non-beneficiaries. After propensity score matching, the cohort included 4 330 122 adults with severe disabilities. Cash transfer beneficiaries had significantly lower odds of developing new disabilities over time than non-beneficiaries (odds ratio [OR] 0·90, 95% CI 0·86-0·94; p<0·0001) and higher odds of having a reduced number of disabilities over time (1·17, 1·10-1·25; p<0·0001). Compared with non-beneficiaries, cash transfer beneficiaries were more likely to use rehabilitation services (2·12, 2·11-2·13; p<0·0001) and medical services (1·74, 1·69-1·78; p<0·0001), and less likely to report financial hardship to access rehabilitation services (0·53, 0·52-0·54; p<0·0001) and medical services (0·88, 0·84-0·93; p<0·0001) at the study endpoint. INTERPRETATION The receipt of cash transfers was associated with improved disability status and increased access to disability-related services. The findings suggest that cash transfers could be a potential method for promoting universal health coverage among individuals living with disabilities. FUNDING China National Natural Science Foundation.
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Affiliation(s)
- Zhihui Li
- Vanke School of Public Health, Tsinghua University, Beijing, China; Institute for Healthy China, Tsinghua University, Beijing, China; Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Hongchuan Wang
- School of Public Policy and Management, Tsinghua University, Beijing, China.
| | - Shaoru Chen
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Yuhao Kong
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Lifeng Xie
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Xiangda Zhang
- School of Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
| | - Chunling Lu
- 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
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, MA, USA; Harvard Center for Population and Development Studies, Cambridge, MA, USA
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Rifat Atun
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Villalaín C, Moon-Grady AJ, Herberg U, Strainic J, Cohen JL, Shah A, Levi DS, Gómez-Montes E, Herraiz I, Galindo A. Prediction of postnatal circulation in pulmonary atresia/critical stenosis with intact ventricular septum: systematic review and external validation of models. Ultrasound Obstet Gynecol 2023; 62:14-22. [PMID: 36776132 DOI: 10.1002/uog.26176] [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] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE A favorable postnatal prognosis in cases of pulmonary atresia/critical stenosis with intact ventricular septum (PA/CS-IVS) is generally equated with the possibility of achieving biventricular (BV) repair. Identification of fetuses that will have postnatal univentricular (UV) circulation is key for prenatal counseling, optimization of perinatal care and decision-making regarding fetal therapy. We aimed to evaluate the accuracy of published models for predicting postnatal circulation in PA/CS-IVS using a large internationally derived validation cohort. METHODS This was a systematic review of published uni- and multiparametric models for the prediction of postnatal circulation based on echocardiographic findings at between 20 and 28 weeks of gestation. Models were externally validated using data from the International Fetal Cardiac Intervention Registry. Sensitivity, specificity, predictive values, area under the receiver-operating-characteristics curves (AUCs) and proportion of cases with true vs predicted outcome were calculated. RESULTS Eleven published studies that reported prognostic parameters of postnatal circulation were identified. Models varied widely in terms of the main outcome (UV (n = 3), non-BV (n = 3), BV (n = 3), right-ventricle-dependent coronary circulation (n = 1) or tricuspid valve size at birth (n = 1)) and in terms of the included predictors (single parameters only (n = 6), multiparametric score (n = 4) or both (n = 1)), and were developed on small sample sizes (range, 15-38). Nine models were validated externally given the availability of the required parameters in the validation cohort. Tricuspid valve diameter Z-score, tricuspid regurgitation, ratios between right and left cardiac structures and the presence of ventriculocoronary connections (VCC) were the most commonly evaluated parameters. Multiparametric models including up to four variables (ratios between right and left structures, right ventricular inflow duration, presence of VCC and tricuspid regurgitation) had the best performance (AUC, 0.80-0.89). Overall, the risk of UV outcome was underestimated and that of BV outcome was overestimated by most models. CONCLUSIONS Current prenatal models for the prediction of postnatal outcome in PA/CS-IVS are heterogeneous. Multiparametric models for predicting UV and non-BV circulation perform well in identifying BV patients but have low sensitivity, underestimating the rate of fetuses that will ultimately have UV circulation. Until better discrimination can be achieved, fetal interventions may need to be limited to only those cases in which non-BV postnatal circulation is certain. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Villalaín
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - A J Moon-Grady
- Department of Pediatrics, Division of Cardiology, University of California San Francisco, UCSF Benioff Children's Hospital, CA, USA
| | - U Herberg
- Klinik für Kinderkardiologie Universitätsklinikum, Aachen, Germany
| | - J Strainic
- Department of Pediatrics, Division of Pediatric Cardiology, The Congenital Heart Collaborative, Rainbow Babies and Children's Hospital, University Hospitals of Cleveland Medical Center, Case Western University, Cleveland, OH, USA
| | - J L Cohen
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Shah
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital of New York, Columbia University Irving Medical Center, New York, NY, USA
| | - D S Levi
- Division of Cardiology, UCLA Mattel Children's Hospital, University of California Los Angeles Medical School, Los Angeles, CA, USA
| | - E Gómez-Montes
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - I Herraiz
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
| | - A Galindo
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Complutense University, Madrid, Spain
- Research Institute Hospital 12 de Octubre (imas12), Madrid, Spain
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin (RICORS network), RD21/0012/0024, Madrid, Spain
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Clarke-Deelder E, Opondo K, Oguttu M, Burke T, Cohen JL, McConnell M. Immediate postpartum care in low- and middle-income countries: A gap in healthcare quality research and practice. Am J Obstet Gynecol MFM 2023; 5:100764. [PMID: 36216312 DOI: 10.1016/j.ajogmf.2022.100764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 09/16/2022] [Accepted: 10/03/2022] [Indexed: 11/09/2022]
Abstract
The immediate postpartum period carries significant risks for complications such as postpartum hemorrhage and sepsis. Postpartum monitoring, including taking vital signs and monitoring blood loss, is important for the early identification and management of complications, but many women in low- and middle-income countries receive minimal attention in the period following childbirth to facility discharge. The World Health Organization recently released new guidelines on postnatal care, which include recommendations for immediate postpartum monitoring. In light of the new guidelines, this presented an opportune moment to address the gaps in postpartum monitoring in low- and middle-income countries. In this commentary, we bring attention to the importance of immediate postpartum monitoring. We identified opportunities for strengthening this often overlooked aspect of maternity care through improvements in quality measurement and data availability, research into barriers against high-quality care, and innovations in service delivery design.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland (Dr Clarke-Deelder).
| | - Kennedy Opondo
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke)
| | - Monica Oguttu
- Kisumu Medical and Education Trust, Kisumu, Kenya (Mr Opondo and Dr Oguttu)
| | - Thomas Burke
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell); Vayu Global Health Foundation, Boston, MA (Mr Opondo and Dr Burke); Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA (Dr Burke); Harvard Medical School, Boston, MA (Dr Burke)
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA (Drs Clarke-Deelder, Burke, Cohen, and McConnell)
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Rokicki S, Steenland MW, Geiger CK, Gourevitch RA, Chen L, Martin MW, Cohen JL. Trends in postpartum mental health care before and during COVID-19. Health Serv Res 2022; 57:1342-1347. [PMID: 36059179 PMCID: PMC9539265 DOI: 10.1111/1475-6773.14051] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE To assess the impact of COVID-19 on trends in postpartum mental health diagnoses and utilization of psychotherapy and prescription drug treatment. DATA SOURCES Data were obtained from a large, national health insurance claims database that tracks individuals longitudinally. STUDY DESIGN We used interrupted time series models to examine changes in trends of postpartum mental health diagnoses before and during the COVID-19 pandemic and t-tests to examine differences in treatment. DATA EXTRACTION METHODS We used billing codes to identify individuals who received mental health-related diagnoses and treatment in the first 90 days after a birth hospitalization. We excluded individuals diagnosed with schizophrenia or bipolar disorder and those with an unknown payer at delivery. PRINCIPAL FINDINGS Compared to the pre-pandemic period, the trend in new postpartum mental health diagnoses increased significantly in the post-COVID-19 period (0.06 percentage points [95%CI 0.01, 0.11]). Over 12 months, the percentage of new diagnoses was 5.0% greater relative to what would be expected in absence of COVID-19. The percentage of diagnosed individuals who did not receive treatment increased from 50.4% to 52.7% (p = 0.003). CONCLUSIONS Findings point to an urgent need to improve screening and treatment pathways for perinatal individuals in the wake of COVID-19.
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Affiliation(s)
- Slawa Rokicki
- Department of Health Behavior, Society, & PolicyRutgers School of Public HealthPiscatawayNew JerseyUSA,Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Maria W. Steenland
- Population Studies and Training CenterBrown UniversityProvidenceRhode IslandUSA
| | - Caroline K. Geiger
- Interfaculty Initiative in Health PolicyHarvard UniversityCambridgeMassachusettsUSA,Evidence for AccessGenentech, Inc.South San FranciscoCaliforniaUSA
| | - Rebecca A. Gourevitch
- Interfaculty Initiative in Health PolicyHarvard UniversityCambridgeMassachusettsUSA,Department of Health Policy and ManagementUniversity of MarylandCollege ParkMarylandUSA
| | - Lucy Chen
- Interfaculty Initiative in Health PolicyHarvard UniversityCambridgeMassachusettsUSA
| | - Michelle W. Martin
- Department of Social and Behavioral ScienceHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Jessica L. Cohen
- Department of Global Health and PopulationHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
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Henry J, Clarke-Deelder E, Han D, Miller N, Opondo K, Oguttu M, Burke T, Cohen JL, McConnell M. Health care providers’ knowledge of clinical protocols for postpartum hemorrhage care in Kenya: a cross-sectional study. BMC Pregnancy Childbirth 2022; 22:828. [PMID: 36357842 PMCID: PMC9647972 DOI: 10.1186/s12884-022-05128-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) remains the leading cause of maternal death worldwide despite its often-preventable nature. Understanding health care providers’ knowledge of clinical protocols is imperative for improving quality of care and reducing mortality. This is especially pertinent in referral and teaching hospitals that train nursing and medical students and interns in addition to managing emergency and referral cases. Methods This study aimed to (1) measure health care providers’ knowledge of clinical protocols for risk assessment, prevention, and management of PPH in 3 referral hospitals in Kenya and (2) examine factors associated with providers’ knowledge. We developed a knowledge assessment tool based on past studies and clinical guidelines from the World Health Organization and the Kenyan Ministry of Health. We conducted in-person surveys with health care providers in three high-volume maternity facilities in Nairobi and western Kenya from October 2018-February 2019. We measured gaps in knowledge using a summative index and examined factors associated with knowledge (such as age, gender, qualification, experience, in-service training attendance, and a self-reported measure of peer-closeness) using linear regression. Results We interviewed 172 providers including consultants, medical officers, clinical officers, nurse-midwives, and students. Overall, knowledge was lowest for prevention-related protocols (an average of 0.71 out of 1.00; 95% CI 0.69–0.73) and highest for assessment-related protocols (0.81; 95% CI 0.79–0.83). Average knowledge scores did not differ significantly between qualified providers and students. Finally, we found that being a qualified nurse, having a specialization, being female, having a bachelor's degree and self-reported closer relationships with colleagues were statistically significantly associated with higher knowledge scores. Conclusion We found gaps in knowledge of PPH care clinical protocols in Kenya. There is a clear need for innovations in clinical training to ensure that providers in teaching referral hospitals are prepared to prevent, assess, and manage PPH. It is possible that training interventions focused on learning by doing and teamwork may be beneficial. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-05128-6.
