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Myring G, Lim AG, Hollingworth W, McLeod H, Beer L, Vickerman P, Hickman M, Radley A, Dillon JF. Cost-effectiveness of pharmacy-led versus conventionally delivered antiviral treatment for hepatitis C in patients receiving opioid substitution therapy: An economic evaluation alongside a pragmatic cluster randomised trial. J Infect 2022; 85:676-682. [PMID: 36170895 DOI: 10.1016/j.jinf.2022.09.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Elimination targets for hepatitis C have been set across the world. In the UK almost 90% of infections are in people who inject drugs. Evidence shows community case-finding is effective at identifying and treating undiagnosed patients. The aim of this analysis was to assess, from a healthcare provider perspective, the cost-effectiveness of a new pharmacist-led test and treat pathway for hepatitis C in opioid agonist treatment (OAT) patients attending community pharmacies compared to conventional care. METHODS In a cluster randomised controlled trial, pharmacies were randomised to the pharmacist-led or conventional care pathway. Mean cost per OAT patient and per patient initiating treatment was identified for each pathway. A Markov model tracking disease progression was developed, with a 50-year time horizon and 3·5% time discount rate, to estimate the incremental cost-effectiveness ratio (ICER) per quality-adjusted life-year (QALY) gained and the probability of being cost-effective at a £30,000 per QALY willingness-to-pay threshold. Probabilistic sensitivity analysis was performed for a range of drug discounts, re-infection rates, and model assumptions. FINDINGS Mean cost per OAT patient (£3,674 vs £1,965) and per patient initiating treatment (£863 vs £404) was higher in the pharmacist-led pathway, due to higher uptake of testing and pharmacist time requirements. Over a 50-year time horizon the ICER per QALY gained was £31,612 at NHS indicative price for treatment (£38,979 for 12 weeks) and 12·1/100 person-years re-infection rate, reducing to £21,027/£10,220/-£501 per QALY gained with 30%/60%/90% drug price discounts and £25,373/£21,738/£14,912 per QALY gained at re-infection rates of 8/5/2 per 100 person-years. At 30%/60%/90% drug discount rates, the pharmacist-led pathway has an 80%/98%/100% probability of being cost-effective. INTERPRETATION The pharmacist-led pathway is effective at increasing testing and treatment uptake, with cost-effectiveness being highly dependent on drug price discounts. FUNDING Trial funding provided by the Scottish Government, Gilead Sciences, and Bristol-Myers Squibb.
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Affiliation(s)
- G Myring
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 2NT, UK.
| | - A G Lim
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK
| | - W Hollingworth
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 2NT, UK
| | - H McLeod
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK; The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Bristol BS1 2NT, UK
| | - L Beer
- Tayside Clinical Trials Unit, Tayside Medical Science Centre, University of Dundee, Dundee DD1 9SY, UK
| | - P Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK
| | - M Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, BS8 1UD, UK
| | - A Radley
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
| | - J F Dillon
- Hepatology & Gastroenterology, Clinical & Molecular Medicine, School of Medicine, University of Dundee, Dundee DD1 9SY, UK
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Payandi-Rolland D, Shirokova LS, Tesfa M, Bénézeth P, Lim AG, Kuzmina D, Karlsson J, Giesler R, Pokrovsky OS. Dissolved organic matter biodegradation along a hydrological continuum in permafrost peatlands. Sci Total Environ 2020; 749:141463. [PMID: 32827830 DOI: 10.1016/j.scitotenv.2020.141463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/30/2020] [Accepted: 08/01/2020] [Indexed: 06/11/2023]
Abstract
Arctic regions contain large amounts of organic carbon (OC) trapped in soil and wetland permafrost. With climate warming, part of this OC is released to aquatic systems and degraded by microorganisms, thus resulting in positive feedback due to carbon (C) emission. In wetland areas, water bodies are spatially heterogenic and separated by landscape position and water residence time. This represents a hydrological continuum, from depressions, smaller water bodies and lakes to the receiving streams and rivers. Yet, the effect of this heterogeneity on the OC release from the soil and its processing in waters is largely unknown and not accounted for in C cycle models of Arctic regions. Here we investigated the dissolved OC (DOC) biodegradation of aquatic systems along a hydrological continuum located in two discontinuous permafrost sites: in western Siberia and northern Sweden. The biodegradable dissolved OC (BDOC15; % DOC lost relative to the initial DOC concentration after 15 days incubation at 20 °C) ranged from 0 to 20% for small water bodies located at the beginning of the continuum (soil solutions, small ponds, fen and lakes) and from 10 to 20% for streams and rivers. While the BDOC15 increased, the removal rate of DOC decreased along the hydrological continuum. The potential maximum CO2 production from DOC biodegradation was estimated to account for only a small part of in-situ CO2 emissions measured in peatland aquatic systems of northern Sweden and western Siberia. This suggests that other sources, such as sediment respiration and soil input, largely contribute to CO2 emissions from small surface waters of permafrost peatlands. Our results highlight the need to account for large heterogeneity of dissolved OC concentration and biodegradability in order to quantify C cycling in arctic water bodies susceptible to permafrost thaw.
