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Clarfield L, Shapiro J, Cherniak R, Szadkowski L, Huszti E, Whittle W, Czikk M, Menzies R. Short Cervix Following Initial Cerclage-Reinforcing Cerclage Versus Expectant Management. J Obstet Gynaecol Can 2024; 46:102286. [PMID: 37972692 DOI: 10.1016/j.jogc.2023.102286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES To determine whether reinforcing cerclage following ultrasound evidence of cerclage failure before 24 weeks is an effective method to delay gestational age at delivery, and to decrease the rate of preterm and peri-viable delivery. METHODS A retrospective review was conducted for all patients who underwent any cervical cerclage procedure at a single tertiary care centre in Toronto, Canada between 1 December 2007 and 31 December 2017. RESULTS Of 1482 cerclage procedures completed during the study period, 40 pregnant persons who underwent reinforcing cerclage were compared with 40 pregnant persons who were found to have cerclage failure before 24 weeks but were managed expectantly. After adjusting for the shortest cervical length measured prior to 24 weeks, there was no significant difference between the reinforcing cerclage and control group for gestational age at delivery, preterm, or peri-viable birth (P = 0.52, P = 0.54, P = 0.74, respectively). In an unadjusted model, there was a statistically significant increase in placental infection identified on postpartum placenta pathology in the reinforcing cerclage group compared with the expectant management group, 92.9% compared with 66.7% (P = 0.028). CONCLUSION Reinforcing cerclage is unlikely to successfully delay the gestational age at delivery and reduce rates of preterm and pre-viable birth, especially if irreversible and progressive cervical change has begun. Future work should examine the role of preoperative amniocentesis to explore the impact of pre-existing intra-amniotic infection and reinforcing cerclage success.
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Affiliation(s)
- Lauren Clarfield
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON.
| | - Justin Shapiro
- Department of Otolaryngology - Head and Neck Surgery, Western University, London, ON
| | - Rebecca Cherniak
- Department of Obstetrics and Gynecology, North York General Hospital, Toronto, ON
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, ON
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON
| | - Wendy Whittle
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - Marie Czikk
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - Rebecca Menzies
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto, ON; Department of Obstetrics and Gynaecology, Trillium Health Partners, Mississauga, ON
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Ravindran R, Szadkowski L, Lovblom LE, Clarke R, Huang QW, Manase D, Parente L, Walmsley S. Decentralized study of COVID Vaccine Antibody Response (STOPCoV): Results of a participant satisfaction survey. PLOS Digit Health 2023; 2:e0000242. [PMID: 37159470 PMCID: PMC10168576 DOI: 10.1371/journal.pdig.0000242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 03/23/2023] [Indexed: 05/11/2023]
Abstract
The Covid-19 pandemic required many clinical trials to adopt a decentralized framework to continue research activities during lock down restrictions. The STOPCoV study was designed to assess the safety and efficacy of Covid-19 vaccines in those aged 70 and above compared to those aged 30-50 years of age. In this sub-study we aimed to determine participant satisfaction for the decentralized processes, accessing the study website and collecting and submitting study specimens. The satisfaction survey was based on a Likert scale developed by a team of three investigators. Overall, there were 42 questions for respondents to answer. The invitation to participate with a link to the survey was emailed to 1253 active participants near the mid-way point of the main STOPCoV trial (April 2022). The results were collated and answers were compared between the two age cohorts. Overall, 70% (83% older, 54% younger cohort, no difference by sex) responded to the survey. The overall feedback was positive with over 90% of respondents answering that the website was easy to use. Despite the age gap, both the older cohort and younger cohort reported ease of performing study activities through a personal electronic device. Only 30% of the participants had previously participated in a clinical trial, however over 90% agreed that they would be willing to participate in future clinical research. Some difficulties were noted in refreshing the browser whenever updates to the website were made. The feedback attained will be used to improve current processes and procedures of the STOPCoV trial as well as share learning experiences to inform future fully decentralized research studies.
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Affiliation(s)
- Rizani Ravindran
- University Health Network, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit; University Health Network; University of Toronto, Toronto, Ontario, Canada
| | - Leif Erik Lovblom
- Biostatistics Research Unit; University Health Network; University of Toronto, Toronto, Ontario, Canada
| | - Rosemarie Clarke
- University Health Network, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Qian Wen Huang
- University Health Network, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Dorin Manase
- DATA Team; University Health Network; University of Toronto, Toronto, Ontario, Canada
| | - Laura Parente
- Health care Human Factors; University Health Network; University of Toronto, Toronto, Ontario, Canada
| | - Sharon Walmsley
- University Health Network, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network; University of Toronto, Toronto, Ontario, Canada
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3
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Walmsley SL, Szadkowski L, Wouters B, Clarke R, Colwill K, Rochon P, Brudno M, Ravindran R, Raboud J, McGeer A, Oza A, Graham C, Silva A, Manase D, Maksymowsky P, Parente L, Dayam RM, Simpson J, Pasculescu A, Gingras AC. COVID-19 Vaccine Antibody Responses in Community Dwelling Adults to 48 weeks Post Primary Vaccine Series. iScience 2023; 26:106506. [PMID: 37073374 PMCID: PMC10043971 DOI: 10.1016/j.isci.2023.106506] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/16/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
We report a decentralized prospective cohort study of self-reported adverse events and antibody responses to COVID vaccines derived from dried blood spots. Data is presented for 911 older (aged >70 years) and 375 younger (30-50 years) recruits to 48 weeks after the primary vaccine series. After a single vaccine, 83% younger and 45% older participants had overall seropositivity (p<0.0001) increasing to 100/98% with the second dose respectively (p=0.084). A cancer diagnosis (p=.009), no mRNA1273 vaccine doses (p<.0001) and older age (p <.0001) predicted lower responses. Antibody levels declined in both cohorts at 12 and 24 weeks increasing with booster doses. At 48 weeks, for participants with 3 vaccine doses, the median antibody levels were higher in the older cohort (p=.04) with any dose of mRNA-1273 (p<.0001) and with COVID infection (p<.001). The vaccines were well tolerated. Breakthrough COVID infections were uncommon (16% older cohort, 29% younger cohort; p<0.0001) and mild.
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Affiliation(s)
- Sharon L. Walmsley
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
- Corresponding author
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Bradly Wouters
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Rosemarie Clarke
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Karen Colwill
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Paula Rochon
- Women’s College Hospital Research Institute, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Michael Brudno
- Department of Computer Science, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Rizanni Ravindran
- Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Allison McGeer
- Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Amit Oza
- Princess Margaret Cancer Center, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Christopher Graham
- Trillium Health Partners, Department of Medicine, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Amanda Silva
- Department of BioInformatics, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Dorin Manase
- Department of BioInformatics, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Peter Maksymowsky
- Department of BioInformatics, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Laura Parente
- Health Care Human Factors, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Roaya Monica Dayam
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Jacqueline Simpson
- Health Care Human Factors, University Health Network, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Adrian Pasculescu
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - Anne-Claude Gingras
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Walmsley S, Ravindran R, Clarke R, Wouters B, Silva A, Gingras AC, Szadkowski L. COVID-19 breakthrough infections in vaccinated participants of the Safety and Efficacy of Preventative COVID Vaccines sub-study. J Assoc Med Microbiol Infect Dis Can 2022; 7:333-342. [PMID: 37397827 PMCID: PMC10312218 DOI: 10.3138/jammi-2022-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 06/30/2022] [Accepted: 07/08/2022] [Indexed: 07/04/2023]
Abstract
BACKGROUND The rate of breakthrough infection in vaccinated Ontarians during the Omicron wave is unknown. METHODS Active participants of the Safety and Efficacy of Preventative COVID Vaccines (STOPCoV) study (892 ≥age 70 years and 369 aged 30-50 years) were invited to participate in a sub-study evaluating breakthrough COVID-19 infection. Self-administered rapid antigen tests (RAT) were reported twice weekly and symptom questionnaires weekly for 6 weeks. The primary outcome was the proportion reporting a positive RAT. RESULTS A total of 806 e-consented, and 727 (90%) completed ≥1 RAT, with total 7,116 RATs completed between January 28 and March 29, 2022. Twenty out of twenty-five participants with a positive RAT had a booster vaccine prior to the positive test. All cases were mild, none requiring hospitalization. Nineteen had positive dried blood spot analysis for IgG antibody to the receptor binding domain (RBD) prior to the positive RAT. The mean normalized IgG ratio to RBD was 1.22 (SD 0.29) for younger and 0.98 (SD 0.44) for older participants, values similar to corresponding ratios for those without positive RATs and those in the main cohort. One hundred and five participants reported one and 96 reported ≥2 possible COVID-19 symptoms despite negative RATs. The false negative RAT was low (4% to 6.6 %) compared with subsequent positive nucleoprotein antibody. CONCLUSIONS Positive RAT for COVID-19 was infrequent (3.4%). We were unable to determine a protective antibody level against breakthrough infection. Our findings can inform public health COVID-19 restrictions guidelines. Our decentralized study provides a model for rapid institution of new questions during a pandemic.