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Steenland MW, Vatsa R, Pace LE, Cohen JL. Immediate Postpartum Long-Acting Reversible Contraceptive Use Following State-Specific Changes in Hospital Medicaid Reimbursement. JAMA Netw Open 2022; 5:e2237918. [PMID: 36269353 PMCID: PMC9587474 DOI: 10.1001/jamanetworkopen.2022.37918] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 08/14/2022] [Indexed: 11/29/2022] Open
Abstract
Importance Facilitating access to the full range of contraceptive options is a health policy goal; however, inpatient provision of postpartum long-acting reversible contraceptive (LARC) methods has been limited due to lack of hospital reimbursement. Between March 2014 and January 2015, the Medicaid programs in 5 states began to reimburse hospitals for immediate postpartum LARC separately from the global maternity payment. Objective To examine the association between Medicaid policies and provision of immediate postpartum LARC, and to examine hospital characteristics associated with policy adoption. Design, Setting, and Participants This cross-sectional study used interrupted time series analysis. The setting was population-based in Georgia, Iowa, Maryland, New York, and Rhode Island. Participants included individuals who gave birth in these states between 2011 and 2017 (n = 3 097 188). Statistical analysis was performed from June 2021 to August 2022. Exposures Childbirth after the start of Medicaid's reimbursement policy. Main Outcomes and Measures Immediate postpartum LARC (outcome), teaching hospital, Catholic-owned or operated, obstetrical care level, and urban or rural location (hospital characteristics). Results The study included a total of 1 521 491 births paid for by Medicaid and 1 575 697 paid for by a commercial payer between 2011 and 2017. Prior to Medicaid reimbursement changes, 489 389 of 726 805 births (67%) were to individuals between 18 and 29 years of age, 219 363 of 715 905 births (31%) were to non-Hispanic Black individuals, 227 639 of 715 905 births (32%) were to non-Hispanic White individuals, 155 298 of 715 905 births (22%) were to Hispanic individuals, and 113 605 of 715 905 births (16%) were to individuals from other non-Hispanic racial groups. Among Medicaid-paid births, the policies were associated with an increase in the rate of immediate postpartum LARC provision in all states, although results for Maryland were not consistent across sensitivity analyses. The change in trend ranged from a quarterly increase of 0.05 percentage points in Maryland (95% CI, 0.01-0.08 percentage points) and 0.05 percentage points in Iowa (95% CI, 0.00-0.11 percentage points) to 0.82 percentage points (95% CI, 0.73-0.91 percentage points) in Rhode Island. The policy was also associated with an increase in immediate postpartum LARC provision among commercially paid births in 4 of 5 states. After the policy, only 38 of 366 hospitals (10%) provided more than 1% of birthing people with immediate postpartum LARC. These adopting hospitals were less likely to be Catholic (0% [0 of 31] vs 17% [41 of 245]), less likely to be rural (10% [3 of 31] vs 33% [81 of 247]), more likely to have the highest level of obstetric care (71% [22 of 31] vs 29% [65 of 223]) and be teaching hospitals (87% [27 of 31] vs 43% [106 of 246]) compared with nonadopting hospitals. Conclusions and Relevance This cross-sectional study's findings suggest that Medicaid policies that reimburse immediate postpartum LARC may increase access to this service; however, policy implementation has been uneven, resulting in unequal access.
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Affiliation(s)
- Maria W Steenland
- Population Studies and Training Center, Brown University, Providence, Rhode Island
| | - Raj Vatsa
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts
| | - Lydia E Pace
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Wang AZ, Barnett ML, Cohen JL. Changes in Cancer Screening Rates Following a New Cancer Diagnosis in a Primary Care Patient Panel. JAMA Netw Open 2022; 5:e2222131. [PMID: 35838669 PMCID: PMC9287757 DOI: 10.1001/jamanetworkopen.2022.22131] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
IMPORTANCE Although screenings for breast and colorectal cancer are widely recommended, patient screening rates vary greatly and remain below public health targets, and primary care physicians' (PCPs') counseling and referrals play critical roles in patients' use of cancer screenings. Recent adverse events may influence PCPs' decision-making, but it remains unknown whether cancer screening rates of PCPs' patients change after PCPs are exposed to new cancer diagnoses. OBJECTIVE To investigate whether PCPs' exposures to patients with new diagnoses of breast or colorectal cancer were associated with changes in screening rates for other patients subsequently visiting the affected PCPs. DESIGN, SETTING, AND PARTICIPANTS This cohort study used stacked difference-in-differences analyses of all-payer claims data for New Hampshire and Maine in 2009 to 2015. Participants were PCPs caring for patients. Data analysis was performed from June 2020 to May 2022. EXPOSURES New diagnosis of a PCP's patient with breast cancer or colorectal cancer. MAIN OUTCOMES AND MEASURES Patients' breast and colorectal cancer screening rates within 1 year of a PCP visit. RESULTS The sample included 3158 PCPs (1819 male PCPs [57.6%]) caring for 1 920 189 patients (1 073 408 female patients [55.9%]; mean [SD] age, 41.0 [21.9] years) aged 18 to 64 years. During the study period, 898 PCPs had a patient with a new diagnosis of breast cancer and 370 PCPs had a patient with a new diagnosis of colorectal cancer. In the preexposure period, 68 837 female patients (37.3% of those visiting a PCP) underwent breast cancer screening within 1 year of the visit, and 13 137 patients (10.1% of those visiting a PCP) underwent colorectal cancer screening within 1 year of the visit. For both cancer types, after exposure to a new cancer diagnosis, PCPs' cancer screening rates displayed a rapid, sustained increase. Breast cancer screening rates increased by 4.5 percentage points (95% CI, 3.0-6.1 percentage points; P < .001). Colorectal cancer screening rates increased by 1.3 percentage points (95% CI, 0.3-2.2 percentage points; P = .01). Observed breast cancer screening increases were higher for male PCPs than for female PCPs (3.1 percentage points; 95% CI, 0.4-5.8 percentage points; P = .03). CONCLUSIONS AND RELEVANCE This study found significant, sustained increases in cancer screening rates for patients visiting PCPs recently exposed to new breast and colorectal cancer diagnoses. These findings suggest that PCPs may update practice patterns on the basis of recent patient diagnoses. Future work should assess whether salient cues to PCPs about patient diagnoses when clinically appropriate can improve screening practices.
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Affiliation(s)
- Annabel Z. Wang
- Harvard Medical School, Harvard University, Cambridge, Massachusetts
| | - Michael L. Barnett
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Abstract
IMPORTANCE Together, preterm birth and low birth weight are the second-leading cause of infant mortality in the US and occur disproportionately among Medicaid-paid births and among the infants of Black birthing persons. In 2012, South Carolina's Medicaid program began to reimburse hospitals for immediate postpartum long-acting reversible contraception (LARC) separately from the global maternity payment. OBJECTIVE To examine the association between South Carolina's policy change and infant health. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study using a difference-in-differences analysis included individuals with a South Carolina Medicaid-paid childbirth between January 2009 and December 2015. Data were analyzed from December 2020 to July 2021. EXPOSURES Medicaid-paid childbirth after March 2012 in South Carolina hospitals that had implemented the policy. MAIN OUTCOMES AND MEASURES Immediate postpartum LARC uptake, subsequent birth within 4 years, subsequent short-interval birth, days to subsequent birth, subsequent preterm, and low-birth-weight birth within 4 years. RESULTS The study sample included 186 953 Medicaid-paid births between January 2009 and December 2015 in South Carolina (81 110 births from 2009 to 2011, 105 843 births from 2012 to 2015, and 46 414 births in exposure hospitals). The policy was associated with an absolute 5.6-percentage point (95% CI, 3.7-7.4) increase in the probability of receiving an immediate postpartum LARC overall, with significantly larger effects for non-Hispanic Black individuals than non-Hispanic White individuals (difference in coefficients 3.54; 95% CI, 1.35-5.73; P = .002). The policy was associated with a 0.4-percentage point (95% CI, -0.7 to -0.1) decrease in the probability of subsequent preterm birth and a 0.3-percentage point (95% CI, -0.7 to 0) decrease in the probability of subsequent low birth weight. No significant difference in the association between the policy and preterm birth or low-birth-weight birth between non-Hispanic Black and non-Hispanic White individuals was found. The policy was associated with a 0.6-percentage point (95% CI, -1.2 to -0.1) decrease in the probability of short-interval birth and a 27-day (95% CI, 11-44) increase in days to next birth among non-Hispanic Black individuals. The policy was associated with a significant decrease in the probability of a subsequent birth overall; however, confidence in this result is attenuated somewhat by nonparallel trends for this outcome before the policy change. CONCLUSIONS AND RELEVANCE Findings of this cohort study suggest policies increasing access to immediate postpartum LARC may improve birth outcomes but should be accompanied by other policy efforts to reduce inequity in these outcomes.
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Affiliation(s)
- Maria W. Steenland
- Population Studies and Training Center, Brown University, Providence, Rhode Island
| | - Lydia E. Pace
- Department of Medicine at Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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Affiliation(s)
- Jessica L. Cohen
- Department of Global Health and Population,Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Jamie R. Daw
- Department of Health Policy and Management, Columbia University Mailman School of Public Health, New York, New York
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Geiger CK, Clapp MA, Cohen JL. Association of Prenatal Care Services, Maternal Morbidity, and Perinatal Mortality With the Advanced Maternal Age Cutoff of 35 Years. JAMA Health Forum 2021; 2:e214044. [PMID: 35977294 PMCID: PMC8796879 DOI: 10.1001/jamahealthforum.2021.4044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/15/2021] [Indexed: 12/21/2022] Open
Abstract
Importance Maternal and perinatal mortality remain high in the US despite growing rates of prenatal services and spending, and little rigorous evidence exists regarding the impact of prenatal care intensity on pregnancy outcomes. Patients with an expected date of delivery just after their 35th birthday may receive more intensive care owing to the advanced maternal age (AMA) designation; whether this increase in prenatal care is associated with improvements in outcomes has not been explored. Objective To determine the association between the AMA designation and prenatal care services, severe maternal morbidity, and perinatal mortality. Design Setting and Participants This cross-sectional study used a regression discontinuity design to compare individuals just above vs just below the 35-year AMA cutoff, using unidentifiable administrative claims data from a large, nationwide commercial insurer. All individuals with a delivery between January 1, 2008, and December 31, 2019, who were aged 35 years within 120 days of their expected date of delivery were included in the study. Analyses were performed from July 1, 2020, to February 1, 2021. Exposures Individuals who were aged 35.0 through 35.3 years on the expected date of delivery were designated as AMA. Main Outcomes and Measures Outcomes were visits with specialists (obstetrician-gynecologists and maternal-fetal medicine), ultrasound scan use, antepartum fetal surveillance, aneuploidy screening, severe maternal morbidity, preterm birth or low birth weight, and perinatal mortality. Results The analysis included 51 290 individuals (mean [SD] age; 34.5 [0.5] years); 26 108 individuals (50.9%) were aged 34.7 to 34.9 years and 25 182 individuals (49.1%) were aged 35.0 to 35.3 years on the expected date of delivery. A total of 2407 pregnant individuals (4.7%) had multiple gestation, 2438 (4.8%) had pregestational diabetes, 2265 (4.4%) had chronic hypertension, and 4963 (9.7%) had obesity. Advanced maternal age was associated with a 4.27 percentage point increase in maternal-fetal medicine visits (95% CI, 2.27-6.26 percentage points; P < .001), a 0.21 unit increase in total ultrasound scans (95% CI, 0.06-0.37; P = .006), a 15.67 percentage point increase in detailed ultrasound scans (95% CI, 13.68-17.66 percentage points; P < .001), and a 4.86 percentage point increase in antepartum surveillance (95% CI, 2.83-6.89 percentage points; P < .001). The AMA designation was associated with a 0.39 percentage point decline in perinatal mortality (95% CI, -0.77 to -0.01 percentage points; P = .04). Conclusions and Relevance In this cross-sectional study, the AMA designation at age 35 years was associated with an increase in receipt of prenatal monitoring and a small decrease in perinatal mortality, suggesting that the AMA designation may be associated with clinical decision-making, with individuals just older than 35 years receiving more prenatal monitoring. These results suggest that increases in prenatal care services stemming from the AMA designation may have important benefits for fetal and infant survival for patients in this age range.
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Affiliation(s)
- Caroline K. Geiger
- Harvard University, Interfaculty Initiative in Health Policy, Cambridge, Massachusetts
- Evidence for Access, Genentech Inc, South San Francisco, California
| | - Mark A. Clapp
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Steenland MW, Geiger CK, Chen L, Rokicki S, Gourevitch RA, Sinaiko AD, Cohen JL. Declines in contraceptive visits in the United States during the COVID-19 pandemic. Contraception 2021; 104:593-599. [PMID: 34400152 PMCID: PMC8570647 DOI: 10.1016/j.contraception.2021.08.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/02/2021] [Accepted: 08/07/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To document the change in contraceptive visits in the United States during the COVID-19 pandemic. STUDY DESIGN Using a nationwide sample of claims we analyzed the immediate and sustained changes in contraceptive visits during the pandemic by calculating the percentage change in number of visits between May 2019 and April 2020 and between December 2019 and December 2020, respectively. We examined these changes by contraceptive method, region, age, and use of telehealth, and separately for postpartum individuals. RESULTS Relative to May 2019, in April 2020, visits for tubal ligation declined by 65% (95% CI, -65.5, -64.1), LARCs by 46% (95% CI, -47.0, -45.6), pill, patch, or ring by 45% (95% CI, -45.8, -44.5), and injectables by 16% (95% CI -17.2, -15.4). The sustained change in visits in December 2020 was larger for tubal ligation (-18%, 95% CI, -19.1, -16.8) and injectable (-11%, 95% CI, -11.4, -9.6) visits than for LARC (-6%, 95% CI, -6.6, -4.4) and pill, patch, and ring (-5%, 95% CI, -5.7, -3.7) visits. The immediate decline was highest in the Northeast and Midwest regions. Declines among postpartum individuals were smaller but still substantial. CONCLUSIONS There were large declines in contraceptive visits at the start of the COVID-19 pandemic and visit numbers remained below pre-pandemic levels through the end of 2020. IMPLICATIONS Declines in contraceptive visits during the pandemic suggest that many people faced difficulties accessing this essential health service during the COVID-19 pandemic.