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Affiliation(s)
- D Payandi-Rolland
- Geoscience and Environment Toulouse, GET-CNRS-IRD-OMP, University of Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France.
| | - L S Shirokova
- Geoscience and Environment Toulouse, GET-CNRS-IRD-OMP, University of Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France; N. Laverov Federal Center for Integrated Arctic Research of the Ural Branch of the Russian Academy of Sciences, Arkhangelsk, Russia
| | - M Tesfa
- Geoscience and Environment Toulouse, GET-CNRS-IRD-OMP, University of Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France
| | - P Bénézeth
- Geoscience and Environment Toulouse, GET-CNRS-IRD-OMP, University of Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France
| | - A G Lim
- BIO-GEO-CLIM Laboratory, Tomsk State University, 35 Lenina Pr., Tomsk, Russia
| | - D Kuzmina
- BIO-GEO-CLIM Laboratory, Tomsk State University, 35 Lenina Pr., Tomsk, Russia
| | - J Karlsson
- Climate Impacts Research Centre (CIRC), Department of Ecology and Environmental Science, Umeå University, SE-981 07 Abisko, Sweden
| | - R Giesler
- Climate Impacts Research Centre (CIRC), Department of Ecology and Environmental Science, Umeå University, SE-981 07 Abisko, Sweden
| | - O S Pokrovsky
- Geoscience and Environment Toulouse, GET-CNRS-IRD-OMP, University of Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France; N. Laverov Federal Center for Integrated Arctic Research of the Ural Branch of the Russian Academy of Sciences, Arkhangelsk, Russia; BIO-GEO-CLIM Laboratory, Tomsk State University, 35 Lenina Pr., Tomsk, Russia
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Trickey A, Stone J, Semchuk N, Saliuk T, Sazonova Y, Varetska O, Lim AG, Walker JG, Vickerman P. Is contact between men who have sex with men and non-governmental organizations providing harm reduction associated with improved HIV outcomes? HIV Med 2020; 22:262-272. [PMID: 33179855 PMCID: PMC7984049 DOI: 10.1111/hiv.13010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2020] [Indexed: 11/27/2022]
Abstract
Objectives There is a high prevalence of HIV (5.2% in 2018) among men who have sex with men (MSM) in Ukraine. HIV testing, condom provision and facilitated linkage to HIV treatment have been funded by various bodies through non‐governmental organizations (NGOs). We investigated whether contact with these NGOs was associated with improved prevention and treatment outcomes among MSM in Ukraine. Methods Data were taken from four rounds of integrated bio‐behavioural surveys among MSM in Ukraine (2011, N = 5950; 2013, N = 8101; 2015, N = 4550; 2018, N = 5971) including HIV testing combined with questionnaire responses. Data were analysed using mixed‐effect regression models, which estimated associations between being an NGO client and behavioural, HIV testing and HIV treatment outcomes, adjusted for demographic factors. Results Those MSM who were NGO clients were more likely than non‐clients to have been HIV tested in the last year [adjusted odds ratio (aOR) = 7.01, 95% confidence interval (CI): 6.45–7.62] or ever (aOR = 11.00, 95% CI: 9.77–12.38), to have used a condom for the last anal sex act (aOR = 1.32, 95% CI: 1.21–1.43), and to have recently either bought or received condoms (aOR = 21.27, 95% CI: 18.01–25.12). HIV‐positive MSM were more likely to have contact with NGOs (aOR = 1.61, 95% CI: 1.39–1.86). Among the HIV‐positive MSM, those who were NGO clients were more likely to be registered at an AIDS centre (aOR = 2.24, 95% CI: 1.61–3.11) and to be on antiretroviral treatment (aOR = 2.20, 95% CI: 1.51–3.20). Conclusions In Ukraine, being in contact with MSM‐targeted NGOs is associated with better outcomes for HIV prevention, testing and treatment, suggesting that NGO harm reduction projects for MSM have had a beneficial impact on reducing HIV transmission and morbidity.