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Affiliation(s)
- Sharon Walmsley
- Department of Medicine, Division of Infectious Diseases, University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Rizani Ravindran
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Rosemarie Clarke
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Immunodeficiency Clinic, Toronto, Ontario, Canada
| | - Bradly Wouters
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, PMCC, Toronto, Ontario, Canada
| | - Amanda Silva
- University of Toronto, Toronto, Ontario, Canada
- DATA Team, University Health Network, Toronto, Ontario, Canada
| | - Anne-Claude Gingras
- University of Toronto, Toronto, Ontario, Canada
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Leah Szadkowski
- University of Toronto, Toronto, Ontario, Canada
- University Health Network, Biostatistics Research Unit, Toronto, Ontario, Canada
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5
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Taylor KL, Frndova H, Szadkowski L, Joffe AR, Parshuram CS. Risk factors for unplanned paediatric intensive care unit admission after anaesthesia—an international multicentre study. Paediatr Child Health 2022; 27:333-339. [DOI: 10.1093/pch/pxac041] [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: 12/17/2021] [Accepted: 04/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objectives
Unplanned intensive care unit (ICU) admissions are associated with near-miss events, morbidity, and mortality. We describe the rate, resource utilization, and outcomes of paediatric patients urgently admitted directly to ICU post-anaesthesia compared to other sources of unplanned ICU admissions.
Methods
We performed a secondary analysis of data from specialist paediatric hospitals in 7 countries. Patients urgently admitted to the ICU post-anaesthesia were combined and matched with 1 to 3 unique controls from unplanned ICU admissions from other locations by age and hospital. Demographic, clinical, and outcome variables were compared using the Wilcoxon rank-sum test for continuous variables and chi-square or Fisher’s exact test for categorical variables. The effect of admission sources on binary outcomes was estimated using univariable conditional logistic regression models with stratification by matched set of anaesthesia and non-anaesthesia admission sources.
Results
Most admissions were <1 year of age and for respiratory reasons. Admissions post-anaesthesia were shorter, occurred later in the day, and were more likely to be mechanically ventilated. Admissions post-anaesthesia were less likely to have had a previous ICU admission (4.8% compared to 11%, P=0.032) or PIM ‘high-risk diagnosis’ (9.5% versus 17.2%, P=0.035) but there was no difference in the number of subsequent ICU admissions. There was no difference in the PIM severity of illness score and no mortality difference between the groups.
Conclusions
Young children and respiratory indications dominated unplanned ICU admissions post-anaesthesia, which was more likely later in the day and with mechanical ventilation.
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Affiliation(s)
- Katherine L Taylor
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Anesthesia, University of Toronto , Toronto, Ontario , Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
| | - Leah Szadkowski
- University Health Network, University of Toronto , Toronto, Ontario , Canada
| | - Ari R Joffe
- Division of Critical Care Medicine, Department of Pediatrics, University of Alberta , Edmonton, Alberta , Canada
| | - Christopher S Parshuram
- Department of Critical Care Medicine, Division of Critical Care Medicine, The Hospital for Sick Children , Toronto, Ontario , Canada
- Department of Critical Care Medicine, Department of Paediatrics, University of Toronto , Toronto, Ontario , Canada
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6
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Lane S, Gross M, Arzola C, Malavade A, Szadkowski L, Huszti E, Friedman Z. What are we missing? The quality of intraoperative handover before and after introduction of a checklist. Can J Anaesth 2022; 69:832-840. [PMID: 35314994 DOI: 10.1007/s12630-022-02238-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE Intraoperative handovers are common in anesthesia practice and are associated with increased patient morbidity and mortality. Checklists may improve transfer of information during handovers. This before-and-after study sought to examine the effect of a checklist on intraoperative handover. We hypothesized that introducing a handover checklist would improve our primary outcome of completeness of data transfer. METHODS From February to August 2016, anesthesia providers (residents, fellows, and consultants) at a single tertiary academic center participated in a handover study. Baseline handovers between anesthesia care providers were videotaped, analyzed, and compared with anesthetic records. An intraoperative handover checklist was then introduced, and handovers completed with it were videotaped. The completeness of handovers was compared between the baseline routine and checklist groups. The primary outcome was completeness of information transfer. RESULTS Sixty-seven anesthesia providers participated in the study. Use of the intraoperative handover checklist improved completeness of handover by 6% (95% confidence interval [CI], 2 to 10; P < 0.01). There was no relationship observed between the provider (consultants/fellows vs resident) of the handovers and the degree of completeness (95% CI, 3 to 8; P = 0.33). Complexity had a significant impact on the handover completeness with low or high complexity cases more completely handed over than those of medium complexity both before and after the intervention-a 6% increase for low complexity (95% CI, 1 to 11; P = 0.02) and a 9% increase for high complexity (95% CI, 3 to 14; P < 0.01). CONCLUSION Use of a checklist during intraoperative handovers improved completeness of data transfer. Handover checklists should be considered to improve handover completeness.
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Affiliation(s)
- Sophia Lane
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Marketa Gross
- Perioperative Services, Sinai Health System, Toronto, ON, Canada
- Department of Nursing, Ryerson University, Toronto, ON, Canada
| | - Cristian Arzola
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada
| | - Archana Malavade
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit (BRU), University Health Network, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit (BRU), University Health Network, Toronto, ON, Canada
| | - Zeev Friedman
- Department of Anaesthesia and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue Toronto, Toronto, ON, M5G1X5, Canada.
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Nicoll J, Dryden-Palmer K, Frndova H, Gottesman R, Gray M, Hunt EA, Hutchison JS, Joffe AR, Lacroix J, Middaugh K, Nadkarni V, Szadkowski L, Tomlinson GA, Wensley D, Parshuram CS, Farrell C. Death and Dying in Hospitalized Pediatric Patients: A Prospective Multicenter, Multinational Study. J Palliat Med 2021; 25:227-233. [PMID: 34847737 DOI: 10.1089/jpm.2021.0205] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background: For hospitalized children admitted outside of a critical care unit, the location, mode of death, "do-not-resuscitate" order (DNR) use, and involvement of palliative care teams have not been described across high-income countries. Objective: To describe location of death, patient and terminal care plan characteristics of pediatric inpatient deaths inside and outside the pediatric intensive care unit (PICU). Design: Secondary analysis of inpatient deaths in the Evaluating Processes of Care and Outcomes of Children in Hospital (EPOCH) randomized controlled trial. Setting/Subjects: Twenty-one centers from Canada, Belgium, the United Kingdom, Ireland, Italy, the Netherlands, and New Zealand. Measurement: Descriptive statistics were used to compare patient and terminal care plan characteristics. A multivariable generalized estimating equation examined if palliative care consult during hospital admission was associated with location of death. Results: A total of 365 of 144,539 patients enrolled in EPOCH died; 219 (60%) died in PICU and 143 (40%) died on another inpatient unit. Compared with other inpatient wards, patients who died in PICU were less likely to be expected to die, have a DNR or palliative care consult. Hospital palliative care consultation was more common in older children and independently associated with a lower adjusted odds (95% confidence interval) of dying in PICU [0.59 (0.52-0.68)]. Conclusion: Most pediatric inpatient deaths occur in PICU where patients were less likely to have a DNR or palliative care consult. Palliative care consultation could be better integrated into end-of-life care for younger children and those dying in PICU.