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Affiliation(s)
- Maria W. Steenland
- Population Studies and Training Center, Brown University, Providence, RI, United States,Corresponding author
| | - Caroline K. Geiger
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, United States
| | - Lucy Chen
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, United States
| | - Slawa Rokicki
- Department of Health Behavior, Society, & Policy, Rutgers School of Public Health, Piscataway, NJ, United States
| | - Rebecca A. Gourevitch
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, MA, United States
| | - Anna D. Sinaiko
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States
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Abstract
OBJECTIVE To assess the relationship between recent changes in Medicaid eligibility and preconception insurance coverage, pregnancy intention, health care use, and risk factors for poor birth outcomes among first-time parents. DATA SOURCE This study used individual-level data from the national Pregnancy Risk Assessment Monitoring System (2006-2017), which surveys individuals who recently gave birth in the United States on their experiences before, during, and after pregnancy. STUDY DESIGN Outcomes included preconception insurance status, pregnancy intention, stress from bills, early prenatal care, and diagnoses of high blood pressure and diabetes. Outcomes were regressed on an index measuring Medicaid generosity, which captures the fraction of female-identifying individuals who would be eligible for Medicaid based on state income eligibility thresholds, in each state and year. DATA COLLECTION/EXTRACTION METHODS The sample included all individuals aged 20-44 with a first live birth in 2009-2017. PRINCIPAL FINDINGS Among all first-time parents, a 10-percentage point (ppt) increase in Medicaid generosity was associated with a 0.7 ppt increase (P = 0.017) in any insurance coverage and a 1.5 ppt increase (P < 0.001) in Medicaid coverage in the month before pregnancy. We also observed significant increases in insurance coverage and early prenatal care and declines in stress from bills and unintended pregnancies among individuals with a high-school degree or less. CONCLUSIONS Increasing Medicaid generosity for childless adults has the potential to improve insurance coverage in the critical period before pregnancy and help improve maternal outcomes among first-time parents.
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Affiliation(s)
- Caroline K Geiger
- Interfaculty Initiative in Health Policy, Harvard University, Cambridge, Massachusetts, USA
- Genentech, Inc., San Francisco, California, USA
| | - Benjamin D Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Harvard Medical School/Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Summer S Hawkins
- School of Social Work, Boston College, Chestnut Hill, Massachusetts, USA
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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Clarke-Deelder E, Suharlim C, Chatterjee S, Brenzel L, Ray A, Cohen JL, McConnell M, Resch SC, Menzies NA. Impact of campaign-style delivery of routine vaccines: a quasi-experimental evaluation using routine health services data in India. Health Policy Plan 2021; 36:454-463. [PMID: 33734362 PMCID: PMC8128004 DOI: 10.1093/heapol/czab026] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 12/16/2022] Open
Abstract
The world is not on track to achieve the goals for immunization coverage and equity described by the World Health Organization's Global Vaccine Action Plan. Many countries struggle to increase coverage of routine vaccination, and there is little evidence about how to do so effectively. In India in 2016, only 62% of children had received a full course of basic vaccines. In response, in 2017-18 the government implemented Intensified Mission Indradhanush (IMI), a nationwide effort to improve coverage and equity using a campaign-style strategy. Campaign-style approaches to routine vaccine delivery like IMI, sometimes called 'periodic intensification of routine immunization' (PIRI), are widely used, but there is little robust evidence on their effectiveness. We conducted a quasi-experimental evaluation of IMI using routine data on vaccine doses delivered, comparing districts participating and not participating in IMI. Our sample included all districts that could be merged with India's 2016 Demographic and Health Surveys data and had available data for the full study period. We used controlled interrupted time-series analysis to estimate the impact of IMI during the 4-month implementation period and in subsequent months. This method assumes that, if IMI had not occurred, vaccination trends would have changed in the same way in the participating and not participating districts. We found that, during implementation, IMI increased delivery of 13 infant vaccines, with a median effect of 10.6% (95% confidence interval 5.1% to 16.5%). We did not find evidence of a sustained effect during the 8 months after implementation ended. Over the 12 months from the beginning of implementation, we estimated reductions in the number of under-immunized children that were large but not statistically significant, ranging from 3.9% (-6.9% to 13.7%) to 35.7% (-7.5% to 77.4%) for different vaccines. The largest effects were for the first doses of vaccines against diphtheria-tetanus-pertussis and polio: IMI reached approximately one-third of children who would otherwise not have received these vaccines. This suggests that PIRI can be successful in increasing routine immunization coverage, particularly for early infant vaccines, but other approaches may be needed for sustained coverage improvements.
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Affiliation(s)
- Emma Clarke-Deelder
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Christian Suharlim
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston MA 02115, USA.,Management Sciences for Health, 200 Rivers Edge Dr, Medford MA 02155, USA
| | - Susmita Chatterjee
- Research Department, George Institute for Global Health, 308-309 Elegance Tower, Plot No. 8, Jasola District Centre, New Delhi -110025, India.,Department of Medicine, University of New South Wales, 18 High Street, Kensington, New South Wales, 2052, Australia
| | - Logan Brenzel
- Bill & Melinda Gates Foundation, 500 5th Ave N, Seattle, WA 98109, USA
| | - Arindam Ray
- Bill & Melinda Gates Foundation, Capital Court, The 5th Floor, Olof Palme Marg, Munirka, New Delhi, Delhi 110067, India
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Margaret McConnell
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115 USA
| | - Stephen C Resch
- Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston MA 02115, USA
| | - Nicolas A Menzies
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA 02115 USA.,Center for Health Decision Science, Harvard T. H. Chan School of Public Health, 718 Huntington Avenue, Boston MA 02115, USA
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Geiger CK, Cohen JL, Sommers BD. Association Between Medicaid Prescription Drug Limits and Access to Medications and Health Care Use Among Young Adults With Disabilities. JAMA Health Forum 2021; 2:e211048. [PMID: 35977173 PMCID: PMC8796920 DOI: 10.1001/jamahealthforum.2021.1048] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/17/2021] [Indexed: 11/22/2022] Open
Abstract
Question Are policies that cap monthly prescriptions in Medicaid associated with access to medication and health care use among young adults with disabilities in Arkansas and Texas? Findings In this cohort study using difference-in-differences analysis of 28 046 young adults with disabilities, including 8214 in states with a 3-drug limit at age 21 years, the 3-drug limit was associated with lower monthly prescriptions for medications used to treat mental health conditions and higher inpatient admissions among all individuals with disabilities in states with the drug cap policy compared with those in states without this policy. Meaning In this study, state drug cap policies in Medicaid were associated with lower access to medications and higher use of inpatient care. Importance Prescription drugs are necessary for managing complex physical and mental health conditions for more than 10 million Medicaid beneficiaries with disabilities. However, some state Medicaid programs limit the number of prescription drugs that beneficiaries can obtain monthly, which may decrease access to essential medications. Objective To examine the association between exposure to the 3-drug limit at age 21 years in Arkansas and Texas and prescription drug and health care use among beneficiaries with disabilities enrolled in Medicaid. Design, Setting, and Participants In this cohort study of 28 046 young adults with disabilities, difference-in-differences analysis was performed using Medicaid Analytic eXtract claims data from January 1, 2007, to December 31, 2012. Analyses were completed December 1, 2020. The analyses included Medicaid beneficiaries with disabilities in Arkansas and Texas (ie, drug cap states) or 15 comparison states without drug cap policies who became age 21 years during the study period and were continuously enrolled in fee-for-service Medicaid in the year before and after that point. Exposures Exposure to the 3-drug prescription limit at age 21 years in 2 drug cap states. Main Outcomes and Measures Monthly total prescriptions and prescriptions for drugs to treat mental health conditions, total prescription drug spending, and inpatient and emergency department visits and spending in the 12 months before and after becoming age 21 years. Results Among 28 046 young adults with disabilities, 8214 (29.3%) resided in drug cap states and were subject to the 3-drug limit at age 21 years. Most individuals were male (drug cap states: 61.4%, comparison states: 60.6%), and the minority were White individuals (drug cap states: 36.7%, comparison states: 49.4%). More than one-half of individuals with disabilities were diagnosed with a mental health condition before age 21 years (drug cap states: 57.0%, comparison states: 60.0%). In the year before the analyzed individuals became aged 21 years, the mean (SD) number of prescriptions per beneficiary per month was 1.58 (2.16) in drug cap states vs 1.82 (1.91) in comparison states. The drug cap policy was associated with 19.6% (95% CI, −21.3% to −17.8%; P < .001) fewer monthly prescriptions and 16.5% (95% CI, −21.9% to −10.8%; P < .001) fewer prescriptions for drugs for mental health conditions but was not associated with total prescription drug spending. The drug cap policy was associated with 13.6% (95% CI, 1.9% to 26.6%; P = .02) more inpatient admissions. Conclusions and Relevance In this cohort study of young adults with disabilities, drug cap policies were associated with lower rates of access to important medications and higher rates of hospitalization among individuals in states with drug cap policies vs those without these policies.
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Affiliation(s)
- Caroline K. Geiger
- Harvard University, Interfaculty Initiative in Health Policy, Cambridge, Massachusetts
- Genentech, Inc, South San Francisco, California
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Benjamin D. Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Harvard Medical School/Brigham & Women’s Hospital, Boston, Massachusetts
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Steenland MW, Pace LE, Sinaiko AD, Cohen JL. Medicaid Payments For Immediate Postpartum Long-Acting Reversible Contraception: Evidence From South Carolina. Health Aff (Millwood) 2021; 40:334-342. [PMID: 33523747 DOI: 10.1377/hlthaff.2020.00254] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In 2012 South Carolina's Medicaid program was the first state Medicaid program to separate payment for the immediate postpartum placement of long-acting reversible contraception (intrauterine devices and contraceptive implants) from its global maternity payment. Examining data on all Medicaid-insured South Carolina women giving birth from 2010 to 2014, we found that the new policy achieved its explicit goal: increasing the availability of immediate postpartum long-acting reversible contraception. Among adolescents, for whom most pregnancies are unintended, this represented new use of long-acting reversible options, rather than substitution for sterilization or for short-acting reversible methods. Therefore, the new policy also significantly increased use of highly effective postpartum contraception in an age group that is particularly vulnerable to closely spaced, higher-risk repeat pregnancies. However, fewer than half of facilities began to offer immediate postpartum long-acting reversible contraceptives after the policy change. Additional policy approaches may be needed to achieve widespread availability of this option.
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Affiliation(s)
- Maria W Steenland
- Maria W. Steenland is an assistant professor of population studies in the Population Studies and Training Center at Brown University, in Providence, Rhode Island
| | - Lydia E Pace
- Lydia E. Pace is an assistant professor in the Division of Women's Health, Brigham and Women's Hospital, and an assistant professor in medicine at Harvard Medical School, in Boston, Massachusetts
| | - Anna D Sinaiko
- Anna D. Sinaiko is an assistant professor of health economics and policy in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Jessica L Cohen
- Jessica L. Cohen is the Bruce A. Beal, Robert L. Beal, and Alexander S. Beal Associate Professor of Global Health in the Department of Global Health and Population, Harvard T. H. Chan School of Public Health
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18
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Glover ME, Cohen JL, Singer JR, Sabbagh MN, Rainville JR, Hyland MT, Morrow CD, Weaver CT, Hodes GE, Kerman IA, Clinton SM. Examining the Role of Microbiota in Emotional Behavior: Antibiotic Treatment Exacerbates Anxiety in High Anxiety-Prone Male Rats. Neuroscience 2021; 459:179-197. [PMID: 33540050 PMCID: PMC7965353 DOI: 10.1016/j.neuroscience.2021.01.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 02/06/2023]
Abstract
Intestinal microbiota are essential for healthy gastrointestinal function and also broadly influence brain function and behavior, in part, through changes in immune function. Gastrointestinal disorders are highly comorbid with psychiatric disorders, although biological mechanisms linking these disorders are poorly understood. The present study utilized rats bred for distinct emotional behavior phenotypes to examine relationships between emotionality, the microbiome, and immune markers. Prior work showed that Low Novelty Responder (LR) rats exhibit high levels of anxiety- and depression-related behaviors as well as myriad neurobiological differences compared to High Novelty Responders (HRs). Here, we hypothesized that the divergent HR/LR phenotypes are accompanied by changes in fecal microbiome composition. We used next-generation sequencing to assess the HR/LR microbiomes and then treated adult HR/LR males with an antibiotic cocktail to test whether it altered behavior. Given known connections between the microbiome and immune system, we also analyzed circulating cytokines and metabolic factors to determine relationships between peripheral immune markers, gut microbiome components, and behavioral measures. There were no baseline HR/LR microbiome differences, and antibiotic treatment disrupted the microbiome in both HR and LR rats. Antibiotic treatment exacerbated aspects of HR/LR behavior, increasing LRs' already high levels of anxiety-like behavior while reducing passive stress coping in both strains. Our results highlight the importance of an individual's phenotype to their response to antibiotics, contributing to the understanding of the complex interplay between gut microbes, immune function, and an individual's emotional phenotype.