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Affiliation(s)
- A Trickey
- Population Health Sciences, University of Bristol, Bristol, UK
| | - J Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - N Semchuk
- Alliance for Public Health, Kiev, Ukraine
| | - T Saliuk
- Alliance for Public Health, Kiev, Ukraine
| | - Y Sazonova
- Alliance for Public Health, Kiev, Ukraine
| | - O Varetska
- Alliance for Public Health, Kiev, Ukraine
| | - A G Lim
- Population Health Sciences, University of Bristol, Bristol, UK
| | - J G Walker
- Population Health Sciences, University of Bristol, Bristol, UK
| | - P Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
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Shirokova LS, Payandi-Rolland D, Lim AG, Manasypov RM, Allen J, Rols JL, Bénézeth P, Karlsson J, Pokrovsky OS. Diel cycles of carbon, nutrient and metal in humic lakes of permafrost peatlands. Sci Total Environ 2020; 737:139671. [PMID: 32521361 DOI: 10.1016/j.scitotenv.2020.139671] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 06/11/2023]
Abstract
Despite the importance of surface waters of permafrost landscapes in carbon (C) emission and dissolved C and metal storage and export, the majority of available observations in high latitude aquatic systems deal with punctual or seasonal sampling without accounting for diurnal variations in temperature and primary productivity-respiration cycles. Towards providing comprehensive understanding of diel variations in CO2 emission, organic C and element concentrations in lakes of frozen peatlands, we monitored, each 2 h over 2 days, the water temperature, pH, CO2 fluxes, CO2, CH4, dissolved organic and inorganic carbon (DOC and DIC, respectively), nutrients, carboxylic acids, bacterial number, and major and trace elements in two acidic (pH = 3.6 and 4.0) and humic (DOC = 15 and 35 mg L-1) thermokarst lakes of discontinuous permafrost zone in Western Siberia. We discovered a factor of 2 to 3 higher CO2 concentrations and fluxes during the night compared to daytime in the high-DOC lake. The emission fluxes in the low-DOC lake increased from zero to negative values during the day to highly positive values during the end of night and early morning. The methane concentration varied within a factor of 5 without any link to the diurnal cycle. The bulk of dissolved (< 0.45 μm) hydrochemical parameters remained highly stable with ±10% variation in concentration over 2 days of observation (DOC, DIC, SUVA254nm, carboxylates (formate, oxalate, puryvate and glutarate), Mn, Fe, Al, other trace elements). Concentrations of Si, P, K, Cu varied within ±20% whereas those of Zn and Ni ranged by a factor of 2 to 4 without any link to diurnal pattern. Overall, the impact of diel cycle on CH4, DOC, nutrient and metal concentration was below 10%. However, neglecting night-time period may underestimate net CO2 emission by ca. 30 to 50% in small organic-rich thaw ponds and switch the CO2 exchange from uptake/zero to net emission in larger thermokarst lakes. Given the dominance of large lakes in permafrost regions, the global underestimation of the emission flux may be quite high. As such, monitoring CO2 concentrations and fluxes in thermokarst lakes during months of extended night time (August to October) is mandatory for assessing the net emissions from lentic waters of frozen peatlands.
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Affiliation(s)
- L S Shirokova
- Géosciences Environnement Toulouse, GET - CNRS - IRD - OMP - Université de Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France; Institute of Ecological Problems of the North, Russian Academy of Science, 23, Naberezhnaya Sev. Dviny, Arkhangelsk, Russia
| | - D Payandi-Rolland
- Géosciences Environnement Toulouse, GET - CNRS - IRD - OMP - Université de Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France
| | - A G Lim
- BIO-GEO-CLIM Laboratory, Tomsk State University, 36 Lenina Pr., Tomsk, Russia
| | - R M Manasypov
- BIO-GEO-CLIM Laboratory, Tomsk State University, 36 Lenina Pr., Tomsk, Russia
| | - J Allen
- EcoLab, Université de Toulouse, CNRS, Toulouse, France
| | - J-L Rols
- EcoLab, Université de Toulouse, CNRS, Toulouse, France
| | - P Bénézeth
- Géosciences Environnement Toulouse, GET - CNRS - IRD - OMP - Université de Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France
| | - J Karlsson
- Climate Impacts Research Centre (CIRC), Department of Ecology and Environmental Science, Umeå University, SE-901 87 Umeå, Sweden
| | - O S Pokrovsky
- Géosciences Environnement Toulouse, GET - CNRS - IRD - OMP - Université de Toulouse, 14, Avenue Edouard Belin, 31400 Toulouse, France.
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Morgalev SY, Morgaleva TG, Morgalev YN, Loiko SV, Manasypov RM, Lim AG, Pokrovsky OS. Experimental modeling of the bacterial community translocation during freezing and thawing of peat permafrost soils of Western Siberia. ACTA ACUST UNITED AC 2019. [DOI: 10.1088/1755-1315/400/1/012017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Serikova S, Pokrovsky OS, Laudon H, Krickov IV, Lim AG, Manasypov RM, Karlsson J. High carbon emissions from thermokarst lakes of Western Siberia. Nat Commun 2019; 10:1552. [PMID: 30948722 PMCID: PMC6449335 DOI: 10.1038/s41467-019-09592-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 03/20/2019] [Indexed: 11/09/2022] Open
Abstract
The Western Siberia Lowland (WSL), the world's largest permafrost peatland, is of importance for understanding the high-latitude carbon (C) cycle and its response to climate change. Warming temperatures increase permafrost thaw and production of greenhouse gases. Also, permafrost thaw leads to the formation of lakes which are hotspots for atmospheric C emissions. Although lakes occupy ~6% of WSL, lake C emissions from WSL remain poorly quantified. Here we show high C emissions from lakes across all permafrost zones of WSL. The C emissions were especially high in shoulder seasons and in colder permafrost-rich regions. The total C emission from permafrost-affected lakes of WSL equals ~12 ± 2.6 Tg C yr-1 and is 2-times greater than region's C export to the Arctic coast. The results show that C emission from WSL lakes is a significant component in the high-latitude C cycle, but also suggest that C emission may decrease with warming.