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Affiliation(s)
- Jessica Nicoll
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Janeway Children's Health and Rehabilitation Centre, Discipline of Pediatrics, Memorial University, St. John's Newfoundland and Labrador, Canada.,Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Karen Dryden-Palmer
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Helena Frndova
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronald Gottesman
- Department of Critical Care, Montreal Children's Hospital, Montreal, Quebec, Canada
| | - Martin Gray
- Pediatric Intensive Care, St. George's Hospital, Tooting, London, United Kingdom
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - James S Hutchison
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ari R Joffe
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
| | - Kristen Middaugh
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - Vinay Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Leah Szadkowski
- Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada
| | - George A Tomlinson
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - David Wensley
- Division of Respiratory Medicine, Department of Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Chris S Parshuram
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada.,Centre for Safety Research, SickKids Research Institute, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Farrell
- Division of Pediatric Intensive Care, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
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8
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McIsaac W, Kukan S, Huszti E, Szadkowski L, O'Neill B, Virani S, Ivers N, Lall R, Toor N, Shah M, Alvi R, Bhatt A, Nakamachi Y, Morris AM. A pragmatic randomized trial of a primary care antimicrobial stewardship intervention in Ontario, Canada. BMC Fam Pract 2021; 22:185. [PMID: 34525972 PMCID: PMC8442308 DOI: 10.1186/s12875-021-01536-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND More than 90% of antibiotics are prescribed in primary care, but 50% may be unnecessary. Reducing unnecessary antibiotic overuse is needed to limit antimicrobial resistance. We conducted a pragmatic trial of a primary care provider-focused antimicrobial stewardship intervention to reduce antibiotic prescriptions in primary care. METHODS Primary care practitioners from six primary care clinics in Toronto, Ontario were assigned to intervention or control groups to evaluate the effectiveness of a multi-faceted intervention for reducing antibiotic prescriptions to adults with respiratory and urinary tract infections. The intervention included provider education, clinical decision aids, and audit and feedback of antibiotic prescribing. The primary outcome was total antibiotic prescriptions for these infections. Secondary outcomes were delayed prescriptions, prescriptions longer than 7 days, recommended antibiotic use, and outcomes for individual infections. Generalized estimating equations were used to estimate treatment effects, adjusting for clustering by clinic and baseline differences. RESULTS There were 1682 encounters involving 54 primary care providers from January until May 31, 2019. In intervention clinics, the odds of any antibiotic prescription was reduced 22% (adjusted Odds Ratio (OR) = 0.78; 95% Confidence Interval (CI) = 0.64.0.96). The odds that a delay in filling a prescription was recommended was increased (adjusted OR=2.29; 95% CI=1.37, 3.83), while prescription durations greater than 7 days were reduced (adjusted OR=0.24; 95% CI=0.13, 0.43). Recommended antibiotic use was similar in control (85.4%) and intervention clinics (91.8%, p=0.37). CONCLUSIONS A community-based, primary care provider-focused antimicrobial stewardship intervention was associated with a reduced likelihood of antibiotic prescriptions for respiratory and urinary infections, an increase in delayed prescriptions, and reduced prescription durations. TRIAL REGISTRATION clinicaltrials.gov ( NCT03517215 ).
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Affiliation(s)
- Warren McIsaac
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada.
| | - Sahana Kukan
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Braden O'Neill
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sophia Virani
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, 60 Murray St, Toronto, ON, M5T 3L9, Canada
| | - Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Department of Family Medicine, and Women's College Research Institute, Women's College Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Rosemarie Lall
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Platinum Medical, Scarborough Health Network Teaching Unit, Toronto, Canada
| | - Navsheer Toor
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Southlake Academic Family Health Team, Southlake Regional Health Centre, Newmarket, Toronto, Ontario, Canada
| | - Mruna Shah
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- West Durham Family Health Team, Pickering, Toronto, Ontario, Canada
| | - Ruby Alvi
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
- Summerville Family Health Team, Mississauga, Ontario, Canada
| | - Aashka Bhatt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Yoshiko Nakamachi
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
| | - Andrew M Morris
- Antimicrobial Stewardship Program, University Health Network, Toronto, Canada
- Department of Medicine, Division of Infectious Diseases, Sinai Health, University Health Network, and University of Toronto, Toronto, Canada
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Leis M, McDermott M, Koziarz A, Szadkowski L, Kariri A, Beattie TS, Kaul R, Kimani J. Intimate partner and client-perpetrated violence are associated with reduced HIV pre-exposure prophylaxis (PrEP) uptake, depression and generalized anxiety in a cross-sectional study of female sex workers from Nairobi, Kenya. J Int AIDS Soc 2021; 24 Suppl 2:e25711. [PMID: 34164924 PMCID: PMC8222843 DOI: 10.1002/jia2.25711] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION UNAIDS has identified female sex workers (FSW) as a key HIV at-risk population. FSW disproportionately experience gender-based violence, which compounds their risk of HIV acquisition and may contribute to adverse mental health outcomes. Pre-exposure prophylaxis (PrEP) is a powerful but underused HIV prevention tool for these women. This study explored the associations between intimate partner violence (IPV) and client-perpetrated violence against FSW, mental health outcomes and PrEP use. METHODS An anonymous questionnaire was administered to a convenience sample of 220 Nairobi FSW attending dedicated clinics from June to July 2019, where PrEP was available free of charge. A modified version of the WHO Violence Against Women Instrument assessed IPV and client-perpetrated violence, and the Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) assessed depressive and anxiety symptoms respectively. Multivariable logistic regressions evaluated predictors of depression, generalized anxiety and PrEP use. RESULTS Of the total 220 women (median [IQR] age 32 [27-39]), 56.8% (125/220) reported depression (PHQ-9 ≥ 10) and 39.1% (86/220) reported anxiety (GAD-7 ≥ 10). Only 41.4% (91/220) reported optimal use of PrEP (taken correctly six to seven days/week) despite the cohort pursuing sex work for a median of 7 (4 to 12) years. Most women reported experiencing any violence in the past 12 months (90%, 198/220). Any recent IPV was frequent (78.7%, 129/164), particularly emotional IPV (66.5%, 109/164), as was any client-perpetrated violence in the past 12 months (80.9%, 178/220). Regression analyses found that violence was independently associated with depression (adjusted OR [aOR] 9.39, 95% CI 2.90 to 30.42, p = 0.0002) and generalized anxiety (aOR 3.47, 95% CI 1.10 to 10.88, p = 0.03), with the strongest associations between emotional IPV and both depression and anxiety. Recent client-perpetrated emotional violence (aOR 0.23, 95% CI 0.07 to 0.71, p = 0.01) was associated with decreased PrEP use, whereas client-perpetrated physical violence was associated with increased PrEP use (aOR 3.01, 95% CI 1.16 to 7.81, p = 0.02). CONCLUSIONS There was a high prevalence of recent violence by different perpetrators as well as depression and anxiety among FSW from Nairobi. PrEP use was relatively infrequent, and recent client-perpetrated emotional violence was associated with PrEP non-use. Interventions to reduce gender-based violence may independently enhance HIV prevention and reduce the mental health burden in this community.