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Affiliation(s)
- M E Glover
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA.
| | - J L Cohen
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - J R Singer
- MD/PhD Medical Scientist Training Program, University of Alabama-Birmingham, Birmingham, AL, USA
| | - M N Sabbagh
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - J R Rainville
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - M T Hyland
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - C D Morrow
- Department of Cell, Developmental, and Integrative Biology, University of Alabama-Birmingham, Birmingham, AL, USA
| | - C T Weaver
- Department of Pathology, University of Alabama-Birmingham, Birmingham, AL, USA
| | - G E Hodes
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Ilan A Kerman
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA; Behavioral Health Service Line, Veterans Affairs Pittsburgh Health System, Pittsburgh, PA, USA
| | - S M Clinton
- School of Neuroscience, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
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Rokicki S, Mwesigwa B, Cohen JL. Know-do gaps in obstetric and newborn care quality in Uganda: a cross-sectional study in rural health facilities. Trop Med Int Health 2021; 26:535-545. [PMID: 33529436 DOI: 10.1111/tmi.13557] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Variable and inadequate quality of maternity care is a critical factor in persistently high rates of maternal and neonatal mortality in Uganda. We investigated whether provider quality of care deviates from knowledge and the factors associated with these 'know-do gaps' in Ugandan maternity facilities. METHODS Data were collected from 109 providers in 40 facilities. Quality was measured using direct observations of intrapartum care, and scores were based on the percentage of essential care actions provided out of a 20-item validated quality index. Knowledge was measured based on the percentage of items that providers reported knowing to do using vignette surveys. The know-do gap was the difference between knowledge and quality. Multivariable models were used to assess the association between provider- and facility-level characteristics and knowledge, quality and know-do gaps. RESULTS The average quality score was 45%, with quality varying widely within and across providers. The mean knowledge score was 70%, yielding a mean know-do gap of 25%. Know-do gaps were largest for practices related to infection control, vitals monitoring, and prevention of postpartum haemorrhage. The association between quality and knowledge scores was positive but small (P = 0.08), so know-do gaps were largest for providers with the highest knowledge scores. Greater provider training was positively associated with knowledge (P = 0.005) but not with quality (P = 0.60). Having 10 or more years of work experience was associated with higher quality scores (5.3, 95%CI: 0.6 to 10.1), while higher patient volumes were associated with lower quality scores (-2.2, 95%CI: -3.7 to - 0.07). None of the factors of provider motivation, cadre, availability of essential medicines and supplies or facility staffing were associated with quality or know-do gaps. CONCLUSIONS Our results indicate that, in Uganda, gaps between knowledge and quality do not appear to be explained by factors such as lack of motivation, education, training or supplies. Gaps are particularly large for essential practices related to prevention of postpartum haemorrhage, a leading cause of maternal mortality in Uganda and similar settings.
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Affiliation(s)
- Slawa Rokicki
- Department of Health Behavior, Society & Policy, Rutgers School of Public Health, Piscataway, NJ, USA.,Geary Institute for Public Policy, University College Dublin, Dublin, Ireland
| | | | - Jessica L Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
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20
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Cohen JL, Leslie HH, Saran I, Fink G. Quality of clinical management of children diagnosed with malaria: A cross-sectional assessment in 9 sub-Saharan African countries between 2007-2018. PLoS Med 2020; 17:e1003254. [PMID: 32925906 PMCID: PMC7489507 DOI: 10.1371/journal.pmed.1003254] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 08/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.
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Affiliation(s)
- Jessica L. Cohen
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
- * E-mail:
| | - Hannah H. Leslie
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Indrani Saran
- Boston College School of Social Work, Chestnut Hill, Massachusetts, United States of America
| | - Günther Fink
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Luisi K, Morabito KM, Burgomaster KE, Sharma M, Kong WP, Foreman BM, Patel S, Fisher B, Aleshnick MA, Laliberte J, Wallace M, Ruckwardt TJ, Gordon DN, Linton C, Ruggiero N, Cohen JL, Johnson R, Aggarwal K, Ko SY, Yang ES, Pelc RS, Dowd KA, O’Hagan D, Ulmer J, Mossman S, Sambor A, Lepine E, Mascola JR, Pierson TC, Graham BS, Yu D. Development of a potent Zika virus vaccine using self-amplifying messenger RNA. Sci Adv 2020; 6:eaba5068. [PMID: 32821824 PMCID: PMC7413734 DOI: 10.1126/sciadv.aba5068] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 06/26/2020] [Indexed: 05/15/2023]
Abstract
Zika virus (ZIKV) is the cause of a pandemic associated with microcephaly in newborns and Guillain-Barre syndrome in adults. Currently, there are no available treatments or vaccines for ZIKV, and the development of a safe and effective vaccine is a high priority for many global health organizations. We describe the development of ZIKV vaccine candidates using the self-amplifying messenger RNA (SAM) platform technology delivered by cationic nanoemulsion (CNE) that allows bedside mixing and is particularly useful for rapid responses to pandemic outbreaks. Two immunizations of either of the two lead SAM (CNE) vaccine candidates elicited potent neutralizing antibody responses to ZIKV in mice and nonhuman primates. Both SAM (CNE) vaccines protected these animals from ZIKV challenge, with one candidate providing complete protection against ZIKV infection in nonhuman primates. The data provide a preclinical proof of concept that a SAM (CNE) vaccine candidate can rapidly elicit protective immunity against ZIKV.
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Affiliation(s)
| | - Kaitlyn M. Morabito
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Katherine E. Burgomaster
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Wing-Pui Kong
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Bryant M. Foreman
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | - Brian Fisher
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Maya A. Aleshnick
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | | | - Tracy J. Ruckwardt
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - David N. Gordon
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | | | | | | | | | - Sung-Youl Ko
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Eun Sung Yang
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Rebecca S. Pelc
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Kimberly A. Dowd
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | | | | | | | | | | | - John R. Mascola
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Theodore C. Pierson
- Laboratory of Viral Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
- Corresponding author. (D.Y.); (B.S.G.); (T.C.P.)
| | - Barney S. Graham
- Vaccine Research Center, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
- Corresponding author. (D.Y.); (B.S.G.); (T.C.P.)
| | - Dong Yu
- GSK Vaccines, Rockville, MD 20850, USA
- Corresponding author. (D.Y.); (B.S.G.); (T.C.P.)
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22
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Rokicki S, Mwesigwa B, Schmucker L, Cohen JL. Shedding light on quality of care: a study protocol for a randomized trial evaluating the impact of the Solar Suitcase in rural health facilities on maternal and newborn care quality in Uganda. BMC Pregnancy Childbirth 2019; 19:306. [PMID: 31438896 PMCID: PMC6704514 DOI: 10.1186/s12884-019-2453-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 09/13/2018] [Accepted: 08/07/2019] [Indexed: 04/28/2023] Open
Abstract
Background Continued progress in reducing maternal and newborn morbidity and mortality in low-income countries requires a renewed focus on quality of delivery care. Reliable electricity and lighting is a cornerstone of a well-equipped health system, but most primary maternity care facilities in sub-Saharan Africa are either not connected to the electrical grid or suffer frequent blackouts. Lack of reliable electricity and light in maternity facilities may contribute to poor quality of both routine and emergency obstetric and newborn care, by hindering infection control, increasing delays in providing care, and reducing health worker morale. The “Solar Suitcase” is a solar electric system designed specifically for maternity care facilities in low-resource environments. The purpose of this trial is to evaluate the impact of the Solar Suitcase on reliability of light, quality of obstetric and newborn care, and health worker satisfaction. Methods We are conducting a study with 30 maternity care facilities in rural Uganda that lack access to a reliable, bright light source. The study is a stepped wedge cluster randomized controlled trial. Study facilities are identified according to predefined eligibility criteria, and randomized by blocking on baseline covariates. The intervention is a “Solar Suitcase”, a complete solar electric system that provides essential lighting and power for charging phones and small medical devices. The primary outcomes are the reliability and quality of light during intrapartum care, the process quality of obstetric and newborn care, and health worker satisfaction. Outcomes will be assessed via direct clinical observation by trained enumerators (estimated n = 1980 birth observations), as well as interviews with health workers and facility managers. Lighting and blackouts will be captured through direct observation and via light sensors installed in facilities. Discussion A key feature of a high quality health system is appropriate infrastructure, including reliable, bright lighting and electricity. Rigorous evidence on the role of a reliable light source in maternal and newborn care is needed to accelerate the “electrification” of maternity facilities across sub-Saharan Africa. This study will be the first to rigorously assess the extent to which reliable light is an important driver of the quality of care experienced by women and newborns. Trial registration ClinicalTrials.gov: NCT03589625 (July 18, 2018); socialscienceregistry.org: AEARCTR-0003078 (dated June 16, 2018). Electronic supplementary material The online version of this article (10.1186/s12884-019-2453-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Slawa Rokicki
- Geary Institute for Public Policy, University College Dublin, Dublin, Ireland.,Department of Health Behavior, Society & Policy, Rutgers School of Public Health, Piscataway, USA
| | | | | | - Jessica L Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA.
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23
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Affiliation(s)
- Jessica L Cohen
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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24
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Steenland MW, Pace LE, Sinaiko AD, Cohen JL. Association Between South Carolina Medicaid's Change in Payment for Immediate Postpartum Long-Acting Reversible Contraception and Birth Intervals. JAMA 2019; 322:76-78. [PMID: 31158852 PMCID: PMC6547092 DOI: 10.1001/jama.2019.6854] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This study evaluates whether a 2012 change in the South Carolina Medicaid policy to reimburse hospitals for provision of immediate postpartum long-acting reversible contraception (IPP-LARC) separately from global payment for all services in a delivery hospitalization was associated with changes in IPP-LARC use and short-interval births between 2010 and 2017.
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Affiliation(s)
- Maria W. Steenland
- Population Studies and Training Center, Brown University, Providence, Rhode Island
| | - Lydia E. Pace
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Anna D. Sinaiko
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
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25
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Bernstock JD, Cohen JL, Singh S, Schlappi CW, Fiveash JB, Johnston JM, Fequiere P, Orr BA, Li R, Friedman GK. Treatment-induced remission of medulloblastoma using a chemotherapeutic regimen devoid of vincristine in a child with Charcot-Marie-Tooth disease. ACTA ACUST UNITED AC 2019; 26:e266-e269. [PMID: 31043836 DOI: 10.3747/co.26.4491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Charcot-Marie-Tooth (cmt) disease is the most common form of inherited neuropathy. Core features include peripheral neuropathy and secondary axonal degeneration, with a noted distal predominance of limb-muscle wasting, weakness, and sensory loss. Given the significant prevalence of cmt, superimposed neoplastic disease can be encountered within this patient population. Malignancies that are treated with vincristine (a microtubule-targeting agent), even at low doses as part of standard treatment, pose a significant challenge for patients with cmt. Here, we present the case of a child with cmt who was successfully treated for medulloblastoma without vincristine, a standard drug used for treatment of that disease, to avoid the risk of severe debilitating neuropathy. This report is the first of a patient successfully treated for medulloblastoma without vincristine.