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Affiliation(s)
- S Serikova
- Climate Impacts Research Centre (CIRC), Department of Ecology and Environmental Science, Umeå University, Linnaeus väg 6, 901 87, Umeå, Sweden.
| | - O S Pokrovsky
- GET UMR 5563 CNRS, Geoscience and Environment, University of Toulouse, 14 Avenue Edouard Belin, 31400, Toulouse, France
| | - H Laudon
- Department of Forest Ecology and Management, The Swedish University of Agricultural Sciences, Skogsmarksgränd, 901 83, Umeå, Sweden
| | - I V Krickov
- BIO-GEO-CLIM Laboratory, Tomsk State University, Lenina 36, 634050, Tomsk, Russia
| | - A G Lim
- BIO-GEO-CLIM Laboratory, Tomsk State University, Lenina 36, 634050, Tomsk, Russia
| | - R M Manasypov
- BIO-GEO-CLIM Laboratory, Tomsk State University, Lenina 36, 634050, Tomsk, Russia.,N. Laverov Federal Center for Integrated Arctic Research, IEPS, Russian Academy of Sciences, Nab. Severnoi Dviny 23, Arkhangelsk, 163000, Russia
| | - J Karlsson
- Climate Impacts Research Centre (CIRC), Department of Ecology and Environmental Science, Umeå University, Linnaeus väg 6, 901 87, Umeå, Sweden.
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Lim AG, Chong VH, Salleh SM, Poh SH. AWARENESS, KNOWLEDGE LEVEL, AND MISCONCEPTIONS ABOUT SEXUALLY TRANSMITTED INFECTIONS AMONG SECONDARY SCHOOL STUDENTS IN BRUNEI DARUSSALAM. Southeast Asian J Trop Med Public Health 2017; 48:386-395. [PMID: 29642301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Sexually transmitted infections (STI) remain an important public health issue globally, particularly among the young population. Despite being preventable and curable, STI continue to spread. Lack of access to treatment is an important factor in many developing and underdeveloped nations. Lack of awareness and knowledge is another important factor. This study assessed the awareness, knowledge, and misconceptions among secondary school students on STI. Overall, awareness was poor but better among male students and those in the Pure Science academic streaming. Similarly, the knowledge level of STI was also poor: low level (63.0%), moderate level (34.4%), and high level (2.6%). Male students (p=0.014) and Pure Science academic streaming students (p<0.001) scored better. There were misconceptions, but poor knowledge was predominant. Common sources of information were teachers, health professionals, Internet, parents and TV programs. Based on our study, more needs to be done to improve the awareness and knowledge level of STI, and detailed inclusion into the educational curriculum may be a consideration.
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Kang JY, Firwana B, Green AE, Matthews H, Poullis A, Barnabas A, Tan LT, Lim AG. Uncomplicated diverticular disease is not a common cause of colonic symptoms. Aliment Pharmacol Ther 2011; 33:487-94. [PMID: 21158878 DOI: 10.1111/j.1365-2036.2010.04540.x] [Citation(s) in RCA: 11] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colonic diverticular disease is common among older individuals whereas colonic symptoms, such as those of irritable bowel syndrome, are frequent in the general population. AIM To determine among patients in secondary care, if uncomplicated diverticular disease is a common cause of colonic symptoms. METHODS Patients aged ≥50 years attending gastroenterology out-patient clinics or scheduled for colonoscopy or barium enema in a secondary care hospital were invited to take part. Those with structural gastrointestinal diseases were excluded. Participants completed a locally validated Rome II questionnaire on colonic symptoms. Patients with diverticular disease were compared with those without. RESULTS Seven hundred and eighty four patients with no structural pathology other than diverticular disease or benign colonic polyps completed the study. A total of 744 patients underwent colonoscopy, 40 barium enema. Of these, 281 patients had diverticular disease. Among patients with and without diverticular disease, the frequency of abdominal pain, diarrhoea, constipation and irritable bowel syndrome were 123 (44%) and 226 (46%), 44 (16%) and 80 (17%), 38 (14%) and 80 (17%) and 66 (25%) and 119 (25%), respectively (N.S.). CONCLUSION Uncomplicated colonic diverticular disease is not a common cause of colonic symptoms among patients in secondary care.
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Affiliation(s)
- J Y Kang
- Department of Gastroenterology, St George's Hospital, London, UK.