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Affiliation(s)
- Maria Leis
- Department of MedicineUniversity of TorontoTorontoCanada
| | | | - Alex Koziarz
- Department of MedicineUniversity of TorontoTorontoCanada
| | - Leah Szadkowski
- Biostatistics Research UnitUniversity Health NetworkTorontoCanada
| | - Antony Kariri
- Department of Medical MicrobiologyUniversity of NairobiNairobiKenya
| | - Tara S Beattie
- Department of Global Health and DevelopmentLondon School of Hygiene and Tropical MedicineLondonEngland
| | - Rupert Kaul
- Department of MedicineUniversity of TorontoTorontoCanada
| | - Joshua Kimani
- Department of Medical MicrobiologyUniversity of NairobiNairobiKenya
- Department of Medical MicrobiologyUniversity of ManitobaManitobaCanada
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10
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Zhabokritsky A, Szadkowski L, Burchell AN, Cooper C, Hogg RS, Hull M, Kelly DV, Klein M, Loutfy M, McClean A, Montaner J, Walmsley SL. Immunological and virological response to initial antiretroviral therapy among older people living with HIV in the Canadian Observational Cohort (CANOC). HIV Med 2021; 22:759-769. [PMID: 34075683 DOI: 10.1111/hiv.13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The aim of this study was to assess the adequacy of immunological recovery and virological suppression in response to antiretroviral therapy (ART) in the growing population of older people living with HIV (PLWH), as treatment regimens become more effective and tolerable. METHODS An interprovincial Canadian cohort of treatment-naïve PLWH who initiated ART after 1 January 2000 was used and age assessed in decades. Longitudinal absolute CD4 count response to treatment was modelled using generalized estimating equations. Cumulative incidence functions and proportional hazards models with a competing risk of death were used to estimate time to: (1) CD4 ≥ 200 cells/µL, (2) CD4 ≥ 500 cells/µL, (3) virological suppression (≤ 50 copies/mL), and (4) virological failure (> 200 copies/mL). RESULTS In all, 12 489 individuals starting ART between 2000 and 2016 with one or more post-treatment CD4 count or viral load were included in the analysis. Age > 60 years was associated with lower absolute CD4 recovery (adjusted β = -31 cells/µL) compared with age ≤ 30 years when pre-treatment CD4 count and other covariates were accounted for. Older age groups were less likely to achieve a CD4 ≥ 500 cells/µL, with the greatest effect in the > 60 group [adjusted hazard ratio (aHR) = 0.69, 95% confidence interval (CI): 0.57-0.84 vs. age ≤ 30). Older age groups were more likely to achieve viral suppression (age > 60, aHR = 1.20, 95% CI: 1.05-1.37) and less likely to have virological failure (age > 60, aHR = 0.46, 95% CI: 0.3-0.71) compared with those aged ≤ 30 years. CONCLUSIONS Older adults have robust virological responses to ART; however, individuals over the age 60 are more likely to experience blunted CD4 recovery.
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Affiliation(s)
- A Zhabokritsky
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - L Szadkowski
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - A N Burchell
- Department of Family and Community Medicine and Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health, Toronto, ON, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - C Cooper
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - R S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - M Hull
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - D V Kelly
- School of Pharmacy, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - M Klein
- McGill University Health Center, Montreal, QC, Canada
| | - M Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - A McClean
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - J Montaner
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - S L Walmsley
- Department of Medicine, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
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11
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Zhabokritsky A, Szadkowski L, Cooper C, Loutfy M, Wong A, McClean A, Hogg RS, Walmsley SL. Increased CD4 : CD8 ratio normalization with implementation of current ART management guidelines. J Antimicrob Chemother 2021; 76:729-737. [PMID: 33249444 PMCID: PMC7879150 DOI: 10.1093/jac/dkaa484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 07/21/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To determine the time to CD4 : CD8 ratio normalization among Canadian adults living with HIV in the modern ART era. To identify characteristics associated with ratio normalization. PATIENTS AND METHODS Retrospective analysis of the Canadian Observational Cohort (CANOC), an interprovincial cohort of ART-naive adults living with HIV, recruited from 11 treatment centres across Canada. We studied participants initiating ART between 1 January 2011 and 31 December 2016 with baseline CD4 : CD8 ratio <1.0 and ≥2 follow-up measurements. Normalization was defined as two consecutive CD4 : CD8 ratios ≥1.0. Kaplan-Meier estimates and log-rank tests described time to normalization. Univariable and multivariable proportional hazards (PH) models identified factors associated with ratio normalization. RESULTS Among 3218 participants, 909 (28%) normalized during a median 2.6 years of follow-up. Participants with higher baseline CD4+ T-cell count were more likely to achieve normalization; the probability of normalization by 5 years was 0.68 (95% CI 0.62-0.74) for those with baseline CD4+ T-cell count >500 cells/mm3 compared with 0.16 (95% CI 0.11-0.21) for those with ≤200 cells/mm3 (P < 0.0001). In a multivariable PH model, baseline CD4+ T-cell count was associated with a higher likelihood of achieving ratio normalization (adjusted HR = 1.5, 95% CI 1.5-1.6 per 100 cells/mm3, P < 0.0001). After adjusting for baseline characteristics, time-dependent ART class was not associated with ratio normalization. CONCLUSIONS Early ART initiation, at higher baseline CD4+ T-cell counts, has the greatest impact on CD4 : CD8 ratio normalization. Our study supports current treatment guidelines recommending immediate ART start, with no difference in ratio normalization observed based on ART class used.
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Affiliation(s)
- Alice Zhabokritsky
- Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Leah Szadkowski
- Department of Medicine, University Health Network, Toronto, Canada
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Curtis Cooper
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Canada
| | - Alexander Wong
- Department of Medicine, University of Saskatchewan, Regina, Canada
| | - Alison McClean
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Robert S Hogg
- British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Sharon L Walmsley
- Department of Medicine, University Health Network, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada
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12
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Younger J, Raboud J, Szadkowski L, Harrigan R, Walmsley S, Bayoumi AM, Klein MB, Cooper C, Burchell AN, Loutfy M, Hull M, Wong A, Thomas R, Hogg R, Montaner J, Tsoukas C, Antoniou T. Tenofovir and emtricitabine resistance among antiretroviral-naive patients in the Canadian Observational Cohort Collaboration: implications for PrEP. Antivir Ther 2020; 24:211-220. [PMID: 30873953 DOI: 10.3851/imp3302] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND The real-world effectiveness of pre-exposure prophylaxis (PrEP) may be influenced by circulating HIV strains resistant to either tenofovir or emtricitabine. Yet, few studies have examined rates of resistance to these drugs in clinical settings. METHODS We conducted a retrospective cohort study of antiretroviral-naive participants in the Canadian Observational Cohort collaboration who initiated antiretroviral therapy between 2006 and 2014. In separate analyses, we determined the prevalence of pretherapy resistance and cumulative incidence of follow-up resistance to tenofovir and emtricitabine. We used multivariable proportional hazards models to examine associations between baseline variables and the development of resistance. RESULTS We studied 6,622 antiretroviral-naive participants initiating therapy, of whom 5,428 (82.0%) had a baseline resistance test. Baseline resistance to tenofovir and emtricitabine was observed in 83 (1.5%) and 21 (0.4%) patients, respectively. Among patients without baseline resistance, the cumulative incidence of resistance to tenofovir and emtricitabine 5 years following treatment initiation was 0.0070 (95% CI 0.0046, 0.0095) and 0.033 (95% CI 0.028, 0.038), respectively. Following multivariable analysis, a baseline viral load ≥100,000 copies/ml was associated with emergence of tenofovir (hazard ratio [HR] 2.88; 95% CI 1.35, 6.15) and emtricitabine (HR 2.27; 95% CI 1.64, 3.15) resistance. Initiating an integrase inhibitor-based regimen and CD4+ T-cell count below 200 cells/mm3 were also associated with resistance to each drug. CONCLUSIONS We observed a low prevalence of baseline resistance and a low incidence of emergence of resistance to tenofovir and emtricitabine among antiretroviral-naive patients in routine clinical care.
