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van der Velden AW, Shanyinde M, Bongard E, Böhmer F, Chlabicz S, Colliers A, García-Sangenís A, Malania L, Pauer J, Tomacinschii A, Yu LM, Loens K, Ieven M, Verheij TJ, Goossens H, Vellinga A, Butler CC. Clinical diagnosis of SARS-CoV-2 infection: An observational study of respiratory tract infection in primary care in the early phase of the pandemic. Eur J Gen Pract 2023; 29:2270707. [PMID: 37870070 PMCID: PMC10990254 DOI: 10.1080/13814788.2023.2270707] [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: 12/22/2022] [Accepted: 10/04/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Early in the COVID-19 pandemic, GPs had to distinguish SARS-CoV-2 from other aetiologies in patients presenting with respiratory tract infection (RTI) symptoms on clinical grounds and adapt management accordingly. OBJECTIVES To test the diagnostic accuracy of GPs' clinical diagnosis of a SARS-CoV-2 infection in a period when COVID-19 was a new disease. To describe GPs' management of patients presenting with RTI for whom no confirmed diagnosis was available. To investigate associations between patient and clinical features with a SARS-CoV-2 infection. METHODS In April 2020-March 2021, 876 patients (9 countries) were recruited when they contacted their GP with symptoms of an RTI of unknown aetiology. A swab was taken at baseline for later analysis. Aetiology (PCR), diagnostic accuracy of GPs' clinical SARS-CoV-2 diagnosis, and patient management were explored. Factors related to SARS-CoV-2 infection were determined by logistic regression modelling. RESULTS GPs suspected SARS-CoV-2 in 53% of patients whereas 27% of patients tested positive for SARS-CoV-2. True-positive patients (23%) were more intensively managed for follow-up, antiviral prescribing and advice than true-negatives (42%). False negatives (5%) were under-advised, particularly for social distancing and isolation. Older age (OR: 1.02 (1.01-1.03)), male sex (OR: 1.68 (1.16-2.41)), loss of taste/smell (OR: 5.8 (3.7-9)), fever (OR: 1.9 (1.3-2.8)), muscle aches (OR: 2.1 (1.5-3)), and a known risk factor for COVID-19 (travel, health care worker, contact with proven case; OR: 2.7 (1.8-4)) were predictive of SARS-CoV-2 infection. Absence of loss of taste/smell, fever, muscle aches and a known risk factor for COVID-19 correctly excluded SARS-CoV-2 in 92.3% of patients, whereas presence of 3, or 4 of these variables correctly classified SARS-CoV-2 in 57.7% and 87.1%. CONCLUSION Correct clinical diagnosis of SARS-CoV-2 infection, without POC-testing available, appeared to be complicated.
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Affiliation(s)
- Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Annelies Colliers
- Department of Family Medicine & Population Health, University of Antwerp, Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d‘Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, Tbilisi, Georgia
| | | | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance of State University of Medicine and Pharmacy “N. Testemițanu”, Chişinǎu, The Republic of Moldova
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Katherine Loens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Theo J. Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin (UCD), Dublin, Ireland
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Cook J, Cook JA, Bongard E, Heneghan C, Butler CC. Conditional versus non-conditional incentives to maximise return of participant completed questionnaires in clinical trials: a cluster randomised study within a trial. Trials 2023; 24:710. [PMID: 37936228 PMCID: PMC10629007 DOI: 10.1186/s13063-023-07604-6] [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: 12/14/2020] [Accepted: 08/26/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND High participant retention enhances the validity of clinical trials. A monetary incentive can increase retention, but it is not known if when it is provided and if it is conditional matters. We aimed to determine whether there was a difference in the number of follow-up trial questionnaires returned when a monetary (gift voucher) incentive was given to participants at recruitment (non-conditional), compared to informing participants at recruitment that the incentive would be given only once their 14-day daily diary (questionnaire) had been returned (conditional). METHOD A cluster randomised study within a trial embedded within the Antivirals for influenza-Like Illness, An rCt of Clinical and Cost effectiveness in primary CarE (ALIC4E) Trial. Matched site pairs (GP practices) were randomised using computer-generated random numbers, to either a non-conditional or conditional monetary voucher incentive (only once their 14-day daily diary (questionnaire) had been returned. Sites were matched on previous recruitment levels and practice list size. Analyses were conducted according to randomised groups irrespective of compliance with a two-sided 5% level statistical significance level. The main analysis of the primary outcome (site proportion of diaries returned) was linear regression accounting for site pair (using cluster-robust variance). Additional weighted, paired and non-parametric sensitivity analyses were conducted. Secondary outcomes were the site average number of completed pages, time to return diary, and cost related to the incentive (administration and postage). RESULTS Of the 42 randomised sites (21 for each intervention), only 28 recruited at least one participant with only 10 practice pairs recruiting participants at both constituent sites. Raw diaries return proportions were 0.58 (127/220) and 0.73 (91/125) for non-conditional and conditional incentive groups. Regression analysis adjusted for site pair showed no significant difference in returns, - 0.09, (95% CI, - 0.29, 0.10, p = 0.34); when weighted, there was still no clear difference: 0.15 (95% CI, - 0.02, 0.31, p = 0.07). There was no clear statistical evidence of a difference in time taken to return questionnaires, nor the proportion of pages completed, by the intervention group in the main analyses (all p > 0.05). The conditional incentive was approximately £23 cheaper per diary returned based upon observed data. CONCLUSION There was no clear evidence of a statistically significant difference in the proportion of participant-completed diaries returned between conditional or non-conditional incentive groups. The time to questionnaire return and completeness of the returned questionnaires were similar in both groups. There was substantial statistical uncertainty in the findings. Some of the sensitivity analyses suggested that a meaningful benefit of a conditional incentive of a magnitude that would be meaningful was plausible. The conditional approach costs less in cash terms.