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Hearle NCM, Rudd MF, Lim W, Murday V, Lim AG, Phillips RK, Lee PW, O'donohue J, Morrison PJ, Norman A, Hodgson SV, Lucassen A, Houlston RS. Exonic STK11 deletions are not a rare cause of Peutz-Jeghers syndrome. J Med Genet 2006; 43:e15. [PMID: 16582077 PMCID: PMC2563227 DOI: 10.1136/jmg.2005.036830] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant cancer predisposition syndrome characterised by oro-facial pigmentation and hamartomatous polyposis of the gastrointestinal tract. A causal germline mutation in STK11 can be identified in 30% to 80% of PJS patients. METHODS Here we report the comprehensive mutational analysis of STK11 in 38 PJS probands applying conventional PCR based mutation detection methods and the recently introduced MLPA (multiplex ligation dependent probe amplification) technique developed for the identification of exonic deletions/duplications. RESULTS Nineteen of 38 probands (50%) had detectable point mutations or small scale deletions/insertions and six probands (16%) had genomic deletions encompassing one or more STK11 exons. CONCLUSIONS These findings demonstrate that exonic STK11 deletions are a common cause of PJS and provide a strong rationale for conducting a primary screen for such mutations in patients.
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Lim W, Hearle N, Shah B, Murday V, Hodgson SV, Lucassen A, Eccles D, Talbot I, Neale K, Lim AG, O'Donohue J, Donaldson A, Macdonald RC, Young ID, Robinson MH, Lee PWR, Stoodley BJ, Tomlinson I, Alderson D, Holbrook AG, Vyas S, Swarbrick ET, Lewis AAM, Phillips RKS, Houlston RS. Further observations on LKB1/STK11 status and cancer risk in Peutz-Jeghers syndrome. Br J Cancer 2003; 89:308-13. [PMID: 12865922 PMCID: PMC2394252 DOI: 10.1038/sj.bjc.6601030] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Germline mutations in the LKB1/STK11 tumour suppressor gene cause Peutz-Jeghers syndrome (PJS), a rare dominant disorder. In addition to typical hamartomatous gastrointestinal polyps and pigmented perioral lesions, PJS is associated with an increased risk of tumours at multiple sites. Follow-up information on carriers is limited and genetic heterogeneity makes counselling and management in PJS difficult. Here we report the analysis of the LKB1/STK11 locus in a series of 33 PJS families, and estimation of cancer risks in carriers and noncarriers. Germline mutations of LKB1/STK11 were identified in 52% of cases. This observation reinforces the hypothesis of a second PJS locus. In carriers of LKB1/STK11 mutations, the risk of cancer was markedly elevated. The risk of developing any cancer in carriers by age 65 years was 47% (95% CI: 27-73%) with elevated risks of both gastrointestinal and breast cancer. PJS with germline mutations in LKB1/STK11 are at a very high relative and absolute risk of multiple gastrointestinal and nongastrointestinal cancers. To obtain precise estimates of risk associated with PJS requires further studies of genotype-phenotype especially with respect to LKB1/STK11 negative cases, as this group is likely to be heterogeneous.
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Affiliation(s)
- W Lim
- Section of Cancer Genetics, Institute of Cancer Research, Sutton, Surrey SM2 5NG, UK.
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Poullis A, Gould SR, Lim AG. It could only happen to a doctor--Haemophilus aphrophilus septicaemia complicated by a prevertebral infection after dental work. Postgrad Med J 2001; 77:261-2. [PMID: 11264493 PMCID: PMC1741965 DOI: 10.1136/pmj.77.906.261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
A 53 year old man presented with severe neck pain and a flu-like illness; he had recently returned from Sri Lanka and had had dental treatment six days before illness onset. Blood culture showed infection by Haemophilus aphrophilus. Magnetic resonance imaging was performed and exploratory surgery undertaken. The prevertebral cervical fascia was inflamed but no abscess identified. He was treated with antibiotics and made an uneventful recovery.
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Affiliation(s)
- A Poullis
- Department of Gastroenterology, Epsom General Hospital, Surrey, UK.
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Abstract
The aetiology of ulcerative colitis is unknown. Two patients without pre-existing inflammatory bowel disease in whom end colostomy for faecal incontinence was complicated by diversion colitis in the defunctioned rectosigmoid colon, are described. In both instances, colitis with the clinical, colonoscopic, and microscopic features of ulcerative colitis developed about a year later in the previously normal in-stream colon proximal to the colostomy. These cases suggest that diversion colitis may be a risk factor for ulcerative colitis in predisposed individuals and that ulcerative colitis can be triggered by anatomically discontinuous inflammation elsewhere in the large intestine.
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Affiliation(s)
- A G Lim
- Department of Gastroenterology, Royal London Hospital, Whitechapel, London, UK
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Abstract
BACKGROUND Elevation of serum IgA is a characteristic feature of alcoholic liver disease. It has been proposed that this occurs partly as an antigenic response to gut-derived proteins or acetaldehyde-modified liver proteins, but the principal antigens responsible remain unknown. AIMS The goal of this study was to determine if serum IgA antibodies were present against human gut luminal antigens or liver antigens in alcoholic liver disease. PATIENTS AND METHODS Twenty-nine patients with alcoholic liver disease, 10 with primary biliary cirrhosis, 12 with "other" liver diseases, 8 alcoholics, and 20 healthy subjects were studied. Western blotting was used to examine the reactivity of sera from these groups against human small and large bowel aspirates and liver tissue from alcoholic liver disease patients. RESULTS Serum IgA antibodies to a 140 kDa colonic luminal protein were found in 22 (76%) patients in the alcoholic liver disease group (p < 0.0001), and 7 (24%) patients had serum IgA antibodies to a 40 kDa colonic luminal protein (p = 0.04). These responses were confined to colonic aspirates and not observed in other disease groups, alcoholics or healthy subjects. There was no significant serum IgA response to human liver proteins in alcoholic liver disease. CONCLUSIONS Serum IgA antibodies to a human 140 kDa colonic luminal protein are frequently found in alcoholic liver disease. This novel antigen may contribute to the increased levels of circulating IgA in alcoholic liver disease.