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Affiliation(s)
- Jaime Younger
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Janet Raboud
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Leah Szadkowski
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Richard Harrigan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Sharon Walmsley
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada
| | - Ahmed M Bayoumi
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Marina B Klein
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Department of Medicine, McGill University Health Centre Research Institute, Montréal, QC, Canada
| | - Curtis Cooper
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ann N Burchell
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, St Michael's Hospital and University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Mona Loutfy
- Department of Medicine, University of Toronto, Toronto, ON, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Maple Leaf Medical Clinic, Toronto, ON, Canada
| | - Mark Hull
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Alex Wong
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,Division of Infectious Diseases, Department of Medicine, University of Saskatchewan, Regina, SK, Canada
| | | | - Robert Hogg
- CIHR Canadian HIV Trials Network, Vancouver, BC, Canada.,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada.,Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Julio Montaner
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada
| | - Chris Tsoukas
- Faculty of Medicine, McGill University Health Centre, Montréal, QC, Canada
| | - Tony Antoniou
- Department of Family and Community Medicine, St Michael's Hospital and University of Toronto, Toronto, ON, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
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13
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Tan DHS, Raboud JM, Szadkowski L, Grinsztejn B, Madruga JV, Figueroa MI, Cahn P, Barton SE, Clarke A, Fox J, Zubyk W, Walmsley SL. Effect of valaciclovir on CD4 count decline in untreated HIV: an international randomized controlled trial. J Antimicrob Chemother 2020; 74:480-488. [PMID: 30376108 PMCID: PMC6337901 DOI: 10.1093/jac/dky433] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/26/2018] [Indexed: 11/14/2022] Open
Abstract
Objectives To determine the impact of valaciclovir on HIV disease progression in treatment-naive HIV-positive adults. Methods In this fully blind, multicentre, 1:1 randomized placebo-controlled trial, treatment-naive HIV-1-positive adults with CD4 counts 400–900 cells/mm3 and not meeting contemporaneous recommendations for combination ART (cART) were randomized to valaciclovir 500 mg or placebo twice daily, and followed quarterly until having two consecutive CD4 counts ≤350 cells/mm3 or initiating cART for any reason. The primary analysis compared the rate of CD4 count decline by study arm after adjusting for baseline CD4 count and viral load (VL). Secondary analyses compared the rate of CD4 percentage decline, HIV VL, herpes simplex virus (HSV) recurrences and drug-related adverse events. The trial closed after release of the START trial results in August 2015. Results We enrolled 198 participants in Canada, Brazil, Argentina and the UK. Median (IQR) age was 35 (30–43) years. Baseline CD4 count was 592 (491–694) cells/mm3 and VL was 4.04 (3.5–4.5) log10 copies/mL. Over 276 person-years of follow-up, CD4 counts declined by 49 cells/mm3/year in the valaciclovir arm versus 58 cells/mm3/year in the placebo arm (P = 0.65). No differences were seen in the rate of change in CD4 percentage (−1.2%/year versus −1.7%/year, P = 0.34). VL was 0.27 log10 copies/mL lower in valaciclovir participants overall (P<0.001). Placebo participants had more HSV recurrences (62 versus 21/100 person-years, P < 0.0001) but similar rates of grade ≥2 drug-related adverse events. Conclusions Unlike prior trials using aciclovir, we found that valaciclovir did not slow CD4 count decline in cART-untreated adults, although power was limited due to premature study discontinuation. Valaciclovir modestly lowered HIV VL.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, University Health Network, Toronto, Canada
| | - Janet M Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Toronto General Research Institute, Toronto, Canada
| | - Leah Szadkowski
- Biostatistics Research Unit, University Health Network, Toronto, Canada
| | - Beatriz Grinsztejn
- Instituto de Pesquisa Clínica Evandro Chagas (IPEC), Fundaçao Oswaldo Cruz, Rio de Janeiro, Brazil
| | | | | | - Pedro Cahn
- Fundación Huesped, Buenos Aires, Argentina
| | | | - Amanda Clarke
- Brighton & Sussex University Hospital NHS Trust, Brighton, UK
| | - Julie Fox
- Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Wendy Zubyk
- CIHR Canadian HIV Trials Network, Vancouver, Canada
| | - Sharon L Walmsley
- Department of Medicine, University of Toronto, Toronto, Canada.,Division of Infectious Diseases, University Health Network, Toronto, Canada.,Toronto General Research Institute, Toronto, Canada.,CIHR Canadian HIV Trials Network, Vancouver, Canada
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14
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Tan DHS, Rolon MJ, Figueroa MI, Sued O, Gun A, Kaul R, Raboud JM, Szadkowski L, Hull MW, Walmsley SL, Cahn P. Inflammatory biomarker levels over 48 weeks with dual vs triple lopinavir/ritonavir-based therapy: Substudy of a randomized trial. PLoS One 2019; 14:e0221653. [PMID: 31490959 PMCID: PMC6730918 DOI: 10.1371/journal.pone.0221653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 05/21/2019] [Accepted: 08/09/2019] [Indexed: 11/18/2022] Open
Abstract
Background Inflammation has been associated with increased morbidity and mortality in HIV-positive patients. We compared inflammatory biomarkers with dual therapy using lopinavir/ritonavir plus lamivudine (LPV/r+3TC) versus triple therapy using LPV/r plus two nucleoside reverse transcriptase inhibitors (LPV/r+2NRTIs) in treatment-naïve HIV-positive adults. Methods This was a substudy among Argentinian participants in the randomized trial GARDEL. We measured hsCRP, IL-6, MCP-1, TNF, D-dimer and sCD14 from plasma collected at baseline, week 24 and week 48. Generalized estimating equations with an identity/logit link were used to model the average impact of dual versus triple therapy on each biomarker over time, controlling for baseline levels. Additional models estimated the average effect of virologic suppression on biomarker levels over time, adjusting for age, sex, and baseline CD4 count. Results Of 191 trial participants enrolled in Argentina, 172 had baseline and follow-up measurements and were included. Median (IQR) age was 35.5 (28.5, 45) years and CD4 cell count was 310 (219, 414) cells/mm3. Dual therapy was not associated with significantly different biomarker levels over 48 weeks relative to triple therapy. Virologic suppression was associated with statistically significant decreases in MCP-1, TNF and D-dimer levels and an unexpected increase in sCD14 levels. No change was observed in hsCRP or the proportion of participants with undetectable IL-6 levels. Conclusions In addition to having virologic non-inferiority, LPV/r+3TC dual therapy is generally associated with similar inflammatory biomarker levels over 48 weeks compared to LPV/r+2NRTIs triple therapy in treatment-naïve adults. Further study of dual treatment regimens is warranted.
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Affiliation(s)
- Darrell H. S. Tan
- St. Michael’s Hospital Division of Infectious Diseases, Toronto, ON, Canada
- University Health Network Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto Department of Medicine, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- * E-mail:
| | - Maria Jose Rolon
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Maria Ines Figueroa
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Omar Sued
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Ana Gun
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
| | - Rupert Kaul
- University Health Network Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto Department of Medicine, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- University of Toronto Department of Immunology, Toronto, ON, Canada
| | - Janet M. Raboud
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Leah Szadkowski
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | | | - Sharon L. Walmsley
- University Health Network Division of Infectious Diseases, Toronto, ON, Canada
- University of Toronto Department of Medicine, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Pedro Cahn
- Fundación Huésped, Pasaje Angel Peluffo 3932 (C1202ABB), Ciudad Autónoma de Buenos Aires, Argentina
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15
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Tan DHS, Schnubb A, Lawless J, Szadkowski L, Grennan T, Wilton J, Fowler S, Hart TA, Maxwell J, Raboud JM. Acceptability and tolerability of and adherence to HIV preexposure prophylaxis among Toronto gay and bisexual men: a pilot study. CMAJ Open 2018; 6:E611-E617. [PMID: 30530721 PMCID: PMC6287974 DOI: 10.9778/cmajo.20180068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Preexposure prophylaxis is efficacious at preventing HIV infection, but concerns persist about adherence and sexually transmitted infections (STIs). We assessed preexposure prophylaxis acceptability, adherence and clinical outcomes in a pilot demonstration project. METHODS HIV-uninfected adult gay and bisexual men who scored 10 or higher on a validated HIV risk score (HIV Incidence Risk Index for MSM) and reported condomless receptive anal sex were sequentially enrolled into a 1-year open-label single-arm pilot study of daily oral therapy with tenofovir disoproxil fumarate/emtricitabine in Toronto. The primary outcome was acceptability of preexposure prophylaxis. Secondary outcomes were preexposure prophylaxis adherence (4-d recall, pill count and dried blood spot analysis), HIV seroconversion, STIs and adverse events. RESULTS Of the 86 men screened, 52 were enrolled. Participants were mostly young (median age 33 yr [interquartile range (IQR) 28-37 yr) white (38 [73%]) gay (49 [94%]) men. Preexposure prophylaxis acceptability was high: all participants reported their experience as "good" or "very good." The median adherence rate was high, at 100% (IQR 95%-100%) by self-report and 96.9% (IQR 93.4%-98.4%) by pill count. Dried blood spot analysis suggested that doses were taken 4-7 days/week at 88.7% (173/195) of month 3-12 visits. No cases of HIV seroconversion occurred, but 25 participants (48%) experienced at least 1 bacterial STI, with incidence rates per 100 person-years of 32.8, 32.8, 8.2 and 8.2 for chlamydia, gonorrhea, syphilis and lymphogranuloma venereum, respectively. No adverse events led to discontinuation of prophylaxis, but the estimated glomerular filtration rate declined by 0.22 mL/min per month. INTERPRETATION Preexposure prophylaxis was associated with high adherence and acceptability and no HIV infections in this study. Frequent STIs and clinically unapparent toxic renal effects reinforce the need for ongoing vigilance. TRIAL REGISTRATION ClinicalTrials. gov, no. NCT02149888.