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Affiliation(s)
- Johanna Cook
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Jonathan A Cook
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Carl Heneghan
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Chris C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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Armitage KF, Porter CE, Ahmed S, Cook J, Boards J, Bongard E, Butler CC, Corfield K, Davoudianfar M, Galal U, Howard P, Mujica-Mota R, Saman R, Santillo M, Savic S, Shinkins B, Tonkin-Crine S, Wanat M, West RM, Yu LM, Pavitt S, Sandoe JAT. Penicillin allergy status and its effect on antibiotic prescribing, patient outcomes and antimicrobial resistance (ALABAMA): protocol for a multicentre, parallel-arm, open-label, randomised pragmatic trial. BMJ Open 2023; 13:e072253. [PMID: 37666558 PMCID: PMC10481831 DOI: 10.1136/bmjopen-2023-072253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/07/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Incorrect penicillin allergy records are recognised as an important barrier to the safe treatment of infection and affect an estimated 2.7 million people in England. Penicillin allergy records are associated with worse health outcome and antimicrobial resistance. The ALlergy AntiBiotics And Microbial resistAnce (ALABAMA) trial aims to determine if an intervention package, centred around a penicillin allergy assessment pathway (PAAP) initiated in primary care, is safe and effective in improving patient health outcomes and antibiotic prescribing. METHODS AND ANALYSIS The ALABAMA trial is a multicentre, parallel-arm, open-label, randomised pragmatic trial with a nested pilot study. Adults (≥18 years) with a penicillin allergy record and who have received antibiotics in the previous 24 months will be eligible for participation. Between 1592 and 2090 participants will be recruited from participating National Health Service general practices in England. Participants will be randomised to either usual care or intervention to undergo a pre-emptive PAAP using a 1:1 allocation ratio. The primary outcome measure is the percentage of treatment response failures within 28 days of an index prescription. 2090 and 1592 participants are estimated to provide 90% and 80% power, respectively, to detect a clinically important absolute difference of 7.9% in primary outcome at 1 year between groups. The trial includes a mixed-methods process evaluation and cost-effectiveness evaluation. ETHICS AND DISSEMINATION This trial has been approved by London Bridge Research Ethics Committee (ref: 19/LO/0176). It will be conducted in compliance with Good Clinical Practice guidelines according to the Declaration of Helsinki. Informed consent will be obtained from all subjects involved in the study. The primary trial results will be submitted for publication to an international, peer-reviewed journal. TRIAL REGISTRATION ISRCTN20579216.
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Affiliation(s)
- Kelsey Fiona Armitage
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Catherine E Porter
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, West Yorkshire, UK
| | - Shadia Ahmed
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Jenny Boards
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Kate Corfield
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, UK
- NHS England, Leeds, UK
| | - Ruben Mujica-Mota
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Razan Saman
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sinisa Savic
- Clinical Immunology and Allergy, University of Leeds Leeds Institute of Medical Research at St James's, Leeds, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, West Yorkshire, UK
| | - Jonathan A T Sandoe
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
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Vellinga A, Luke-Currier A, Garzón-Orjuela N, Aabenhus R, Anastasaki M, Balan A, Böhmer F, Lang VB, Chlabicz S, Coenen S, García-Sangenís A, Kowalczyk A, Malania L, Tomacinschii A, van der Linde SR, Bongard E, Butler CC, Goossens H, van der Velden AW. Disease-Specific Quality Indicators for Outpatient Antibiotic Prescribing for Respiratory Infections (ESAC Quality Indicators) Applied to Point Prevalence Audit Surveys in General Practices in 13 European Countries. Antibiotics (Basel) 2023; 12:antibiotics12030572. [PMID: 36978439 PMCID: PMC10044809 DOI: 10.3390/antibiotics12030572] [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: 01/27/2023] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
Up to 80% of antibiotics are prescribed in the community. An assessment of prescribing by indication will help to identify areas where improvement can be made. A point prevalence audit study (PPAS) of consecutive respiratory tract infection (RTI) consultations in general practices in 13 European countries was conducted in January–February 2020 (PPAS-1) and again in 2022 (PPAS-4). The European Surveillance of Antibiotic Consumption quality indicators (ESAC-QI) were calculated to identify where improvements can be made. A total of 3618 consultations were recorded for PPAS-1 and 2655 in PPAS-4. Bacterial aetiology was suspected in 26% (PPAS-1) and 12% (PPAS-4), and an antibiotic was prescribed in 30% (PPAS-1) and 16% (PPAS-4) of consultations. The percentage of adult patients with bronchitis who receive an antibiotic should, according to the ESAC-QI, not exceed 30%, which was not met by participating practices in any country except Denmark and Spain. For patients (≥1) with acute upper RTI, less than 20% should be prescribed an antibiotic, which was achieved by general practices in most countries, except Ireland (both PPAS), Croatia (PPAS-1), and Greece (PPAS-4) where prescribing for acute or chronic sinusitis (0–20%) was also exceeded. For pneumonia in adults, prescribing is acceptable for 90–100%, and this is lower in most countries. Prescribing for tonsillitis (≥1) exceeded the ESAC-QI (0–20%) in all countries and was 69% (PPAS-1) and 75% (PPAS-4). In conclusion, ESAC-QI applied to PPAS outcomes allows us to evaluate appropriate antibiotic prescribing by indication and benchmark general practices and countries.