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Affiliation(s)
- J D Bernstock
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - J L Cohen
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - S Singh
- Department of Radiology, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - C W Schlappi
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - J B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - J M Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - P Fequiere
- Department of Pediatrics, Division of Neurology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
| | - B A Orr
- Pathology Department, St. Jude Children's Research Hospital, Memphis, TN, U.S.A
| | - R Li
- Department of Pathology, Children's of Alabama, Birmingham, AL, U.S.A
| | - G K Friedman
- Department of Pediatrics, Division of Pediatric Hematology and Oncology, University of Alabama at Birmingham, Birmingham, AL, U.S.A
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Tessema M, Gunaratna NS, Brouwer ID, Donato K, Cohen JL, McConnell M, Belachew T, Belayneh D, De Groote H. Associations among High-Quality Protein and Energy Intake, Serum Transthyretin, Serum Amino Acids and Linear Growth of Children in Ethiopia. Nutrients 2018; 10:E1776. [PMID: 30453477 PMCID: PMC6266228 DOI: 10.3390/nu10111776] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 11/05/2018] [Accepted: 11/09/2018] [Indexed: 12/17/2022] Open
Abstract
Limited evidence is available on the associations of high-quality protein and energy intake, serum transthyretin (TTR), serum amino acids and serum insulin-like growth factor-1 (IGF-1) with linear growth of young children. Data collected during the baseline of a randomized control trial involving rural Ethiopian children aged 6⁻35 months (n = 873) were analyzed to evaluate the associations among height/length-for-age z-scores, dietary intakes, and these biomarkers (i.e., serum level of TTR, IGF-1, tryptophan and lysine, and inflammation). The prevalence of stunting was higher for children >23 months (38%) than ≤23 months (25%). The prevalence of inflammation was 35% and of intestinal parasites 48%. Three-quarters of the children were energy deficient, and stunted children had lower daily energy intake that non-stunted children (p < 0.05). Intakes of tryptophan, protein, and energy, and serum levels of tryptophan and IGF-1 were positively correlated with the linear growth of children. Controlling for inflammation, intestinal parasites, and sociodemographic characteristics, daily tryptophan (b = 0.01, p = 0.001), protein (b = 0.01, p = 0.01) and energy (b = 0.0003, p = 0.04) intakes and serum TTR (b = 2.58, p = 0.04) and IGF-1 (b = 0.01, p = 0.003) were positively associated with linear growth of children. Linear growth failure in Ethiopian children is likely associated with low quality protein intake and inadequate energy intake. Nutrition programs that emphasize improved protein quantity and quality and energy intake may enhance the linear growth of young children and need to be further investigated in longitudinal and interventional studies.
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Affiliation(s)
- Masresha Tessema
- Division of Human Nutrition, Wageningen University, 6700 AA Wageningen, The Netherlands.
- Ethiopian Public Health Institute, Gulele Sub City, P.O. Box 1242, Addis Ababa, Ethiopia.
- Human Nutrition Unit, Jimma University, P.O. Box 378, Jimma, Ethiopia.
| | - Nilupa S Gunaratna
- Department of Nutrition Science and Public Health Graduate Program, Purdue University, West Lafayette, IN 47907, USA.
| | - Inge D Brouwer
- Division of Human Nutrition, Wageningen University, 6700 AA Wageningen, The Netherlands.
| | - Katherine Donato
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
| | - Jessica L Cohen
- Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA.
| | | | - Tefera Belachew
- Human Nutrition Unit, Jimma University, P.O. Box 378, Jimma, Ethiopia.
| | - Demissie Belayneh
- International Maize and Wheat Improvement Centre (CIMMYT), P.O. Box 5689, Addis Ababa, Ethiopia.
| | - Hugo De Groote
- International Maize and Wheat Improvement Centre (CIMMYT), P.O. Box 1041-00621, Nairobi, Kenya.
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27
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Shen Y, Cohen JL, Nicoloro SM, Kelly M, Yenilmez B, Henriques F, Tsagkaraki E, Edwards YJK, Hu X, Friedline RH, Kim JK, Czech MP. CRISPR-delivery particles targeting nuclear receptor-interacting protein 1 ( Nrip1) in adipose cells to enhance energy expenditure. J Biol Chem 2018; 293:17291-17305. [PMID: 30190322 DOI: 10.1074/jbc.ra118.004554] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 06/22/2018] [Revised: 08/22/2018] [Indexed: 12/26/2022] Open
Abstract
RNA-guided, engineered nucleases derived from the prokaryotic adaptive immune system CRISPR-Cas represent a powerful platform for gene deletion and editing. When used as a therapeutic approach, direct delivery of Cas9 protein and single-guide RNA (sgRNA) could circumvent the safety issues associated with plasmid delivery and therefore represents an attractive tool for precision genome engineering. Gene deletion or editing in adipose tissue to enhance its energy expenditure, fatty acid oxidation, and secretion of bioactive factors through a "browning" process presents a potential therapeutic strategy to alleviate metabolic disease. Here, we developed "CRISPR-delivery particles," denoted CriPs, composed of nano-size complexes of Cas9 protein and sgRNA that are coated with an amphipathic peptide called Endo-Porter that mediates entry into cells. Efficient CRISPR-Cas9-mediated gene deletion of ectopically expressed GFP by CriPs was achieved in multiple cell types, including a macrophage cell line, primary macrophages, and primary pre-adipocytes. Significant GFP loss was also observed in peritoneal exudate cells with minimum systemic toxicity in GFP-expressing mice following intraperitoneal injection of CriPs containing Gfp-targeting sgRNA. Furthermore, disruption of a nuclear co-repressor of catabolism, the Nrip1 gene, in white adipocytes by CriPs enhanced adipocyte browning with a marked increase of uncoupling protein 1 (UCP1) expression. Of note, the CriP-mediated Nrip1 deletion did not produce detectable off-target effects. We conclude that CriPs offer an effective Cas9 and sgRNA delivery system for ablating targeted gene products in cultured cells and in vivo, providing a potential therapeutic strategy for metabolic disease.
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Affiliation(s)
| | | | | | - Mark Kelly
- From the Program in Molecular Medicine and
| | | | | | - Emmanouela Tsagkaraki
- From the Program in Molecular Medicine and.,the Molecular Basis of Human Disease Graduate Program, School of Sciences, Faculty of Medicine, University of Crete, P.O. Box 2208, Heraklion, Crete 71003, Greece
| | | | - Xiaodi Hu
- the Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605 and
| | - Randall H Friedline
- the Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605 and
| | - Jason K Kim
- From the Program in Molecular Medicine and.,the Division of Endocrinology, Metabolism, and Diabetes, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605 and
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28
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Shrime MG, Weinstein MC, Hammitt JK, Cohen JL, Salomon JA. Trading Bankruptcy for Health: A Discrete-Choice Experiment. Value Health 2018; 21:95-104. [PMID: 29304947 PMCID: PMC6739632 DOI: 10.1016/j.jval.2017.07.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 07/01/2017] [Accepted: 07/16/2017] [Indexed: 05/05/2023]
Abstract
BACKGROUND Although nearly two-third of bankruptcy in the United States is medical in origin, a common assumption is that individuals facing a potentially lethal disease opt for cure at any cost. This assumption has never been tested, and knowledge of how the American population values a trade-off between cure and bankruptcy is unknown. OBJECTIVES To determine the relative importance among the general American population of improved health versus improved financial risk protection, and to determine the impact of demographics on these preferences. METHODS A discrete-choice experiment was performed with 2359 members of the US population. Respondents were asked to value treatments with varying chances of cure and bankruptcy in the presence of a lethal disease. Latent class analysis with concomitant variables was performed, weighted for national representativeness. Sensitivity analyses were undertaken to test the robustness of the results. RESULTS It was found that 31.3% of the American population values cure at all costs. Nevertheless, for 8.5% of the US population, financial solvency dominates concerns for health in medical decision making. Individuals who value cure at all costs are more likely to have had experience with serious disease and to be women. No demographic characteristics significantly predicted individuals who value solvency over cure. CONCLUSIONS Although the average American values cure more than financial solvency, a cure-at-all-costs rubric describes the preferences of a minority of the population, and 1 in 12 value financial protection over any chances of cure. This study provides empirical evidence for how the US population values a trade-off between avoiding adverse health outcomes and facing bankruptcy. These findings bring to the fore the decision making that individuals face in balancing the acute financial burden of health care access.
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Affiliation(s)
- Mark G Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA; Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
| | - Milton C Weinstein
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - James K Hammitt
- Center for Health Decision Science, Harvard TH Chan School of Public Health, Boston, MA, USA; Department of Health Policy and Management, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Jessica L Cohen
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Joshua A Salomon
- Department of Medicine, Stanford Medical School, Stanford, CA, USA
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Awad M, Czer LSC, Esmailian F, Jordan S, De Robertis MA, Mirocha J, Patel J, Chang DH, Kittleson M, Ramzy D, Arabia F, Chung JS, Cohen JL, Trento A, Kobashigawa JA. Combined Heart and Kidney Transplantation: A 23-Year Experience. Transplant Proc 2017; 49:348-353. [PMID: 28219597 DOI: 10.1016/j.transproceed.2016.11.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 11/10/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND We report clinical experience with combined heart and kidney transplantation (HKTx) over a 23-year time period. METHODS From June 1992 to August 2015, we performed 83 combined HKTx procedures at our institution. We compared the more recent cohort of 53 HKTx recipients (group 2, March 2009 to August 2015) with the initial 30 previously reported HKTx recipients (group 1, June 1992 to February 2009). Pre-operative patient characteristics, peri-operative factors, and post-operative outcomes including survival were examined. RESULTS The baseline characteristics of the two groups were similar, except for a lower incidence of ethanol use and higher pre-operative left-ventricular ejection fraction, cardiac output, and cardiac index in group 2 when compared with group 1 (P = .007, .046, .037, respectively). The pump time was longer in group 2 compared with group 1 (153.30 ± 38.68 vs 129.60 ± 37.60 minutes; P = .007), whereas the graft ischemic time was not significantly different between the groups, with a trend to a longer graft ischemic time in group 2 versus group 1 (195.17 ± 45.06 vs 178.07 ± 52.77 minutes; P = .056, respectively). The lengths of intensive care unit (ICU) and hospital stay were similar between the groups (P = .083 and .39, respectively). In addition, pre-operative and post-operative creatinine levels at peak, discharge, 1 year, and 5 years and the number of people on post-operative dialysis were similar between the groups (P = .37, .75, .54, .87, .56, and P = .139, respectively). Overall survival was not significantly different between groups 2 and 1 for the first 5 years after transplant, with a trend toward higher survival in group 2 (P = .054). CONCLUSIONS The most recent cohort of combined heart and kidney transplant recipients had similar ICU and hospital lengths of stay and post-operative creatinine levels at peak, discharge, and 1 and 5 years and a similar number of patients on post-operative dialysis when compared with the initial cohort. Overall survival was not significantly different between the later and earlier groups, with a trend toward higher overall survival at 5 years in the more recent cohort of patients. In selected patients with co-existing heart and kidney failure, combined heart and kidney transplantation is safe to perform and has excellent outcomes.
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Affiliation(s)
- M Awad
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - L S C Czer
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California.
| | - F Esmailian
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - S Jordan
- Division of Pediatric Nephrology, Cedars-Sinai Medical Center, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - M A De Robertis
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California
| | - J Mirocha
- Section of Biostatistics and Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - J Patel
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - D H Chang
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - M Kittleson
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - D Ramzy
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - F Arabia
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J S Chung
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J L Cohen
- Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - A Trento
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
| | - J A Kobashigawa
- Division of Cardiology, Cedars-Sinai Heart Institute, Los Angeles, California; Multiorgan Transplant Program, Cedars-Sinai Medical Center, Los Angeles, California
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Visser T, Bruxvoort K, Maloney K, Leslie T, Barat LM, Allan R, Ansah EK, Anyanti J, Boulton I, Clarke SE, Cohen JL, Cohen JM, Cutherell A, Dolkart C, Eves K, Fink G, Goodman C, Hutchinson E, Lal S, Mbonye A, Onwujekwe O, Petty N, Pontarollo J, Poyer S, Schellenberg D, Streat E, Ward A, Wiseman V, Whitty CJM, Yeung S, Cunningham J, Chandler CIR. Introducing malaria rapid diagnostic tests in private medicine retail outlets: A systematic literature review. PLoS One 2017; 12:e0173093. [PMID: 28253315 PMCID: PMC5333947 DOI: 10.1371/journal.pone.0173093] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Accepted: 02/15/2017] [Indexed: 11/22/2022] Open
Abstract
Background Many patients with malaria-like symptoms seek treatment in private medicine retail outlets (PMR) that distribute malaria medicines but do not traditionally provide diagnostic services, potentially leading to overtreatment with antimalarial drugs. To achieve universal access to prompt parasite-based diagnosis, many malaria-endemic countries are considering scaling up malaria rapid diagnostic tests (RDTs) in these outlets, an intervention that may require legislative changes and major investments in supporting programs and infrastructures. This review identifies studies that introduced malaria RDTs in PMRs and examines study outcomes and success factors to inform scale up decisions. Methods Published and unpublished studies that introduced malaria RDTs in PMRs were systematically identified and reviewed. Literature published before November 2016 was searched in six electronic databases, and unpublished studies were identified through personal contacts and stakeholder meetings. Outcomes were extracted from publications or provided by principal investigators. Results Six published and six unpublished studies were found. Most studies took place in sub-Saharan Africa and were small-scale pilots of RDT introduction in drug shops or pharmacies. None of the studies assessed large-scale implementation in PMRs. RDT uptake varied widely from 8%-100%. Provision of artemisinin-based combination therapy (ACT) for patients testing positive ranged from 30%-99%, and was more than 85% in five studies. Of those testing negative, provision of antimalarials varied from 2%-83% and was less than 20% in eight studies. Longer provider training, lower RDT retail prices and frequent supervision appeared to have a positive effect on RDT uptake and provider adherence to test results. Performance of RDTs by PMR vendors was generally good, but disposal of medical waste and referral of patients to public facilities were common challenges. Conclusions Expanding services of PMRs to include malaria diagnostic services may hold great promise to improve malaria case management and curb overtreatment with antimalarials. However, doing so will require careful planning, investment and additional research to develop and sustain effective training, supervision, waste-management, referral and surveillance programs beyond the public sector.