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Affiliation(s)
- A C Douds
- Liver Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
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Abstract
BACKGROUND H2-receptor antagonists and proton pump inhibitors account for approximately 15% of primary care prescribing costs in the UK. AIM To examine the use of antisecretory drugs in primary care between October 1991 and September 1996. METHOD Analysis of prescribing data from an ongoing postal survey performed every 3 months on a rolling quota of 250 UK general practitioners (GPs), identified from a representative sampling frame of 1000 GPs. RESULTS There were 8811 new courses of proton pump inhibitors and 11,948 new courses of H2-receptor antagonists during this study. The number of new prescriptions for proton pump inhibitors increased by 174.5%, but decreased for H2-receptor antagonists by 12.5%. Proton pump inhibitors were mostly prescribed for reflux disease (52.7%) and H2-receptor antagonists for non-specific dyspepsia (43.6%). Proton pump inhibitors (14.1%) were less likely to be stopped than H2-receptor antagonists (35.3%) overall, and they were less likely to be stopped because of perceived ineffectiveness (5.3%) than H2-receptor antagonists (23.8%). The rate of stopping treatment because of side-effects was about 3% for both classes of drug. CONCLUSIONS Prescribing of proton pump inhibitors has increased sharply each year since 1991. One reason may be that GPs perceive proton pump inhibitors to be more effective than H2-receptor antagonists.
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Affiliation(s)
- R M Martin
- Division of General Practice and Primary Care, St George's Hospital Medical School, London, UK
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Affiliation(s)
- L R Ranganath
- Department of Chemical Pathology, Epsom General Hospital, Surrey, UK
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Abstract
AIM To evaluate the efficacy of a 7-day regimen of clarithromycin 250 mg b.d., amoxycillin 1 g b.d., and lansoprazole 30 mg b.d. as a treatment for Helicobacter pylori infection. METHODS H. pylori status of dyspeptic patients was assessed by 13C-urea breath test and at endoscopy by histology, culture and rapid urease testing of gastric biopsies. Fifty-one H. pylori-positive patients were treated with the above regimen. H. pylori status was reassessed by 13C-urea breath test not less than 28 days after completing treatment. Adverse events and compliance were evaluated. RESULTS On an intention-to-treat basis. H. pylori infection was cured in 77% (95% CI: 65-88%) of patients. Minor side-effects including diarrhoea, nausea and taste disturbance were reported by 64% of patients. Ninety-five per cent of patients consumed > 95% of tablets. Metronidazole resistance was 29% but all cultures were sensitive to amoxycillin and clarithromycin. CONCLUSION This 7-day treatment with low-dose clarithromycin was moderately effective in curing H. pylori infection. Although compliance was excellent, there was a high frequency of minor adverse events.
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Affiliation(s)
- A G Lim
- Department of Gastroenterology, Epsonn Healthcare NHS Trust, Surrey, UK
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Lim AG, Martin RM, Montileone M, Walker AC, Gould SR. Helicobacter pylori serology and the management of young dyspeptics: a UK survey of gastroenterologists and general practitioners with an interest in gastroenterology. Aliment Pharmacol Ther 1997; 11:299-303. [PMID: 9146766 DOI: 10.1046/j.1365-2036.1997.137313000.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
AIM To survey the current use of Helicobacter pylori serology for pre-endoscopy screening and management of young dyspeptics amongst gastroenterologists and general practitioners with an interest in gastroenterology in the United Kingdom. METHODS A postal questionnaire was sent to 536 members of the British Society of Gastroenterology and 164 members of the Primary Care Society in Gastroenterology. RESULTS Of those who responded (66%), 25% of general practitioners and 17% of gastroenterologists were using H. pylori serology as a screening test for young dyspeptics. General practitioners and gastroenterologists differed in their use of serology to guide management strategies (P < 0.0003): general practitioners eradicate infection from sero-positive patients prior to endoscopy (92%), whilst the majority of gastroenterologists endoscope sero-positive patients before treatment (55%). More gastroenterologists (89%) would re-test all or selected patients to assess eradication compared to general practitioners (45%). 106 different drug regimes were being used as first line treatment. CONCLUSIONS H. pylori serology as a pre-endoscopy screening test for young dyspeptic patients was used by only a fifth of respondents. There were wide variations in attitudes and practice in the way H. pylori serology was used in the management of young dyspeptics. Trials comparing clinical outcome and cost-effectiveness of different serology-based strategies are needed.