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Affiliation(s)
- Akke Vellinga
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
- Correspondence:
| | - Addiena Luke-Currier
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Nathaly Garzón-Orjuela
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Rune Aabenhus
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, DK-2200 Copenhagen, Denmark
| | - Marilena Anastasaki
- Department of Social Medicine, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - Anca Balan
- Balan Medfam Srl, 400064 Cluj Napoca, Romania
| | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, 18057 Rostock, Germany
| | - Valerija Bralić Lang
- Department of Family Medicine, “Andrija Stampar” School of Public Health, School of Medicine, University of Zagreb, 10020 Zagreb, Croatia
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, 15-089 Bialystok, Poland
| | - Samuel Coenen
- Department of Family Medicine & Population Health, University of Antwerp, 2610 Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Ana García-Sangenís
- Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), 08007 Barcelona, Spain
- Centro de investigación Biomédica en Red Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - Anna Kowalczyk
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, 92-213 Lodz, Poland
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi and Arner Science Management LLC, 0190 Tbilisi, Georgia
| | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine and Pharmacy “Nicolae Testemițanu”, MD-2004 Chişinǎu, Moldova
| | - Sanne R. van der Linde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford OX1 4BH, UK
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, 2610 Antwerp, Belgium
| | - Alike W. van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands
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5
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Li X, Bilcke J, van der Velden AW, Bruyndonckx R, Coenen S, Bongard E, de Paor M, Chlabicz S, Godycki-Cwirko M, Francis N, Aabenhus R, Bucher HC, Colliers A, De Sutter A, Garcia-Sangenis A, Glinz D, Harbin NJ, Kosiek K, Lindbæk M, Lionis C, Llor C, Mikó-Pauer R, Radzeviciene Jurgute R, Seifert B, Sundvall PD, Touboul Lundgren P, Tsakountakis N, Verheij TJ, Goossens H, Butler CC, Beutels P. Cost-effectiveness of adding oseltamivir to primary care for influenza-like-illness: economic evaluation alongside the randomised controlled ALIC 4E trial in 15 European countries. Eur J Health Econ 2022:10.1007/s10198-022-01521-2. [PMID: 36131214 DOI: 10.1007/s10198-022-01521-2] [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: 09/24/2021] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Oseltamivir is usually not often prescribed (or reimbursed) for non-high-risk patients consulting for influenza-like-illness (ILI) in primary care in Europe. We aimed to evaluate the cost-effectiveness of adding oseltamivir to usual primary care in adults/adolescents (13 years +) and children with ILI during seasonal influenza epidemics, using data collected in an open-label, multi-season, randomised controlled trial of oseltamivir in 15 European countries. METHODS Direct and indirect cost estimates were based on patient reported resource use and official country-specific unit costs. Health-Related Quality of Life was assessed by EQ-5D questionnaires. Costs and quality adjusted life-years (QALY) were bootstrapped (N = 10,000) to estimate incremental cost-effectiveness ratios (ICER), from both the healthcare payers' and the societal perspectives, with uncertainty expressed through probabilistic sensitivity analysis and expected value for perfect information (EVPI) analysis. Additionally, scenario (self-reported spending), comorbidities subgroup and country-specific analyses were performed. RESULTS The healthcare payers' expected ICERs of oseltamivir were €22,459 per QALY gained in adults/adolescents and €13,001 in children. From the societal perspective, oseltamivir was cost-saving in adults/adolescents, but the ICER is €8,344 in children. Large uncertainties were observed in subgroups with comorbidities, especially for children. The expected ICERs and extent of decision uncertainty varied between countries (EVPI ranged €1-€35 per patient). CONCLUSION Adding oseltamivir to primary usual care in Europe is likely to be cost-effective for treating adults/adolescents and children with ILI from the healthcare payers' perspective (if willingness-to-pay per QALY gained > €22,459) and cost-saving in adults/adolescents from a societal perspective.