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Affiliation(s)
- Theodoor Visser
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
- * E-mail:
| | - Katia Bruxvoort
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kathleen Maloney
- Bill and Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Toby Leslie
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Lawrence M. Barat
- US President’s Malaria Initiative, United States Agency for International Development, Washington DC, United States of America
| | | | - Evelyn K. Ansah
- Research & Development Division, Ghana Health Service, Accra, Ghana
| | | | - Ian Boulton
- TropMed Pharma Consulting, Lower Shiplake, Oxfordshire, United Kingdom
| | - Siân E. Clarke
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jessica L. Cohen
- Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Justin M. Cohen
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | | | - Caitlin Dolkart
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Katie Eves
- Mentor Initiative, West Sussex, United Kingdom
| | - Günther Fink
- Harvard T.H. Chan School of Public Health, Boston, United States of America
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Eleanor Hutchinson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sham Lal
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | | | - Nora Petty
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | | | | | - David Schellenberg
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Abigail Ward
- Clinton Health Access Initiative, Boston, Massachusetts, United States of America
| | - Virginia Wiseman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- School of Public Health and Community Medicine, University of New South Wales, UNSW, Sydney, Australia
| | - Christopher J. M. Whitty
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Shunmay Yeung
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jane Cunningham
- Global Malaria Program, World Health Organization, Geneva, Switzerland
| | - Clare I. R. Chandler
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
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31
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Shrime MG, Sekidde S, Linden A, Cohen JL, Weinstein MC, Salomon JA. Sustainable Development in Surgery: The Health, Poverty, and Equity Impacts of Charitable Surgery in Uganda. PLoS One 2016; 11:e0168867. [PMID: 28036357 PMCID: PMC5201287 DOI: 10.1371/journal.pone.0168867] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 12/06/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The recently adopted Sustainable Development Goals call for the end of poverty and the equitable provision of healthcare. These goals are often at odds, however: health seeking can lead to catastrophic spending, an outcome for which cancer patients and the poor in resource-limited settings are at particularly high risk. How various health policies affect the additional aims of financial wellbeing and equity is poorly understood. This paper evaluates the health, financial, and equity impacts of governmental and charitable policies for surgical oncology in a resource-limited setting. METHODS Three charitable platforms for surgical oncology delivery in Uganda were compared to six governmental policies aimed at improving healthcare access. An extended cost-effectiveness analysis using an agent-based simulation model examined the numbers of lives saved, catastrophic expenditure averted, impoverishment averted, costs, and the distribution of benefits across the wealth spectrum. FINDINGS Of the nine policies and platforms evaluated, two were able to provide simultaneous health and financial benefits efficiently and equitably: mobile surgical units and governmental policies that simultaneously address surgical scaleup, the cost of surgery, and the cost of transportation. Policies that only remove user fees are dominated, as is the commonly employed short-term "surgical mission trip". These results are robust to scenario and sensitivity analyses. INTERPRETATION The most common platforms for increasing access to surgical care appear unable to provide health and financial risk protection equitably. On the other hand, mobile surgical units, to date an underutilized delivery platform, are able to deliver surgical oncology in a manner that meets sustainable development goals by improving health, financial solvency, and equity. These platforms compare favorably with policies that holistically address surgical delivery and should be considered as countries strengthen health systems.
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Affiliation(s)
- Mark G. Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States of America
- Office of Global Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, United States of America
| | - Serufusa Sekidde
- Aspen Global Health and Development, Aspen Institute, Aspen, CO, United States of America
| | - Allison Linden
- Division of Pediatric Surgery, Children’s Hospital Los Angeles, Los Angeles, CA, United States of America
| | - Jessica L. Cohen
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Milton C. Weinstein
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Joshua A. Salomon
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
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32
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Bigot J, Pilon C, Matignon M, Grondin C, Leibler C, Aissat A, Pirenne F, Cohen JL, Grimbert P. Transcriptomic Signature of the CD24 hi CD38 hi Transitional B Cells Associated With an Immunoregulatory Phenotype in Renal Transplant Recipients. Am J Transplant 2016; 16:3430-3442. [PMID: 27273606 DOI: 10.1111/ajt.13904] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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: 12/24/2015] [Revised: 05/25/2016] [Accepted: 05/27/2016] [Indexed: 01/25/2023]
Abstract
The role of B cells after transplant regarding allograft rejection or tolerance has become a topic of major interest. Recently, in renal transplant recipients, a B cell signature characterized by the overexpression of CD19+ CD38hi CD24hi transitional B cells has been observed in operationally tolerant patients and in belatacept-treated patients with significantly lower incidence of donor-specific antibodies. The phenotypic and functional characterization of these transitional B cells is far from exhaustive. We present the first transcriptomic and phenotypic analysis associated with this cell phenotype. Three populations were studied and compared: (i) transitional CD24hi CD38hi , (ii) CD24+ CD38- , and (iii) CD24int CD38int B cells. Transcriptome bioinformatic analysis revealed a particular signature for the CD24hi CD38hi population. Phenotypic analysis showed that CD24hi CD38hi transitional B cells also expressed CD9, CD10, CD1b and inducible T cell costimulator ligand (ICOS-L) markers. In addition, we found enrichment of IL-10+ cells among CD24hi CD38hi cells expressing ICOS-L and CD1b, the latter showing regulatory properties. Renal transplant recipients treated with belatacept exhibited significant expression of CD1b. Our results show that transitional CD24hi CD38hi B cells exhibit a distinct and specific profile, and this could be helpful for understanding of immune-regulatory mechanisms and immune monitoring in the field of organ transplant and autoimmune disease.
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Affiliation(s)
- J Bigot
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France
| | - C Pilon
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, CIC-BT-504, Créteil, France
| | - M Matignon
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, Service de Néphrologie, Créteil, France
| | - C Grondin
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France
| | - C Leibler
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, Service de Néphrologie, Créteil, France
| | - A Aissat
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 5, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, Service Hospitalier, Créteil, France
| | - F Pirenne
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 2, Créteil, France.,Etablissement Français du Sang, Ile-de-France Mondor, Créteil, France
| | - J L Cohen
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, CIC-BT-504, Créteil, France
| | - P Grimbert
- Université Paris-Est Créteil, Faculté de Médecine, Créteil, France.,Institut Mondor de Recherche Biomédicale (IMRB), INSERM U955, Equipe 21, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, CIC-BT-504, Créteil, France.,AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, Service de Néphrologie, Créteil, France
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33
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Tessema M, Gunaratna NS, Donato K, Cohen JL, McConnell M, Belayneh D, Brouwer ID, Belachew T, De Groote H. Translating the impact of quality protein maize into improved nutritional status for Ethiopian children: study protocol for a randomized controlled trial. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0089-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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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34
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Cohen JL, Shen Y, Aouadi M, Vangala P, Tencerova M, Amano SU, Nicoloro SM, Yawe JC, Czech MP. Peptide- and Amine-Modified Glucan Particles for the Delivery of Therapeutic siRNA. Mol Pharm 2016; 13:964-978. [PMID: 26815386 DOI: 10.1021/acs.molpharmaceut.5b00831] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Translation of siRNA technology into the clinic is limited by the need for improved delivery systems that target specific cell types. Macrophages are particularly attractive targets for RNAi therapy because they promote pathogenic inflammatory responses in a number of important human diseases. We previously demonstrated that a multicomponent formulation of β-1,3-d-glucan-encapsulated siRNA particles (GeRPs) can specifically and potently silence genes in mouse macrophages. A major advance would be to simplify the GeRP system by reducing the number of delivery components, thus enabling more facile manufacturing and future commercialization. Here we report the synthesis and evaluation of a simplified glucan-based particle (GP) capable of delivering siRNA in vivo to selectively silence macrophage genes. Covalent attachment of small-molecule amines and short peptides containing weak bases to GPs facilitated electrostatic interaction of the particles with siRNA and aided in the endosomal release of siRNA by the proton-sponge effect. Modified GPs were nontoxic and were efficiently internalized by macrophages in vitro. When injected intraperitoneally (i.p.), several of the new peptide-modified GPs were found to efficiently deliver siRNA to peritoneal macrophages in lean, healthy mice. In an animal model of obesity-induced inflammation, i.p. administration of one of the peptide-modified GPs (GP-EP14) bound to siRNA selectively reduced the expression of target inflammatory cytokines in the visceral adipose tissue macrophages. Decreasing adipose tissue inflammation resulted in an improvement of glucose metabolism in these metabolically challenged animals. Thus, modified GPs represent a promising new simplified system for the efficient delivery of therapeutic siRNAs specifically to phagocytic cells in vivo for modulation of inflammation responses.
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Affiliation(s)
- Jessica L Cohen
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Yuefei Shen
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Myriam Aouadi
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Pranitha Vangala
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Michaela Tencerova
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Shinya U Amano
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Sarah M Nicoloro
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Joseph C Yawe
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
| | - Michael P Czech
- Program in Molecular Medicine, University of Massachusetts Medical School, 373 Plantation Street, Worcester, Massachusetts 01605, United States
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35
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Tencerova M, Aouadi M, Vangala P, Nicoloro SM, Yawe JC, Cohen JL, Shen Y, Garcia-Menendez L, Pedersen DJ, Gallagher-Dorval K, Perugini RA, Gupta OT, Czech MP. Activated Kupffer cells inhibit insulin sensitivity in obese mice. FASEB J 2015; 29:2959-69. [PMID: 25805830 DOI: 10.1096/fj.15-270496] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [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: 01/21/2015] [Accepted: 03/05/2015] [Indexed: 12/21/2022]
Abstract
Obesity promotes insulin resistance associated with liver inflammation, elevated glucose production, and type 2 diabetes. Although insulin resistance is attenuated in genetic mouse models that suppress systemic inflammation, it is not clear whether local resident macrophages in liver, denoted Kupffer cells (KCs), directly contribute to this syndrome. We addressed this question by selectively silencing the expression of the master regulator of inflammation, NF-κB, in KCs in obese mice. We used glucan-encapsulated small interfering RNA particles (GeRPs) that selectively silence gene expression in macrophages in vivo. Following intravenous injections, GeRPs containing siRNA against p65 of the NF-κB complex caused loss of NF-κB p65 expression in KCs without disrupting NF-κB in hepatocytes or macrophages in other tissues. Silencing of NF-κB expression in KCs in obese mice decreased cytokine secretion and improved insulin sensitivity and glucose tolerance without affecting hepatic lipid accumulation. Importantly, GeRPs had no detectable toxic effect. Thus, KCs are key contributors to hepatic insulin resistance in obesity and a potential therapeutic target for metabolic disease.
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Affiliation(s)
- Michaela Tencerova
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Myriam Aouadi
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Pranitha Vangala
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sarah M Nicoloro
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Joseph C Yawe
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jessica L Cohen
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Yuefei Shen
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Lorena Garcia-Menendez
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - David J Pedersen
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Karen Gallagher-Dorval
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Richard A Perugini
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Olga T Gupta
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Michael P Czech
- *Program in Molecular Medicine, Department of Surgery, and Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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36
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Pilon CB, Petillon S, Naserian S, Martin GH, Badoual C, Lang P, Azoulay D, Piaggio E, Grimbert P, Cohen JL. Administration of low doses of IL-2 combined to rapamycin promotes allogeneic skin graft survival in mice. Am J Transplant 2014; 14:2874-82. [PMID: 25394722 DOI: 10.1111/ajt.12944] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [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: 03/03/2014] [Revised: 06/25/2014] [Accepted: 07/12/2014] [Indexed: 01/25/2023]
Abstract
Human CD4(+) CD25(+) FoxP3(+) regulatory T cells (Tregs) prevent allogeneic graft rejection by inhibiting T cell activation, as has been shown in mouse models. Recently, low-dose IL-2 administration was shown to specifically activate Tregs but not pathogenic conventional T cells, leading to resolution of type 1 diabetes in nonobese diabetic mice. We therefore tested the ability of low-dose IL-2 to prevent allogeneic skin graft rejection. We found that while IL-2 alone was inefficient in preventing rejection, combined with rapamycin, IL-2 treatment promoted skin graft survival both in minor disparate and semi-allogeneic skin graft combinations. Tregs are activated by this combined treatment while conventional CD4(+) cell expansion and activation are markedly inhibited. Co-administration of anti-CD25 antibodies dramatically reduces the effect of the IL-2/rapamycin treatment, strongly supporting a central role for Treg activation. Thus, we provide the first preclinical data showing that low-dose IL-2 combined with rapamycin can significantly delay transplant rejection in mice. These findings may form the rational for clinical evaluation of this novel approach for the prevention of transplant rejection.