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Affiliation(s)
- A G Lim
- Department of Gastroenterology, Epsom General Hospital, Surrey, UK
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Douds AC, Lim AG, Jazrawi RP, Finlayson C, Maxwell JD. Serum intercellular adhesion molecule-1 in alcoholic liver disease and its relationship with histological disease severity. J Hepatol 1997; 26:280-6. [PMID: 9059947 DOI: 10.1016/s0168-8278(97)80042-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Infiltration of the liver by leukocytes is a histological feature of alcoholic liver disease. Intercellular adhesion molecule-1 (ICAM-1) mediates the migration of lymphocytes from the circulation to target sites of inflammation. It has been demonstrated in the liver of alcoholic liver disease subjects and as a circulating soluble form (sICAM-1). The origin of sICAM-1 and its relationship to disease severity is unknown, although it has been postulated that it may arise from activated T lymphocytes and is an inflammatory marker. AIMS The aim of the study was to determine the relationship of sICAM-1 to clinical and histological severity of alcoholic liver disease and to serum T-cell (soluble interleukin-2 receptor (sIL-2R), beta 2-microglobulin) and monocyte (neopterin) immune activation markers. METHODS Serum from 48 outpatients with biopsy proven alcoholic liver disease (steatosis = 9, cirrhosis = 28, hepatitis +/- cirrhosis = 11), 31 with primary biliary cirrhosis and 27 normals was assayed for sICAM-1, sIL-2R, beta 2-microglobulin, and neopterin. RESULTS sICAM-1 was significantly elevated, p = 0.0001, in alcoholic liver disease and primary biliary cirrhosis patients compared to normals. Circulating sIL-2R (p = 0.0001) and beta 2-microgloblin (p = 0.0034) were significantly elevated in alcoholic liver disease compared to controls. There was a highly significant correlation between levels of sICAM-1 and histological grade of disease, Rs = 0.80 (p = 0.0001), but no significant correlation with clinical correlates of disease severity or circulating immune activation markers. CONCLUSIONS sICAM-1 is elevated in alcoholic liver disease, is a marker of histological severity of disease and does not appear to originate from activated T lymphocytes. Measurements of sICAM-1 may be useful in assessing histological severity of alcoholic liver disease.
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Affiliation(s)
- A C Douds
- Department of Medicine, St. George's Hospital Medical School, London, United Kingdom
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Lim AG, Wolfhagen FH, Verma A, van Buuren HR, Jazrawi RP, Levy JH, Northfield TC, Schalm SW. Soluble intercellular adhesion molecule-1 in primary biliary cirrhosis: effect of ursodeoxycholic acid and immunosuppressive therapy. Eur J Gastroenterol Hepatol 1997; 9:155-61. [PMID: 9058626 DOI: 10.1097/00042737-199702000-00009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Soluble intercellular adhesion molecule-1 (sICAM-1) is thought to be released by a variety of cells at sites of inflammation, and their serum levels have been used as markers of inflammatory and immune activity. Our aim was to determine the effect of therapy with ursodeoxycholic acid alone and in combination with azathioprine and prednisone on serum sICAM-1 levels in primary biliary cirrhosis. DESIGN/METHODS Twenty-four patients with primary biliary cirrhosis and 17 healthy subjects were studied. Primary biliary cirrhosis patients received ursodeoxycholic acid for 12 months and were then randomized in a double-blind fashion to receive prednisone and azathioprine, or placebo in addition to ursodeoxycholic acid. RESULTS sICAM-1 levels were significantly higher in primary biliary cirrhosis patients than healthy subjects and fell by a median of 20% after 12 months' therapy with ursodeoxycholic acid (P<0.0004). Addition of azathioprine and prednisone to ursodeoxycholic acid resulted in a further reduction of sICAM-1 levels by a median of 25% (P< 0.01). Reductions in sICAM-1 were accompanied by improvement in liver function tests but not in the lymphocyte activation marker, soluble interleukin-2 receptor. CONCLUSION sICAM-1 levels in primary biliary cirrhosis are reduced by ursodeoxycholic acid. Further reductions were achieved by adding prednisone and azathioprine. These reductions probably reflect an improvement in hepatobiliary excretion and a reduction in cellular production of sICAM-1.