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Affiliation(s)
- Xiao Li
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium.
| | - Joke Bilcke
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Robin Bruyndonckx
- Interuniversity Institute for Biostatistics and Statistical Bioinformatics (I-BIOSTAT), Data Science Institute (DSI), Hasselt University, Hasselt, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Samuel Coenen
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Muirrean de Paor
- RCSI Department of General Practice, 123 St Stephens Green, Dublin 2, Ireland
| | - Slawomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Białystok, Poland
| | | | - Nick Francis
- School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Heiner C Bucher
- Division of Infectious Diseases and Hospital Hygiene, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Annelies Colliers
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - An De Sutter
- Department of Public Health and Primary Care (Centre for Family Medicine), Gent University, Gent, Belgium
| | - Ana Garcia-Sangenis
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Dominik Glinz
- Department of Clinical Research, Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Nicolay J Harbin
- Department of General Practice, Antibiotic Center for Primary Care, Institute of Health and Society, University of Oslo, Oslo, Norway
| | | | - Morten Lindbæk
- Research Leader Antibiotic Centre for Primary Care, Department of General Practice, University of Oslo, Oslo, Norway
| | - Christos Lionis
- General Practice and Primary Health Care at the School of Medicine, University of Crete, Crete, Greece
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
- Research Unit for General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | | | - Bohumil Seifert
- Institute of General Practice, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
| | - Pär-Daniel Sundvall
- General Practice/Family Medicine, School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Research, Education, Development and Innovation, Primary Health Care, Region Västra Götaland, Sandared, Sweden
| | | | | | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - Herman Goossens
- Department of Family Medicine and Population Health (FAMPOP), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Campus Drie Eiken, room D.S.221, Universiteitsplein 1, 2610, Antwerp, Belgium
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6
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Wanat M, Santillo M, Galal U, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Mixed-methods evaluation of a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice. BMJ Open 2022; 12:e057471. [PMID: 36691248 PMCID: PMC9171226 DOI: 10.1136/bmjopen-2021-057471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES About 6% of the UK general practice population has a record of a penicillin allergy but fewer than 10% of these are likely to be truly allergic. In the ALABAMA (Allergy Antibiotics and Microbial resistance) feasibility trial, primary care patients with penicillin allergy were randomised to penicillin allergy assessment pathway or usual care to assess the effect on health outcomes. A behavioural intervention package was developed to aid delabelling. This study aimed to investigate patients' and clinicians' views of penicillin allergy testing (PAT). DESIGN We conducted a mixed-methods process evaluation embedded within the ALABAMA trial, which included a clinician survey, a patient survey (at baseline and follow-up) and semistructured interviews with patients and clinicians. SETTINGS The study was conducted in primary care, as part of the feasibility stage of the ALABAMA trial. PARTICIPANTS Patients and primary care clinicians. RESULTS Clinicians (N=53; 52.2%) were positive about PAT and its potential value but did not have previous experience of referring patients for a PAT and were unsure whether patients would take penicillin after a negative allergy test. Patients (N=36; 46%) were unsure whether they were severely allergic to penicillin and did not fear a severe allergic reaction to penicillin. Clinician interviews showed that they were already aware of the benefit of PAT. Interviews with patients suggested the importance of safety as patients valued having numerous opportunities to address their concerns about safety of the test. CONCLUSIONS This study highlights the positive effects of the ALABAMA behavioural intervention for both patients and clinicians. TRIAL REGISTRATION NUMBER NCT04108637; ISRCTN20579216; Pre-results.
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Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Louise Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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7
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Ouchi D, García-Sangenís A, Moragas A, van der Velden AW, Verheij TJ, Butler CC, Bongard E, Coenen S, Cook J, Francis NA, Godycki-Cwirko M, Lundgren PT, Lionis C, Radzeviciene Jurgute R, Chlabicz S, De Sutter A, Bucher HC, Seifert B, Kovács B, de Paor M, Sundvall PD, Aabenhus R, Harbin NJ, Ieven G, Goossens H, Lindbæk M, Bjerrum L, Llor C. Clinical prediction of laboratory-confirmed influenza in adults with influenza-like illness in primary care. A randomized controlled trial secondary analysis in 15 European countries. Fam Pract 2022; 39:398-405. [PMID: 34611715 DOI: 10.1093/fampra/cmab122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Clinical findings do not accurately predict laboratory diagnosis of influenza. Early identification of influenza is considered useful for proper management decisions in primary care. OBJECTIVE We evaluated the diagnostic value of the presence and the severity of symptoms for the diagnosis of laboratory-confirmed influenza infection among adults presenting with influenza-like illness (ILI) in primary care. METHODS Secondary analysis of patients with ILI who participated in a clinical trial from 2015 to 2018 in 15 European countries. Patients rated signs and symptoms as absent, minor, moderate, or major problem. A nasopharyngeal swab was taken for microbiological identification of influenza and other microorganisms. Models were generated considering (i) the presence of individual symptoms and (ii) the severity rating of symptoms. RESULTS A total of 2,639 patients aged 18 or older were included in the analysis. The mean age was 41.8 ± 14.7 years, and 1,099 were men (42.1%). Influenza was microbiologically confirmed in 1,337 patients (51.1%). The area under the curve (AUC) of the model for the presence of any of seven symptoms for detecting influenza was 0.66 (95% confidence interval [CI]: 0.65-0.68), whereas the AUC of the symptom severity model, which included eight variables-cough, fever, muscle aches, sweating and/or chills, moderate to severe overall disease, age, abdominal pain, and sore throat-was 0.70 (95% CI: 0.69-0.72). CONCLUSION Clinical prediction of microbiologically confirmed influenza in adults with ILI is slightly more accurate when based on patient reported symptom severity than when based on the presence or absence of symptoms.