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Affiliation(s)
- Darrell H S Tan
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont.
| | - Alexandre Schnubb
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - James Lawless
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Leah Szadkowski
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Troy Grennan
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - James Wilton
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Shawn Fowler
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Trevor A Hart
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - John Maxwell
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
| | - Janet M Raboud
- Division of Infectious Diseases (Tan, Schnubb, Lawless), St. Michael's Hospital; Department of Medicine (Tan), University of Toronto; Toronto General Hospital Research Institute (Tan, Raboud) and Biostatistics Research Unit (Szadkowski), University Health Network, Toronto, Ont.; British Columbia Centre for Disease Control (Grennan); Division of Infectious Diseases (Grennan), University of British Columbia, Vancouver, BC; Ontario HIV Treatment Network (Wilton); Hassle Free Clinic (Fowler); Department of Psychology (Hart), Ryerson University; Dalla Lana School of Public Health (Hart, Raboud), University of Toronto; AIDS Committee of Toronto (Maxwell), Toronto, Ont
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16
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Abstract
Poor retention in HIV care is associated with poor clinical outcomes and mortality. Previous studies of predictors of poor retention have been conducted with a wide variety of populations, using different measures of retention, and occasionally have conflicting results. We studied demographic and psychosocial factors associated with inter-visit interval length in a setting of universal health care and modern cART. Patients attending ≥2 appointments with an HIV specialist at the Toronto General Hospital Immunodeficiency Clinic from 2004 to 2013 were studied. A sub-analysis included psychosocial measures from annual questionnaires for Ontario HIV Treatment Network Cohort Study (OCS) participants. Median inter-visit interval and constancy (percentage of 4-month intervals with ≥1 visit) were calculated by patient. Multivariable generalized estimating equation models identified factors associated with inter-visit interval length and intervals ≥12 months. 1591 patients were included. 615 patients completed an OCS questionnaire and were more likely to be older white MSM from Canada with a viral load (VL) <50 copies/ml. The median (IQR) of patients' median inter-visit intervals was 3.15 (2.78, 3.84) months and median (IQR) constancy was 90% (71%, 100%). Two percent of inter-visit intervals were ≥12 months and 25% of patients had ≥1 interval ≥12 months. Longer inter-visit intervals were associated with younger age, white race, earlier calendar year, longer duration of HIV, VL < 50 copies/mL and higher CD4 counts. Patients who were younger, white, had injection drug use as a risk factor, had a longer duration of HIV, and had VL ≥50 copies/mL were more likely to have an inter-visit interval ≥12 months. In the OCS sub-analysis including psychosocial variables, lower levels of depression were associated with longer inter-visit intervals. Retention at this tertiary care centre was high. Efforts to maximize attendance should focus on younger patients and those with substance abuse issues.
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Affiliation(s)
- Leah Szadkowski
- a Toronto General Hospital Research Institute , University Health Network , Toronto , Canada
| | - Sharon Walmsley
- a Toronto General Hospital Research Institute , University Health Network , Toronto , Canada.,b Division of Infectious Diseases , University Health Network , Toronto , Canada.,c Faculty of Medicine , University of Toronto , Toronto , Canada
| | - Ann N Burchell
- d Centre for Urban Health Solutions, Keenan Research Centre , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada.,e Department of Family and Community Medicine , St. Michael's Hospital , Toronto , Canada.,f Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Evan Collins
- b Division of Infectious Diseases , University Health Network , Toronto , Canada.,g Department of Psychiatry , University of Toronto , Toronto , Canada
| | - Sean B Rourke
- d Centre for Urban Health Solutions, Keenan Research Centre , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada.,g Department of Psychiatry , University of Toronto , Toronto , Canada.,h Ontario HIV Treatment Network , Toronto , Canada
| | - Janet Raboud
- a Toronto General Hospital Research Institute , University Health Network , Toronto , Canada.,f Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
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- a Toronto General Hospital Research Institute , University Health Network , Toronto , Canada
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17
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Antoniou T, Szadkowski L, Walmsley S, Cooper C, Burchell AN, Bayoumi AM, Montaner JSG, Loutfy M, Klein MB, Machouf N, Tsoukas C, Wong A, Hogg RS, Raboud J. Comparison of atazanavir/ritonavir and darunavir/ritonavir based antiretroviral therapy for antiretroviral naïve patients. BMC Infect Dis 2017; 17:266. [PMID: 28399819 PMCID: PMC5387339 DOI: 10.1186/s12879-017-2379-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 04/04/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Atazanavir/ritonavir and darunavir/ritonavir are common protease inhibitor-based regimens for treating patients with HIV. Studies comparing these drugs in clinical practice are lacking. METHODS We conducted a retrospective cohort study of antiretroviral naïve participants in the Canadian Observational Cohort (CANOC) collaboration initiating atazanavir/ritonavir- or darunavir/ritonavir-based treatment. We used separate Fine and Gray competing risk regression models to compare times to regimen failure (composite of virologic failure or discontinuation for any reason). Additional endpoints included virologic failure, discontinuation due to virologic failure, discontinuation for other reasons, and virologic suppression. RESULTS We studied 222 patients treated with darunavir/ritonavir and 1791 patients treated with atazanavir/ritonavir. Following multivariable adjustment, there was no difference between darunavir/ritonavir and atazanavir-ritonavir in the risk of regimen failure (adjusted hazard ratio 0.76, 95% CI 0.56 to 1.03) Darunavir/ritonavir-treated patients were at lower risk of virologic failure relative to atazanavir/ritonavir treated patients (aHR 0.50, 95% CI 0.28 to 0.91), findings driven largely by high rates of virologic failure among atazanavir/ritonavir-treated patients in the province of British Columbia. Of 108 discontinuations due to virologic failure, all occurred in patients starting atazanavir/ritonavir. There was no difference between regimens in time to discontinuation for reasons other than virologic failure (aHR 0.93; 95% CI 0.65 to 1.33) or virologic suppression (aHR 0.99, 95% CI 0.82 to 1.21). CONCLUSIONS The risk of regimen failure was similar between patients treated with darunavir/ritonavir and atazanavir/ritonavir. Although darunavir/ritonavir was associated with a lower risk of virologic failure relative to atazanavir/ritonavir, this difference varied substantially by Canadian province and likely reflects regional variation in prescribing practices and patient characteristics.