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Affiliation(s)
- C B Pilon
- Faculté de Médecine, Université Paris-Est Créteil, Créteil, France; Institut Mondor de Recherche Biomédicale (IMRB), INSERM U 955, Créteil, France; AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, CIC-BT-504, Créteil, France
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Glover ME, Pugh PC, Jackson NL, Cohen JL, Fant AD, Akil H, Clinton SM. Early-life exposure to the SSRI paroxetine exacerbates depression-like behavior in anxiety/depression-prone rats. Neuroscience 2014; 284:775-797. [PMID: 25451292 DOI: 10.1016/j.neuroscience.2014.10.044] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [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: 04/29/2014] [Revised: 10/27/2014] [Accepted: 10/28/2014] [Indexed: 12/26/2022]
Abstract
Selective serotonin reuptake inhibitor (SSRI) antidepressants are the mainstay treatment for the 10-20% of pregnant and postpartum women who suffer major depression, but the effects of SSRIs on their children's developing brain and later emotional health are poorly understood. SSRI use during pregnancy can elicit antidepressant withdrawal in newborns and increase toddlers' anxiety and social avoidance. In rodents, perinatal SSRI exposure increases adult depression- and anxiety-like behavior, although certain individuals are more vulnerable to these effects than others. Our study establishes a rodent model of individual differences in susceptibility to perinatal SSRI exposure, utilizing selectively bred Low Responder (bLR) and High Responder (bHR) rats that were previously bred for high versus low behavioral response to novelty. Pregnant bHR/bLR females were chronically treated with the SSRI paroxetine (10 mg/kg/day p.o.) to examine its effects on offspring's emotional behavior and gene expression in the developing brain. Paroxetine treatment had minimal effect on bHR/bLR dams' pregnancy outcomes or maternal behavior. We found that bLR offspring, naturally prone to an inhibited/anxious temperament, were susceptible to behavioral abnormalities associated with perinatal SSRI exposure (which exacerbated their Forced Swim Test immobility), while high risk-taking bHR offspring were resistant. Microarray studies revealed robust perinatal SSRI-induced gene expression changes in the developing bLR hippocampus and amygdala (postnatal days 7-21), including transcripts involved in neurogenesis, synaptic vesicle components, and energy metabolism. These results highlight the bLR/bHR model as a useful tool to explore the neurobiology of individual differences in susceptibility to perinatal SSRI exposure.
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Affiliation(s)
- M E Glover
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama-Birmingham, USA
| | - P C Pugh
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama-Birmingham, USA
| | - N L Jackson
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama-Birmingham, USA
| | - J L Cohen
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama-Birmingham, USA
| | - A D Fant
- Division of Chemical Biology and Medicinal Chemistry, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, USA
| | - H Akil
- Molecular and Behavioral Neuroscience Institute, University of Michigan, USA
| | - S M Clinton
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama-Birmingham, USA.
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Cohen JL, Pilon C, Maury S, Grimbert P. Searching for factors to improve regulatory T cell therapy in organ transplantation. Am J Transplant 2014; 14:2430-1. [PMID: 25039852 DOI: 10.1111/ajt.12855] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- J L Cohen
- Faculté de médecine, Université Paris-Est Créteil, Créteil, France; INSERM U 955, Institut Mondor de Recherche Biomédicale, Créteil, France; AP-HP, Groupe Hospitalier Henri-Mondor Albert-Chenevier, Créteil, France
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Aouadi M, Vangala P, Yawe JC, Tencerova M, Nicoloro SM, Cohen JL, Shen Y, Czech MP. Lipid storage by adipose tissue macrophages regulates systemic glucose tolerance. Am J Physiol Endocrinol Metab 2014; 307:E374-83. [PMID: 24986598 PMCID: PMC4137117 DOI: 10.1152/ajpendo.00187.2014] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Proinflammatory pathways in adipose tissue macrophages (ATMs) can impair glucose tolerance in obesity, but ATMs may also be beneficial as repositories for excess lipid that adipocytes are unable to store. To test this hypothesis, we selectively targeted visceral ATMs in obese mice with siRNA against lipoprotein lipase (LPL), leaving macrophages within other organs unaffected. Selective silencing of ATM LPL decreased foam cell formation in visceral adipose tissue of obese mice, consistent with a reduced supply of fatty acids from VLDL hydrolysis. Unexpectedly, silencing LPL also decreased the expression of genes involved in fatty acid uptake (CD36) and esterification in ATMs. This deficit in fatty acid uptake capacity was associated with increased circulating serum free fatty acids. Importantly, ATM LPL silencing also caused a marked increase in circulating fatty acid-binding protein-4, an adipocyte-derived lipid chaperone previously reported to induce liver insulin resistance and glucose intolerance. Consistent with this concept, obese mice with LPL-depleted ATMs exhibited higher hepatic glucose production from pyruvate and glucose intolerance. Silencing CD36 in ATMs also promoted glucose intolerance. Taken together, the data indicate that LPL secreted by ATMs enhances their ability to sequester excess lipid in obese mice, promoting systemic glucose tolerance.
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Affiliation(s)
- Myriam Aouadi
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Pranitha Vangala
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Joseph C Yawe
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Michaela Tencerova
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Sarah M Nicoloro
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jessica L Cohen
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Yuefei Shen
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Michael P Czech
- Program in Molecular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
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Larson PS, Yadav P, Alphs S, Arkedis J, Massaga J, Sabot O, Cohen JL. Diffusion of subsidized ACTs in accredited drug shops in Tanzania: determinants of stocking and characteristics of early and late adopters. BMC Health Serv Res 2013; 13:526. [PMID: 24350611 PMCID: PMC3880543 DOI: 10.1186/1472-6963-13-526] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 12/11/2013] [Indexed: 11/30/2022] Open
Abstract
Background Many households in sub-Saharan Africa utilize the private sector as a primary source of treatment for malaria episodes. Expanding access to effective treatment in private drug shops may help reduce incidence of severe disease and mortality. This research leveraged a longitudinal survey of stocking of subsidized artemisinin combination therapies (ACTs), an effective anti-malarial, in Accredited Drug Dispensing Outlets (ADDOs) in two regions of Tanzania. This provided a unique opportunity to explore shop and market level determinants of product diffusion in a developing country retail market. Methods 356 ADDOs in the Rukwa and Mtwara regions of Tanzania were surveyed at seven points between Feb 2011 and May 2012. Shop level audits were used to measure the availability of subsidized ACTs at each shop. Data on market and shop level factors were collected during the survey and also extracted from GIS layers. Regression and network based methodologies were used. Shops classified as early and late adopters, following Rogers’ model of product diffusion, were compared. The Bass model of product diffusion was applied to determine whether shops stocked ACTs out of a need to imitate market competitors or a desire to satisfy customer needs. Results Following the introduction of a subsidy for ACTs, stocking increased from 12% to nearly 80% over the seven survey rounds. Stocking was influenced by higher numbers of proximal shops and clinics, larger customer traffic and the presence of a licensed pharmacist. Early adopters were characterized by a larger percentage of customers seeking care for malaria, a larger catchment and sourcing from specific wholesalers/suppliers. The Bass model of product diffusion indicated that shops were adopting products in response to competitor behavior, rather than customer demand. Conclusions Decisions to stock new pharmaceutical products in Tanzanian ADDOs are influenced by a combination of factors related to both market competition and customer demand, but are particularly influenced by the behavior of competing shops. Efforts to expand access to new pharmaceutical products in developing country markets could benefit from initial targeting of high profile shops in competitive markets and wholesale suppliers to encourage faster product diffusion across all drug retailers.
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Affiliation(s)
- Peter S Larson
- Department of Epidemiology, School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109-2029, USA.
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Fink G, Dickens WT, Jordan M, Cohen JL. Access to subsidized ACT and malaria treatment--evidence from the first year of the AMFm program in six districts in Uganda. Health Policy Plan 2013; 29:517-27. [PMID: 23783833 DOI: 10.1093/heapol/czt041] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To determine the effect of the Affordable Medicines Facility for malaria (AMFm) launched in April 2011 in Uganda on the use of Artemisinin Combination Therapies (ACTs) for malaria treatment. METHODS 2398 households across six districts in Eastern Uganda were monitored through monthly survey visits from April 2011 to April 2012. During each visit, health seeking modules were completed for any morbidity episode reported by the household. Additional surveys were conducted with 114 licensed drug shops in the same districts in April 2011 and April 2012. Changes in drug shops' stocking and pricing of ACTs, as well as changes in households' treatment behaviour and drug usage were analysed. RESULTS The fraction of licensed drug shops reporting that an ACT was one of their top five bestselling antimalarial drugs increased from 32% to 84% (Δ=0.517, 95% Confidence Intervals (CI) [0.407, 0.628], P<0.001). The fraction of children under the age of 5 with fevers getting an ACT increased from 37% to 47% (Δ=0.103, 95% CI [0.070, 0.136], P<0.001), and the fraction of ACT treatments among patients getting any antimalarial increased from 51% to 65% (Δ=0.145, 95% CI [0.121, 0.169], P<0.001). The observed changes were particularly large among poorer households, and were smallest for households from the highest wealth quintile. CONCLUSIONS The study results suggest that, during its first year of implementation in Uganda, the AMFm achieved its main objective of increasing the availability and use of ACTs. Estimates of the impact of the AMFm on ACT use for children under 5 imply that the program should be considered highly cost-effective under current World Health Organization (WHO) guidelines. The overall results look promising, but larger and longer term studies will be needed to assess the health impact and cost-effectiveness of the program.
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Affiliation(s)
- Günther Fink
- Harvard School of Public Health, Department of Global Health and Population, 665 Huntington Avenue, Boston, MA 02115, USA, Department of Economics, Northeastern University, 360 Huntington Avenue, 301 Lake Hall, Boston, MA 02115-5000, USA, The Brookings Institution, 1775 Massachusetts Ave, NW, Washington, DC 20036 and Harvard School of Public Health and Brookings Institution
| | - William T Dickens
- Harvard School of Public Health, Department of Global Health and Population, 665 Huntington Avenue, Boston, MA 02115, USA, Department of Economics, Northeastern University, 360 Huntington Avenue, 301 Lake Hall, Boston, MA 02115-5000, USA, The Brookings Institution, 1775 Massachusetts Ave, NW, Washington, DC 20036 and Harvard School of Public Health and Brookings Institution
| | - Matthew Jordan
- Harvard School of Public Health, Department of Global Health and Population, 665 Huntington Avenue, Boston, MA 02115, USA, Department of Economics, Northeastern University, 360 Huntington Avenue, 301 Lake Hall, Boston, MA 02115-5000, USA, The Brookings Institution, 1775 Massachusetts Ave, NW, Washington, DC 20036 and Harvard School of Public Health and Brookings Institution
| | - Jessica L Cohen
- Harvard School of Public Health, Department of Global Health and Population, 665 Huntington Avenue, Boston, MA 02115, USA, Department of Economics, Northeastern University, 360 Huntington Avenue, 301 Lake Hall, Boston, MA 02115-5000, USA, The Brookings Institution, 1775 Massachusetts Ave, NW, Washington, DC 20036 and Harvard School of Public Health and Brookings Institution
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Ornelas-Megiatto C, Shah PN, Wich PR, Cohen JL, Tagaev JA, Smolen JA, Wright BD, Panzner MJ, Youngs WJ, Fréchet JMJ, Cannon CL. Aerosolized antimicrobial agents based on degradable dextran nanoparticles loaded with silver carbene complexes. Mol Pharm 2012; 9:3012-22. [PMID: 23025592 PMCID: PMC3579655 DOI: 10.1021/mp3004379] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Degradable acetalated dextran (Ac-DEX) nanoparticles were prepared and loaded with a hydrophobic silver carbene complex (SCC) by a single-emulsion process. The resulting particles were characterized for morphology and size distribution using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and dynamic light scattering (DLS). The average particle size and particle size distribution were found to be a function of the ratio of the organic phase to the surfactant containing aqueous phase with a 1:5 volume ratio of Ac-DEX CH(2)Cl(2) (organic):PBS (aqueous) being optimal for the formulation of nanoparticles with an average size of 100 ± 40 nm and a low polydispersity. The SCC loading was found to increase with an increase in the SCC quantity in the initial feed used during particle formulation up to 30% (w/w); however, the encapsulation efficiency was observed to be the best at a feed ratio of 20% (w/w). In vitro efficacy testing of the SCC loaded Ac-DEX nanoparticles demonstrated their activity against both Gram-negative and Gram-positive bacteria; the nanoparticles inhibited the growth of every bacterial species tested. As expected, a higher concentration of drug was required to inhibit bacterial growth when the drug was encapsulated within the nanoparticle formulations compared with the free drug illustrating the desired depot release. Compared with free drug, the Ac-DEX nanoparticles were much more readily suspended in an aqueous phase and subsequently aerosolized, thus providing an effective method of pulmonary drug delivery.