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Affiliation(s)
- Dan Ouchi
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), Spain
| | - Ana García-Sangenís
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Ana Moragas
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Christopher C Butler
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Emily Bongard
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Samuel Coenen
- Centre for General Practice, Department of Family Medicine & Population Health, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Nuffield Department of Primary Health Care Sciences, University of Oxford, Oxford, United Kingdom
| | - Nick A Francis
- Primary Care Research Centre, University of Southampton, Southampton,United Kingdom
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | | | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - An De Sutter
- Centre for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Muireann de Paor
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - Pär-Daniel Sundvall
- Research, Education, Development & Innovation Primary Health Care, Region Västra Götaland and Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Greet Ieven
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Clinical Microbiology, Antwerp, University Hospital, Edegem, Belgium
| | - Morten Lindbæk
- Antibiotic Centre for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol i Gurina, Barcelona, Spain.,Department of Public Health, General Practice, University of Southern Denmark, Odense, Denmark
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8
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Matheeussen V, Loens K, Kuijstermans M, Jacobs K, Coenen S, van der Velden AW, Bongard E, Butler CC, Verheij TJ, Goossens H, Ieven M. Diagnostic performance of the Idylla™ respiratory panel for molecular detection of influenza A/B in patients presenting to primary care with influenza-like illness during 3 consecutive influenza seasons. J Clin Virol 2021; 144:104998. [PMID: 34653942 DOI: 10.1016/j.jcv.2021.104998] [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] [Received: 07/01/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Influenza virus (IFV) is often encountered in primary care. Implementation of a rapid diagnostic test for its detection at the point-of-care would enable discrimination from other viral causes of influenza-like-illness (ILI) and might be helpful in individual patient management. In this study, the diagnostic performance of such a point-of-care platform was evaluated. METHODS Respiratory samples (n = 1490) from ILI-patients in primary care in 15 European countries were collected as part of a prospective clinical trial. Both children (n = 252) and adults (n = 1238) were sampled during 3 consecutive periods of high IFV endemicity. Samples were analysed in a central laboratory, after storage at -70 °C, with the Idylla™ Respiratory Panel, detecting both IFV and RSV, on the Idylla™ platform. The Fast Track Diagnostics (FTD) Respiratory Pathogens 21 plus assay was used as reference. A subset of samples (n = 192) was analysed both fresh and after being frozen. RESULTS The reference method detected IFV-A in 42% and IFV-B in 13% of the samples. Sensitivity of the Idylla for detection of IFV-A and IFV-B was 98.2% and 92.3% and specificity 97.7% and 98.4% respectively. False negative samples contained significantly lower viral loads than true positive samples (FTD mean Ct-value 30.7 versus 26.1 for IFV-A and 30.4 versus 25.1 for IFV-B, p < 0.001). Comparable results were obtained for Idylla analysis using fresh and frozen samples. CONCLUSIONS The Idylla Respiratory Panel is a promising point-of-care test for detection of IFV in ILI patients due to its excellent diagnostic performance, minimal training requirements and limited hands-on time.
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Affiliation(s)
- Veerle Matheeussen
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium; Department of Microbiology, University Hospital Antwerp, Edegem, Belgium; Department of Medical Biochemistry, University of Antwerp, Wilrijk, Belgium.
| | - Katherine Loens
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium; Department of Microbiology, University Hospital Antwerp, Edegem, Belgium
| | - Mandy Kuijstermans
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | - Kevin Jacobs
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | - Samuel Coenen
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Chris C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Theo Jm Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium; Department of Microbiology, University Hospital Antwerp, Edegem, Belgium
| | - Margareta Ieven
- Department of Medical Microbiology, Vaccine & Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Wilrijk, Belgium; Department of Microbiology, University Hospital Antwerp, Edegem, Belgium
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9
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van der Velden AW, Bax EA, Bongard E, Munck Aabenhus R, Anastasaki M, Anthierens S, Balan A, Böhmer F, Bruno P, Chlabicz S, Coenen S, Colliers A, Emmerich S, Garcia-Sangenis A, Ghazaryan H, van der Linde SR, Malania L, Pauer J, Tomacinschii A, Tonkin-Crine S, Vellinga A, Zastavnyy I, Verheij T, Goossens H, Butler CC. Primary care for patients with respiratory tract infection before and early on in the COVID-19 pandemic: an observational study in 16 European countries. BMJ Open 2021; 11:e049257. [PMID: 34326052 PMCID: PMC8326026 DOI: 10.1136/bmjopen-2021-049257] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/07/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe primary health care (consultation characteristics and management) for patients contacting their general practitioner (GP) with a respiratory tract infection (RTI) early on in the COVID-19 pandemic in contrasting European countries, with comparison to prepandemic findings. SETTING Primary care in 16 countries (79 practices), when no routine SARS-CoV-2 testing was generally available. DESIGN AND PARTICIPANTS Before (n=4376) and early in the pandemic (n=3301), patients with RTI symptoms were registered in this prospective audit study. OUTCOME MEASURES Consultation characteristics (type of contact