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Affiliation(s)
- Tony Antoniou
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
- University of Toronto, 410 Sherbourne Street, Toronto, ON ON M4X 1K2 Canada
| | - Leah Szadkowski
- Toronto General Research Institute, University Health Network, Toronto, ON Canada
| | - Sharon Walmsley
- University of Toronto, 410 Sherbourne Street, Toronto, ON ON M4X 1K2 Canada
- Toronto General Research Institute, University Health Network, Toronto, ON Canada
| | - Curtis Cooper
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Ann N. Burchell
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, ON Canada
- University of Toronto, 410 Sherbourne Street, Toronto, ON ON M4X 1K2 Canada
| | - Ahmed M. Bayoumi
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON Canada
- University of Toronto, 410 Sherbourne Street, Toronto, ON ON M4X 1K2 Canada
| | - Julio S. G. Montaner
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC Canada
- University of British Columbia, Vancouver, BC Canada
| | - Mona Loutfy
- University of Toronto, 410 Sherbourne Street, Toronto, ON ON M4X 1K2 Canada
- Women’s College Hospital Research Institute, Toronto, ON Canada
- Maple Leaf Medical Clinic, Toronto, ON Canada
| | - Marina B. Klein
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Nima Machouf
- Clinique Médicale l’Actuel, Montreal, Quebec, Canada
| | - Christos Tsoukas
- McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | | | - Robert S. Hogg
- British Columbia Centre for Excellence in HIV/AIDS, St. Paul’s Hospital, Vancouver, BC Canada
- Simon Fraser University, Burnaby, BC Canada
| | - Janet Raboud
- University of Toronto, 410 Sherbourne Street, Toronto, ON ON M4X 1K2 Canada
- Toronto General Research Institute, University Health Network, Toronto, ON Canada
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18
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Tan DHS, Raboud J, Szadkowski L, Szabo E, Hu H, Wong Q, Cheung AM, Walmsley SL. Novel imaging modalities for the comparison of bone microarchitecture among HIV+ patients with and without fractures: a pilot study. HIV Clin Trials 2016; 18:28-38. [PMID: 27951753 DOI: 10.1080/15284336.2016.1266074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND HIV-infected adults have increased fracture risk. OBJECTIVES To generate pilot data comparing bone density, structure, and strength between HIV-infected adults with and without a prior fracture. METHODS Adults with and without a prior fracture after their HIV diagnosis were matched 1:1 based on age, sex, race, and smoking history. Participants underwent dual-energy X-ray absorptiometry (DXA), trabecular bone score (TBS), hip structural analyses (HSA), vertebral fracture assessment (VFA), high-resolution peripheral quantitative tomography (HR-pQCT) and measurement of bone turnover markers. Results were compared between cases and controls, with differences expressed as percentages of control group values. RESULTS 23 pairs were included. On DXA, cases had lower areal bone mineral density (aBMD) at the total hip (median difference in T-score -0.25, p = 0.04), but not the lumbar spine (median difference in T-score 0.10, p = 0.68). Cases had greater abnormalities in HSA and most HR-pQCT and HSA measures, by up to 15%. VFA revealed two subclinical fractures among cases but none among controls. TBS, CTX, and P1NP levels were similar between groups, with differences of 1.9% (p = 0.90), 9.7% (p = 0.55), and 10.0% (p = 0.24), respectively. For each parameter, we report the median and interquartile range for the absolute and relative difference between cases and controls, the correlation between cases and controls, and our recruitment rates, to inform the design of future studies. CONCLUSIONS These pilot data suggest potential differences in bone structure, estimated bone strength, and asymptomatic vertebral fractures among HIV-infected adults with and without fracture, warranting further study as markers of fracture risk in HIV.
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Affiliation(s)
- Darrell H S Tan
- a Division of Infectious Diseases , St. Michael's Hospital , Toronto , Canada.,b Division of Infectious Diseases , University Health Network , Toronto , Canada.,c Toronto General Research Institute , University Health Network , Toronto , Canada.,d Department of Medicine , University of Toronto , Toronto , Canada.,e CIHR - Canadian HIV Trials Network , Vancouver , Canada
| | - Janet Raboud
- c Toronto General Research Institute , University Health Network , Toronto , Canada.,f Dalla Lana School of Public Health , University of Toronto , Toronto , Canada
| | - Leah Szadkowski
- c Toronto General Research Institute , University Health Network , Toronto , Canada
| | - Eva Szabo
- g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada
| | - Hanxian Hu
- g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada
| | - Queenie Wong
- g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada
| | - Angela M Cheung
- c Toronto General Research Institute , University Health Network , Toronto , Canada.,d Department of Medicine , University of Toronto , Toronto , Canada.,f Dalla Lana School of Public Health , University of Toronto , Toronto , Canada.,g Centre for Excellence in Skeletal Health Assessment , University Health Network , Toronto , Canada.,h Divisions of General Internal Medicine and Endocrinology , University Health Network , Toronto , Canada
| | - Sharon L Walmsley
- b Division of Infectious Diseases , University Health Network , Toronto , Canada.,c Toronto General Research Institute , University Health Network , Toronto , Canada.,d Department of Medicine , University of Toronto , Toronto , Canada.,e CIHR - Canadian HIV Trials Network , Vancouver , Canada
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19
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Tan DHS, Szadkowski L, Raboud J, Yi TJ, Shannon B, Kaul R, Liles WC, Walmsley S. Effect of Intercurrent Infections and Vaccinations on Immune and Inflammatory Biomarkers Among Human Immunodeficiency Virus-Infected Adults on Suppressive Antiretroviral Therapy. Open Forum Infect Dis 2015; 2:ofv036. [PMID: 26380337 PMCID: PMC4567101 DOI: 10.1093/ofid/ofv036] [Citation(s) in RCA: 4] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 03/03/2015] [Indexed: 01/20/2023] Open
Abstract
We used generalized estimating equations to quantify the impact of recent vaccination or intercurrent infections on immune and inflammatory biomarkers among 144 human immunodeficiency virus (HIV)-infected adults with HIV RNA < 50 copies/mL on antiretroviral therapy. These events were associated with a 2.244 µg/mL increase in high sensitivity C-reactive protein and should be routinely assessed in future studies.
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Affiliation(s)
- Darrell H S Tan
- Departments of Medicine ; Division of Infectious Diseases , St. Michael's Hospital ; Division of Infectious Diseases ; Toronto General Research Institute , University Health Network , Ontario, Canada
| | - Leah Szadkowski
- Toronto General Research Institute , University Health Network , Ontario, Canada
| | - Janet Raboud
- Dalla Lana School of Public Health , University of Toronto ; Toronto General Research Institute , University Health Network , Ontario, Canada
| | | | | | - Rupert Kaul
- Departments of Medicine ; Immunology ; Division of Infectious Diseases ; Toronto General Research Institute , University Health Network , Ontario, Canada
| | - W Conrad Liles
- Department of Medicine , University of Washington , Seattle
| | - Sharon Walmsley
- Departments of Medicine ; Division of Infectious Diseases ; Toronto General Research Institute , University Health Network , Ontario, Canada
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Tan DH, Raboud JM, Szadkowski L, Yi TJ, Shannon B, Kaul R, Liles WC, Walmsley SL. Herpes simplex virus type 2 serostatus is not associated with inflammatory or metabolic markers in antiretroviral therapy-treated HIV. AIDS Res Hum Retroviruses 2015; 31:276-81. [PMID: 25399537 PMCID: PMC4348084 DOI: 10.1089/aid.2014.0183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 11/12/2022] Open
Abstract
Systemic inflammation and immune activation may persist in HIV-infected persons on suppressive combination antiretroviral therapy (cART) and contribute to adverse health outcomes. We compared markers of immune activation, inflammation, and abnormal glucose and lipid metabolism in HIV-infected adults according to herpes simplex virus type 2 (HSV-2) serostatus in a 6-month observational cohort study in Toronto, Canada. HIV-infected adults on suppressive (viral load <50 copies/ml) cART were categorized as HSV-2 seropositive or seronegative using the HerpeSelect ELISA, and underwent study visits at baseline, 3 months, and 6 months. The primary outcome was the median percentage of activated (CD38(+)HLADR(+)) CD8 T cells. Secondary outcome measures included additional immune (activated CD4, regulatory T cells) and inflammatory (hsCRP, D-dimer, IL-1b, IL-6, MCP-1, TNF, sICAM-1, sVCAM-1, Ang1/Ang2 ratio) markers. Metabolic outcomes included the proportion with impaired fasting glucose/impaired glucose tolerance/diabetes, insulin sensitivity (calculated using the Matsuda index), insulin resistance (homeostasis model assessment of insulin resistance), and fasting lipids. The impact of HSV-2 on each outcome was estimated using generalized estimating equation regression models. Of 84 participants, 38 (45%) were HSV-2 seropositive. HSV signs and symptoms were uncommon. Aside from D-dimer, which was more often detectable in HSV-2 seropositives (adjusted odds ratio=3.58, 95% CI=1.27, 10.07), HSV-2 serostatus was not associated with differences in any other immune, inflammatory cytokine, acute phase reactant, endothelial activation, or metabolic markers examined in univariable or multivariable models. During the study, CD8 and CD4 T cell activation declined by 0.16% and 0.08% per month, respectively, while regulatory T cells increased by 0.05% per month. HSV-2 serostatus was not consistently associated with immune activation, inflammatory, or lipid and glucose metabolic markers in this cohort of HIV-infected adults on suppressive cART.