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Affiliation(s)
| | - Parth N. Shah
- Division of Pulmonary and Vascular Biology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas 75390-9063, USA
| | - Peter R. Wich
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
| | - Jessica L. Cohen
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
| | - Jasur A. Tagaev
- Division of Pulmonary and Vascular Biology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas 75390-9063, USA
| | - Justin A. Smolen
- Division of Pulmonary and Vascular Biology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas 75390-9063, USA
| | - Brian D. Wright
- Department of Chemistry, University of Akron, Akron, Ohio 44325-0002, USA
| | - Matthew J. Panzner
- Department of Chemistry, University of Akron, Akron, Ohio 44325-0002, USA
| | - Wiley J. Youngs
- Department of Chemistry, University of Akron, Akron, Ohio 44325-0002, USA
| | - Jean M. J. Fréchet
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
- King Abdullah University of Science and Technology, Thuwal, 23955-6900, Saudi Arabia
| | - Carolyn L. Cannon
- Division of Pulmonary and Vascular Biology, Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas 75390-9063, USA
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Cui L, Cohen JL, Chu CK, Wich PR, Kierstead PH, Fréchet JMJ. Conjugation Chemistry through Acetals toward a Dextran-Based Delivery System for Controlled Release of siRNA. J Am Chem Soc 2012; 134:15840-8. [DOI: 10.1021/ja305552u] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Lina Cui
- College of
Chemistry, University of California, Berkeley,
California 94720-1460, United States
| | - Jessica L. Cohen
- College of
Chemistry, University of California, Berkeley,
California 94720-1460, United States
| | - Crystal K. Chu
- College of
Chemistry, University of California, Berkeley,
California 94720-1460, United States
| | - Peter R. Wich
- College of
Chemistry, University of California, Berkeley,
California 94720-1460, United States
| | - Paul H. Kierstead
- College of
Chemistry, University of California, Berkeley,
California 94720-1460, United States
| | - Jean M. J. Fréchet
- College of
Chemistry, University of California, Berkeley,
California 94720-1460, United States
- King Abdullah University of Science and Technology (KAUST), Bldg 16, Suite 4428, Thuwal, 23955-6900 Saudi Arabia
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Yadav P, Cohen JL, Alphs S, Arkedis J, Larson PS, Massaga J, Sabot O. Trends in availability and prices of subsidized ACT over the first year of the AMFm: evidence from remote regions of Tanzania. Malar J 2012; 11:299. [PMID: 22929587 PMCID: PMC3502171 DOI: 10.1186/1475-2875-11-299] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 08/15/2012] [Indexed: 11/28/2022] Open
Abstract
Background The Affordable Medicines Facility for malaria (AMFm) is a pilot supra-national subsidy program that aims to increase access and affordability of artemisinin combination therapy (ACT) in public sector clinics and private retail shops. It is unclear to what extent the AMFm model will translate into wide scale availability and price reductions in ACT, particularly for rural, remote areas where disparities in access to medicines often exist. This study is the first to rigorously examine the availability and price of subsidized ACT during the first year of the AMFm, measured through retail audits in remote regions of Tanzania. Methods Periodic retail audits of Accredited Drug Dispensing Outlets (ADDOs) were conducted in two remote regions of Tanzania (Mtwara and Rukwa). Temporal and spatial variation in ACT availability and pricing were explored. A composite measure of ADDO remoteness, using variables, such as distance to suppliers and towns, altitude and population density, was used to explore whether ACT availability and price vary systematically with remoteness. Results Between February 2011 and January 2012, the fraction of ADDOs stocking AMFm-ACT increased from 25% to 88% in Mtwara and from 3% to 62% in Rukwa. Availability was widespread, though diffusion throughout the region was achieved more quickly in Mtwara. No significant relationship was found between ACT availability and remoteness. Adult doses of AMFm-ACT were much more widely available than any other age/weight band. Average prices fell from 1529 TZS (1.03 USD) to 1272 TZS (0.81 USD) over the study period, with prices in Rukwa higher than Mtwara. The government recommended retail price for AMFm- ACT is 1,000 TZS ($0.64 USD). The median retail ACT price in the final round of data collection was 1,000 TZS. Conclusions The AMFm led to large increases in availability of low priced ACT in Tanzania, with no significant variation in availability based on remoteness. Availability did remain lower and prices remained higher in Rukwa, which is a more remote region overall. Low availability of child and adolescent ACT doses could be due in part to lower quantities of non-adult packs imported into Tanzania. Future research will explore whether increased availability and affordability persists and whether it translates into higher ACT use in Tanzania.
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Affiliation(s)
- Prashant Yadav
- Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA
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Cohen JL, Yavuz E, Morris A, Arkedis J, Sabot O. Do patients adhere to over-the-counter artemisinin combination therapy for malaria? evidence from an intervention study in Uganda. Malar J 2012; 11:83. [PMID: 22443291 PMCID: PMC3342228 DOI: 10.1186/1475-2875-11-83] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 03/23/2012] [Indexed: 11/20/2022] Open
Abstract
Background Increasing affordability of artemisinin combination therapy (ACT) in the African retail sector could be critical to expanding access to effective malaria treatment, but must be balanced by efforts to protect the efficacy of these drugs. Previous research estimates ACT adherence rates among public sector patients, but adherence among retail sector purchasers could differ substantially. This study aimed to estimate adherence rates to subsidized, over-the-counter ACT in rural Uganda. Methods An intervention study was conducted with four licensed drug shops in Eastern Uganda in December 2009. Artemether-lumefantrine (AL) was made available for sale at a 95% subsidy over-the counter. Customers completed a brief survey at the time of purchase and then were randomly assigned to one of three study arms: no follow-up, follow-up after two days or follow-up after three days. Surveyors recorded the number of pills remaining through blister pack observation or through self-report if the pack was unavailable. The purpose of the three-day follow-up arm was to capture non-adherence in the sense of an incomplete treatment course ("under-dosing"). The purpose of the two-day follow-up arm was to capture whether participants completed the full course too soon ("over-dosing"). Results Of the 106 patients in the two-day follow-up sample, 14 (13.2%) had finished the entire treatment course by the second day. Of the 152 patients in the three-day follow-up sample, 49 (32.2%) were definitely non-adherent, three (2%) were probably non-adherent and 100 (65.8%) were probably adherent. Among the 52 who were non-adherent, 31 (59.6%) had more than a full day of treatment remaining. Conclusions Overall, adherence to subsidized ACT purchased over-the-counter was found to be moderate. Further, a non-trivial fraction of those who complete treatment are taking the full course too quickly. Strategies to increase adherence in the retail sector are needed in the context of increasing availability and affordability of ACT in this sector.
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Affiliation(s)
- Jessica L Cohen
- Harvard School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA.
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Cohen JL, Schubert S, Wich PR, Cui L, Cohen JA, Mynar JL, Fréchet JMJ. Acid-degradable cationic dextran particles for the delivery of siRNA therapeutics. Bioconjug Chem 2011; 22:1056-65. [PMID: 21539393 PMCID: PMC3152952 DOI: 10.1021/bc100542r] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [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: 12/18/2022]
Abstract
We report a new acid-sensitive, biocompatible, and biodegradable microparticulate delivery system, spermine modified acetalated-dextran (Spermine-Ac-DEX), which can be used to efficiently encapsulate siRNA. These particles demonstrated efficient gene knockdown in HeLa-luc cells with minimal toxicity. This knockdown was comparable to that obtained using Lipofectamine, a commercially available transfection reagent generally limited to in vitro use due to its high toxicity.
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Affiliation(s)
- Jessica L. Cohen
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
| | | | - Peter R. Wich
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
| | - Lina Cui
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
| | | | - Justin L. Mynar
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
| | - Jean M. J. Fréchet
- College of Chemistry, University of California, Berkeley, California 94720-1460, USA
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Sabot O, Cohen JM, Hsiang MS, Kahn JG, Basu S, Tang L, Zheng B, Gao Q, Zou L, Tatarsky A, Aboobakar S, Usas J, Barrett S, Cohen JL, Jamison DT, Feachem RGA. Costs and financial feasibility of malaria elimination. Lancet 2010; 376:1604-15. [PMID: 21035839 PMCID: PMC3044845 DOI: 10.1016/s0140-6736(10)61355-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The marginal costs and benefits of converting malaria programmes from a control to an elimination goal are central to strategic decisions, but empirical evidence is scarce. We present a conceptual framework to assess the economics of elimination and analyse a central component of that framework-potential short-term to medium-term financial savings. After a review that showed a dearth of existing evidence, the net present value of elimination in five sites was calculated and compared with effective control. The probability that elimination would be cost-saving over 50 years ranged from 0% to 42%, with only one site achieving cost-savings in the base case. These findings show that financial savings should not be a primary rationale for elimination, but that elimination might still be a worthy investment if total benefits are sufficient to outweigh marginal costs. Robust research into these elimination benefits is urgently needed.
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Affiliation(s)
- Oliver Sabot
- Clinton Health Access Initiative, Boston, MA 02127, USA.
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Dréno B, Fischer TC, Perosino E, Poli F, Viera MS, Rendon MI, Berson DS, Cohen JL, Roberts WE, Starker I, Wang B. Expert Opinion: Efficacy of superficial chemical peels in active acne management - what can we learn from the literature today? Evidence-based recommendations. J Eur Acad Dermatol Venereol 2010; 25:695-704. [DOI: 10.1111/j.1468-3083.2010.03852.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [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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Cohen JA, Beaudette TT, Cohen JL, Broaders KE, Bachelder EM, Fréchet JMJ. Acetal-modified dextran microparticles with controlled degradation kinetics and surface functionality for gene delivery in phagocytic and non-phagocytic cells. Adv Mater 2010; 22:3593-7. [PMID: 20518040 PMCID: PMC3379559 DOI: 10.1002/adma.201000307] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
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Bergot AS, Durgeau A, Levacher B, Colombo BM, Cohen JL, Klatzmann D. Antigen quality determines the efficiency of antitumor immune responses generated in the absence of regulatory T cells. Cancer Gene Ther 2010; 17:645-54. [PMID: 20467452 PMCID: PMC2924606 DOI: 10.1038/cgt.2010.21] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The observation that depletion or inhibition of regulatory T cells (Tregs) unleashes efficient antitumor effector immune responses that can lead to tumor eradication in mice has opened new perspectives for the development of cancer immunotherapy. The quality and overall efficiency of the effector immune responses induced in the absence of Tregs seem to depend on multiple factors that determine the result of a battle involving effector T cells (Teffs), Tregs and tumor cells. In this study, we investigated the quality of tumor-associated antigens (TAAs) as one such factor. We show that the presence of a strong dominant antigen is required for the induction of effector responses capable of tumor eradication in the absence of Tregs. The sole addition of a dominant antigen on tumor cells does not change tumor growth in unmanipulated mice, but improves tumor eradication rate from a few to almost 100% in the absence of Tregs. This eradication can be shown to result from the recruitment and activation of specific Teffs recognizing this antigen. We also show that the presence of such dominant antigens has the side effect of restricting the breadth of the immune response to other TAAs, which could favor the generation of escape mutant by tumor editing. Taken together, our results highlight the potential, and some requirements for cancer immunotherapy based on Treg depletion. They also show that, ultimately, tumor fate depends on multiple factors that should all be taken into consideration for the design of more efficient immunotherapy.
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Affiliation(s)
- A-S Bergot
- UPMC Univ Paris 06, UMR 7211, Immunology-Immunopathology-Immunotherapy (I3), Paris, France
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