and use of PPE) and management characteristics (clinical assessments, diagnostic testing, prescribing, advice and referral) were registered. Differences in these characteristics between countries and between pandemic and prepandemic care are described. RESULTS Care for patients with RTIs rapidly switched to telephone/video consultations (10% in Armenia, 91% in Denmark), and when consultations were face-to-face, GPs used PPE during 97% (95% CI 96% to 98%) of contacts. Laboratory testing for SARS-CoV-2 in primary care patients with RTIs was rapidly implemented in Denmark (59%) and Germany (31%), while overall testing for C reactive protein decreased. The proportion of patients prescribed antibiotics varied considerably between countries (3% in Belgium, 48% in UK) and was lower during the pandemic compared with the months before, except for Greece, Poland and UK. GPs provided frequent and varied COVID-related advice and more frequently scheduled a follow-up contact (50%, 95% CI 48% to 52%). GPs reported a slightly higher degree of confidence in the likely effectiveness of their management in face-to-face (73% (very) confident, 95% CI 71% to 76%) than in virtual consultations (69%, 95% CI 67% to 71%). CONCLUSIONS Despite between-country variation in consultation characteristics, access to SARS-CoV-2 laboratory testing and medication prescribing, GPs reported a high degree of confidence in managing their patients with RTIs in the emerging pandemic. Insight in the highly variable pandemic responses, as measured in this multicountry audit, can aid in fine-tuning national action and in coordinating a pan-European response during future pandemic threats.
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Affiliation(s)
- Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Eva A Bax
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Marilena Anastasaki
- Clinic of Social and Family Medicine, University of Crete, Heraklion, Greece
| | - Sibyl Anthierens
- Family Medicine and Population Health, Universiteit Antwerpen, Antwerpen, Belgium
| | | | - Femke Böhmer
- Institute of General Practice, Rostock University Medical Center, Rostock, Germany
| | - Pascale Bruno
- Département de Santé Publique, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Slawomir Chlabicz
- Department of Family Medicine Medical, University of Bialystok, Bialystok, Poland
| | - Samuel Coenen
- Family Medicine and Population Health, Universiteit Antwerpen, Antwerpen, Belgium
| | - Annelies Colliers
- Family Medicine and Population Health, Universiteit Antwerpen, Antwerpen, Belgium
| | | | - Ana Garcia-Sangenis
- Medicines Research Unit, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Hrachuhi Ghazaryan
- General Pediatrics, Wigmore Clinic Medical Center Yerevan, Yerevan, Armenia
| | - Sanne R van der Linde
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Lile Malania
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | | | - Angela Tomacinschii
- University Clinic of Primary Medical Assistance, State University of Medicine 'N. Testemițanu', Chişinǎu, the Republic of Moldova
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Ihor Zastavnyy
- NGO Academy of Family Medicine of Ukraine, Lviv, Ukraine
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, UMC Utrecht, Utrecht, The Netherlands
| | - Herman Goossens
- Medical Microbiology, Vaccine and Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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10
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Hayward G, Butler CC, Yu LM, Saville BR, Berry N, Dorward J, Gbinigie O, van Hecke O, Ogburn E, Swayze H, Bongard E, Allen J, Tonner S, Rutter H, Tonkin-Crine S, Borek A, Judge D, Grabey J, de Lusignan S, Thomas NPB, Evans PH, Andersson MI, Llewelyn M, Patel M, Hopkins S, Hobbs FDR. Platform Randomised trial of INterventions against COVID-19 In older peoPLE (PRINCIPLE): protocol for a randomised, controlled, open-label, adaptive platform, trial of community treatment of COVID-19 syndromic illness in people at higher risk. BMJ Open 2021; 11:e046799. [PMID: 34145016 PMCID: PMC8214989 DOI: 10.1136/bmjopen-2020-046799] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 05/14/2021] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION There is an urgent need to idenfy treatments for COVID-19 that reduce illness duration and hospital admission in those at higher risk of a longer illness course and complications. METHODS AND ANALYSIS The Platform Randomised trial of INterventions against COVID-19 In older peoPLE trial is an open-label, multiarm, prospective, adaptive platform, randomised clinical trial to evaluate potential treatments for COVID-19 in the community. A master protocol governs the addition of new interventions as they become available, as well as the inclusion and cessation of existing intervention arms via frequent interim analyses. The first three interventions are hydroxychloroquine, azithromycin and doxycycline. Eligible participants must be symptomatic in the community with possible or confirmed COVID-19 that started in the preceding 14 days and either (1) aged 65 years and over or (2) aged 50-64 years with comorbidities. Recruitment is through general practice, health service helplines, COVID-19 'hot hubs' and directly through the trial website. Participants are randomised to receive either usual care or a study drug plus usual care, and outcomes are collected via daily online symptom diary for 28 days from randomisation. The research team contacts participants and/or their study partner following days 7, 14 and 28 if the online diary is not completed. The trial has two coprimary endpoints: time to first self-report of feeling recovered from possible COVID-19 and hospital admission or death from possible COVID-19 infection, both within 28 days from randomisation. Prespecified interim analyses assess efficacy or futility of interventions and to modify randomisation probabilities that allocate more participants to interventions with better outcomes. ETHICS AND DISSEMINATION Ethical approval Ref: 20/SC/0158 South Central - Berkshire Research Ethics Committee; IRAS Project ID: 281958; EudraCT Number: 2020-001209-22. Results will be presented to policymakers and at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER ISRCTN86534580.