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Affiliation(s)
- A G Lim
- Division of Biochemical Medicine, St George's Hospital Medical School, London, UK
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Lim AG, Hine KR. Pyrexia and breathlessness in a patient with a cardiac pacemaker. Postgrad Med J 1996; 72:571-3. [PMID: 8949601 PMCID: PMC2398564 DOI: 10.1136/pgmj.72.851.571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- A G Lim
- Department of Medicine, St. George's Hospital, London, UK
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Lim AG, Jazrawi RP. Treatment of gall stones. Non-surgical treatments should not be dismissed. BMJ 1995; 311:1091-2. [PMID: 7580685 PMCID: PMC2551393 DOI: 10.1136/bmj.311.7012.1091d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Affiliation(s)
- A G Lim
- Division of Biochemical Medicine, St George's Hospital Medical School, London
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Lim AG, Jazrawi RP, Levy JH, Petroni ML, Douds AC, Maxwell JD, Northfield TC. Soluble E-selectin and vascular cell adhesion molecule-1 (VCAM-1) in primary biliary cirrhosis. J Hepatol 1995; 22:416-22. [PMID: 7545197 DOI: 10.1016/0168-8278(95)80104-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND/AIMS E-selectin and vascular cell adhesion molecule-1, important in leucocyte adhesion, have recently been detected in soluble form in the circulation. However, their clinical significance remains unclear. Our aims were to determine whether the levels of these molecules are increased in primary biliary cirrhosis, and to relate these to histological disease stage, biochemical measures of liver damage and to lymphocyte activation. METHODS We studied 42 patients with primary biliary cirrhosis, nine with primary sclerosing cholangitis, 14 with alcoholic liver disease and 17 healthy subjects. Circulating E-selectin and vascular cell adhesion molecule-1 levels were measured by enzyme-linked immunosorbent assay. In subgroups of patients with primary biliary cirrhosis, hepatic bile acid uptake and excretory rates and T-cell activation were also determined. RESULTS Soluble E-selectin and vascular cell adhesion molecule-1 levels were significantly elevated in primary biliary cirrhosis compared to healthy controls. However, there was no difference between primary biliary cirrhosis and other liver disease groups. In primary biliary cirrhosis, both adhesion molecules correlated with disease stage, but differed in their relationships with specific liver function tests. They did not correlate with either hepatic bile acid uptake or excretion, or lymphocyte activation. CONCLUSIONS We conclude that soluble E-selectin and vascular cell adhesion molecule-1 are elevated in chronic liver diseases. In primary biliary cirrhosis, they reflect the stage of disease and may reflect the degree of leucocyte adhesion and migration.
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Affiliation(s)
- A G Lim
- Department of Medicine, St. George's Hospital Medical School, London, United Kingdom
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Lim AG, Jazrawi RP, Ahmed HA, Levy JH, Zuin M, Douds AC, Maxwell JD, Northfield TC. Soluble intercellular adhesion molecule-1 in primary biliary cirrhosis: relationship with disease stage, immune activity and cholestasis. Hepatology 1994; 20:882-8. [PMID: 7927229 DOI: 10.1002/hep.1840200416] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Intercellular adhesion molecule-1, strongly expressed on the interlobular and proliferating bile ducts in primary biliary cirrhosis, is important in the migration and adhesion of inflammatory cells from the circulation to these structures. A soluble form has been found to be elevated in serum in primary biliary cirrhosis. Our aim was to check on the role of soluble intercellular adhesion molecule-1 in primary biliary cirrhosis with particular reference to its specificity by comparison with other disease control groups and to assess its relationship with stage of disease activity, circulating lymphocyte activation and cholestasis. Soluble intercellular adhesion molecule-1 (enzyme-linked immunosorbent assay) and liver biochemistry were measured in 41 patients with primary biliary cirrhosis, 9 with primary sclerosing cholangitis, 12 with alcoholic liver disease and 17 healthy controls. In subgroups of patients with primary biliary cirrhosis, lymphocyte activation and hepatic bile acid uptake and excretory rates were determined. Soluble intercellular adhesion molecule-1 was significantly higher in all three disease groups. Levels in primary biliary cirrhosis and primary sclerosing cholangitis were similar and significantly higher than alcoholic liver disease. Soluble intercellular adhesion molecule-1 expression was greater in late primary biliary cirrhosis than early disease and correlated with histological progression. Correlations were also found with alkaline phosphatase, gamma-glutamyl transpeptidase and conjugated bilirubin. A trend toward an inverse correlation with hepatic excretory rate was found, but no correlation was detected with circulating lymphocyte interleukin-2 receptor expression.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- A G Lim
- Department of Medicine, St. George's Hospital Medical School, London, United Kingdom
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Lim AG. Evaluation of new treatment for primary biliary cirrhosis. Lancet 1994; 344:61. [PMID: 7912329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Affiliation(s)
- A G Lim
- Princess Royal Hospital, Haywards Heath, West Sussex
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Khoo KS, Ang PT, Lim AG. Common toxicities of cancer chemotherapy. Singapore Med J 1993; 34:418-20. [PMID: 8153689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Sixty cancer patients who were receiving chemotherapy at an outpatient Oncology Centre were surveyed for their views on a list of treatment-related toxicities. The severity of each toxicity was assessed using a visual analogue scale. Sixty percent of patients felt that the overall toxicity was acceptable. Ten percent felt like giving up. Problem with venous access was named the worst toxicity by 37% of patients, followed by nausea and vomiting (19%), and long waiting time (11%). Male patients tended to tolerate chemotherapy better. The female patients were significantly more affected by hair loss than their male counterpart. Better understanding of the toxicities of chemotherapy as perceived by the patients themselves allows them to take appropriate measures in improving their quality of life.
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Affiliation(s)
- K S Khoo
- Department of Medical Oncology, Singapore General Hospital
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