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Affiliation(s)
- Darrell H.S. Tan
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, St. Michael's Hospital, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada
| | - Janet M. Raboud
- Toronto General Research Institute, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | | | - Tae Joon Yi
- Department of Immunology, University of Toronto, Toronto, Canada
| | - Brett Shannon
- Department of Immunology, University of Toronto, Toronto, Canada
| | - Rupert Kaul
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada
- Department of Immunology, University of Toronto, Toronto, Canada
| | - W. Conrad Liles
- Department of Medicine, University of Washington, Seattle, Washington
| | - Sharon L. Walmsley
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
- Toronto General Research Institute, Toronto, Canada
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21
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Tseng A, Szadkowski L, Walmsley S, Salit I, Raboud J. Association of Age With Polypharmacy and Risk of Drug Interactions With Antiretroviral Medications in HIV-Positive Patients. Ann Pharmacother 2013; 47:1429-39. [DOI: 10.1177/1060028013504075] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Alice Tseng
- Toronto General Hospital, University Health Network, ON, Canada
- University of Toronto, ON, Canada
| | - Leah Szadkowski
- Toronto General Research Institute, University Health Network, ON, Canada
| | - Sharon Walmsley
- Toronto General Hospital, University Health Network, ON, Canada
- Toronto General Research Institute, University Health Network, ON, Canada
- University of Toronto, ON, Canada
| | - Irving Salit
- Toronto General Hospital, University Health Network, ON, Canada
- University of Toronto, ON, Canada
| | - Janet Raboud
- Toronto General Research Institute, University Health Network, ON, Canada
- University of Toronto, ON, Canada
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22
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Yi TJ, Walmsley S, Szadkowski L, Raboud J, Rajwans N, Shannon B, Kumar S, Kain KC, Kaul R, Tan DHS. A randomized controlled pilot trial of valacyclovir for attenuating inflammation and immune activation in HIV/herpes simplex virus 2-coinfected adults on suppressive antiretroviral therapy. Clin Infect Dis 2013; 57:1331-8. [PMID: 23946220 DOI: 10.1093/cid/cit539] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) is associated with increased systemic inflammation and immune activation that persist despite suppressive antiretroviral therapy (ART). Herpes simplex virus type 2 (HSV-2) is a common coinfection that may contribute to this inflammation. METHODS Sixty HIV type 1 (HIV-1)/HSV-2-coinfected adults on suppressive ART were randomized 1:1:1 to 12 weeks of placebo, low-dose valacyclovir (500 mg twice daily), or high-dose valacyclovir (1 g twice daily) in this 18-week trial. Co-primary outcome measures were the percentage of activated (CD38(+)HLA-DR(+)) CD8 T cells in blood, and highly sensitive C-reactive protein, interleukin 6, and soluble intercellular adhesion molecule 1 in plasma. Secondary outcomes included additional immune, inflammatory cytokine, and endothelial activation markers. The impact of valacyclovir (both groups combined) on each outcome was estimated using treatment × time interaction terms in generalized estimating equation regression models. RESULTS Participants were mostly white (75%) men who have sex with men (80%). Median age was 51 (interquartile range [IQR], 47-56) years, median duration of HIV infection was 15 (IQR, 8-21) years, median CD4 count at enrollment was 520 (IQR, 392-719) cells/µL, and median nadir CD4 count was 142 (IQR, 42-240) cells/µL. Valacyclovir was not associated with significant changes in any primary or secondary immunological outcomes in bivariate or multivariable models. Medication adherence was 97% by self-report, 96% by pill count, and 84% by urine monitoring. Eight patients had adverse events deemed possibly related to the study drug (5 placebo, 1 low-dose, 2 high-dose), and 6 patients reported at least 1 HSV outbreak (3 placebo, 3 low-dose, 0 high-dose). CONCLUSIONS Valacyclovir did not decrease systemic immune activation or inflammatory biomarkers in HIV-1/HSV-2-coinfected adults on suppressive ART. CLINICAL TRIALS REGISTRATION NCT01176409.
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Affiliation(s)
- Tae Joon Yi
- Department of Medicine, University of Toronto
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23
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Szadkowski L, Tseng A, Walmsley SL, Salit I, Raboud JM. Short communication: effects of age on virologic suppression and CD4 cell response in HIV-positive patients initiating combination antiretroviral therapy. AIDS Res Hum Retroviruses 2012; 28:1579-83. [PMID: 22734840 DOI: 10.1089/aid.2012.0018] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Older HIV-positive patients may experience reduced benefit and increased toxicities from combination antiretroviral therapies (cART) due to late diagnosis, weakened immune systems, and other age-related physiological changes. This study investigates the effect of age on time to virologic suppression and CD4 cell count response to cART. Data were collected from a tertiary care immunodeficiency clinic in Toronto. HIV-positive patients with cART initiation after 1/1/1998 were included. Log logistic accelerated failure time models were used to estimate the effect of age on time to virologic suppression. Mixed linear models were used to evaluate CD4 cell response to treatment. A total of 502 patients were studied; 445 were less than 50 years old and 57 were age 50 or over. Of these 73% were male. Thirty-one percent started treatment with boosted protease inhibitors and 43% with nonnucleoside reverse transcriptase inhibitors. In a log logistic model adjusting for gender, immigration status, AIDS-defining illness, years since HIV diagnosis, baseline CD4 count and viral load, cART type, calendar year of cART initiation, and hepatitis C diagnosis, older age was not associated with time to virologic suppression (n=418, time ratio=0.94, p=0.20). In a multivariable mixed linear regression model adjusting for the same covariates, age was not associated with CD4 cell count response (n=418, β=0.34, p=0.96). Time to virologic suppression and immunologic response were not significantly different among older and younger patients. Further studies should investigate adherence, comorbidities, and regimen changes in addition to the current covariates.
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Affiliation(s)
- Leah Szadkowski
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Clinical Decision Making and Health Care, University Health Network, Toronto, Canada
| | - Alice Tseng
- Faculty of Pharmacy, University of Toronto, Toronto, Canada
- Immunodeficiency Clinic, University Health Network, Toronto, Canada
| | - Sharon L. Walmsley
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
| | - Irving Salit
- Faculty of Medicine, University of Toronto, Toronto, Canada
- Division of Infectious Diseases, University Health Network, Toronto, Canada
| | - Janet M. Raboud
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Clinical Decision Making and Health Care, University Health Network, Toronto, Canada
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Tasca GA, Szadkowski L, Illing V, Trinneer A, Grenon R, Demidenko N, Krysanski V, Balfour L, Bissada H. Adult attachment, depression, and eating disorder symptoms: The mediating role of affect regulation strategies. Personality and Individual Differences 2009. [DOI: 10.1016/j.paid.2009.06.006] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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