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Affiliation(s)
- Gail Hayward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | | | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Centre for the Aids Programme of Research in South Africa, Durban, South Africa
| | - Oghenekome Gbinigie
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Oliver van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emma Ogburn
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Hannah Swayze
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Allen
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sharon Tonner
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Aleksandra Borek
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Judge
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jenna Grabey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK
| | - Nicholas P B Thomas
- Windrush Medical Practice, Witney, UK
- Royal College of General Practitioners, London, UK
| | - Philip H Evans
- St Leonard's Research Practice, Exeter, UK
- University of Exeter Medical School, Exeter, UK
| | | | - Martin Llewelyn
- Department of Microbiology and Infection, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, Brighton, UK
| | - Mahendra Patel
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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11
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Santillo M, Wanat M, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use. BMJ Open 2020; 10:e035793. [PMID: 33004384 PMCID: PMC7534681 DOI: 10.1136/bmjopen-2019-035793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 07/29/2020] [Accepted: 08/14/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To develop a behavioural intervention package to support clinicians and patients to amend incorrect penicillin allergy records in general practice. The intervention aimed to: (1) support clinicians to refer patients for penicillin allergy testing (PAT), (2) support patients to attend for PAT and (3) support clinicians and patients to prescribe or consume penicillin, when indicated, following a negative PAT result. METHODS Theory-based, evidence-based and person-based approaches were used in the intervention development. We used evidence from a rapid review, two qualitative studies, and expert consultations with the clinical research team to identify the intervention 'guiding principles' and develop an intervention plan. Barriers and facilitators to the target behaviours were mapped to behaviour change theory in order to describe the proposed mechanisms of change. In the final stage, think-aloud interviews were conducted to optimise intervention materials. RESULTS The collated evidence showed that the key barriers to referral of patients by clinicians were limited experience of referral and limited knowledge of referral criteria and PAT. Barriers for patients attending PAT were lack of knowledge of the benefits of testing and lack of motivation to get tested. The key barriers to the prescription and consumption of first-line penicillin following a negative test result were patient and clinician beliefs about the accuracy of PAT and whether taking penicillin was safe. Intervention materials were designed and developed to address these barriers. CONCLUSIONS We present a novel behavioural intervention package designed to address the multiple barriers to uptake of PAT in general practice by clinicians and patients. The intervention development details how behaviour change techniques have been incorporated to hypothesise how the intervention is likely to work to help amend incorrect penicillin allergy records. The intervention will go on to be tested in a feasibility trial and randomised controlled trial in England.
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Affiliation(s)
- Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- Faculty of Medicine and Health, University of Leeds, Leeds, Leeds, UK
| | - Louise Savic
- Faculty of Medicine and Health, University of Leeds, Leeds, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | | | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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12
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van der Velden A, Goossens H, Cianci D, Bongard E, Saville B, Ieven M, Verheij TJM, Butler CC, Coenen S. Oseltamivir bij infectie door een humaan coronavirus. Huisarts Wet 2020; 63:24-26. [PMID: 32836343 PMCID: PMC7335764 DOI: 10.1007/s12445-020-0792-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Alike van der Velden
- Senior onderzoeker huisartsgeneeskunde, UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijnsgeneeskunde, Utrecht, Nederland
| | - Herman Goossens
- Microbioloog, University of Antwerp, Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute, Antwerpen, Nederland
| | - Daniela Cianci
- Senior onderzoeker biostatistiek, UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijnsgeneeskunde, Utrecht, Nederland
| | - Emily Bongard
- Senior trial manager, University of Oxford, Nuffield Departement of Primary Care, Oxford, United Kingdom
| | - Benjamin Saville
- Professor of biostatistics, Vanderbilt University, Department of Biostatistics, Nashville (TN) en Berry Consultants, Austin, United States
| | - Margareta Ieven
- Microbioloog, Universiteit Antwerpen, Laboratorium Medische Microbiologie, Antwerpen, Nederland
| | - Th. J. M. Verheij
- Huisarts, hoogleraar huisartsgeneeskunde., UMC Utrecht, Julius Centrum voor Gezondheidswetenschappen en Eerstelijnsgeneeskunde, Utrecht, Nederland
| | - C. C. Butler
- Professor of primary care, NIHR senior investigator, University of Oxford, Nuffield Departement of Primary Care, Oxford, United Kingdom
| | - S. Coenen
- Hoogleraar klinische epidemiologie, Universiteit Antwerpen, Vakgroep Eerstelijns- en Interdisciplinaire Zorg, Antwerpen, Nederland
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13
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Butler CC, van der Velden AW, Bongard E, Saville BR, Holmes J, Coenen S, Cook J, Francis NA, Lewis RJ, Godycki-Cwirko M, Llor C, Chlabicz S, Lionis C, Seifert B, Sundvall PD, Colliers A, Aabenhus R, Bjerrum L, Jonassen Harbin N, Lindbæk M, Glinz D, Bucher HC, Kovács B, Radzeviciene Jurgute R, Touboul Lundgren P, Little P, Murphy AW, De Sutter A, Openshaw P, de Jong MD, Connor JT, Matheeussen V, Ieven M, Goossens H, Verheij TJ. Oseltamivir plus usual care versus usual care for influenza-like illness in primary care: an open-label, pragmatic, randomised controlled trial. Lancet 2020; 395:42-52. [PMID: 31839279 DOI: 10.1016/s0140-6736(19)32982-4] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Antivirals are infrequently prescribed in European primary care for influenza-like illness, mostly because of perceived ineffectiveness in real world primary care and because individuals who will especially benefit have not been identified in independent trials. We aimed to determine whether adding antiviral treatment to usual primary care for patients with influenza-like illness reduces time to recovery overall and in key subgroups. METHODS We did an open-label, pragmatic, adaptive, randomised controlled trial of adding oseltamivir to usual care in patients aged 1 year and older presenting with influenza-like illness in primary care. The primary endpoint was time to recovery, defined as return to usual activities, with fever, headache, and muscle ache minor or absent. The trial was designed and powered to assess oseltamivir benefit overall and in 36 prespecified subgroups defined by age, comorbidity, previous symptom duration, and symptom severity, using a Bayesian piece-wise exponential primary analysis model. The trial is registered with the ISRCTN Registry, number ISRCTN 27908921. FINDINGS Between Jan 15, 2016, and April 12, 2018, we recruited 3266 participants in 15 European countries during three seasonal influenza seasons, allocated 1629 to usual care plus oseltamivir and 1637 to usual care, and ascertained the primary outcome in 1533 (94%) and 1526 (93%). 1590 (52%) of 3059 participants had PCR-confirmed influenza infection. Time to recovery was shorter in participants randomly assigned to oseltamivir (hazard ratio 1·29, 95% Bayesian credible interval [BCrI] 1·20-1·39) overall and in 30 of the 36 prespecified subgroups, with estimated hazard ratios ranging from 1·13 to 1·72. The estimated absolute mean benefit from oseltamivir was 1·02 days (95% [BCrI] 0·74-1·31) overall, and in the prespecified subgroups, ranged from 0·70 (95% BCrI 0·30-1·20) in patients younger than 12 years, with less severe symptoms, no comorbidities, and shorter previous illness duration to 3·20 (95% BCrI 1·00-5·50) in patients aged 65 years or older who had more severe illness, comorbidities, and longer previous illness duration. Regarding harms, an increased burden of vomiting or nausea was observed in the oseltamivir group. INTERPRETATION Primary care patients with influenza-like illness treated with oseltamivir recovered one day sooner on average than those managed by usual care alone. Older, sicker patients with comorbidities and longer previous symptom duration recovered 2-3 days sooner. FUNDING European Commission's Seventh Framework Programme.
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Affiliation(s)
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Emily Bongard
- Department of Primary Care Health Services, University of Oxford, Oxford, UK
| | - Benjamin R Saville
- Berry Consultants, Austin, Texas; Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Samuel Coenen
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Johanna Cook
- Department of Primary Care Health Services, University of Oxford, Oxford, UK
| | - Nick A Francis
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Roger J Lewis
- Harbor-UCLA Medical Center, Torrance, CA, USA; David Geffen School of Medicine at UCLA, Los Angeles, CA, USA; Berry Consultants, Austin, TX, USA
| | - Maciek Godycki-Cwirko
- Centre for Family and Community Medicine, Faculty of Health Sciences, Medical University of Lodz, Lodz, Poland
| | - Carl Llor
- University Institute in Primary Care Research Jordi Gol, Via Roma Health Centre, Barcelona, Spain
| | - Sławomir Chlabicz
- Department of Family Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Christos Lionis
- Clinic of Social and Family Medicine, Faculty of Medicine, University of Crete, Crete, Greece
| | - Bohumil Seifert
- Department of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pär-Daniel Sundvall
- Research and Development Primary Health Care-Region Västra Götaland, Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Annelies Colliers
- Centre for General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Rune Aabenhus
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Lars Bjerrum
- Section and Research Unit of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolay Jonassen Harbin
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Morten Lindbæk
- Antibiotic Center for Primary Care, Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Dominik Glinz
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | | | | | - Pia Touboul Lundgren
- Département de Santé Publique, Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Nice, France
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Andrew W Murphy
- Health Research Board Primary Care Clinical Trial Network Ireland, National University of Ireland Galway, Galway, Ireland
| | - An De Sutter
- Center for Family Medicine UGent, Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Peter Openshaw
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Menno D de Jong
- Department of Medical Microbiology, Amsterdam UMC, University of Amsterdam, Netherlands
| | - Jason T Connor
- ConfluenceStat, Orlando, FL, USA; College of Medicine, University of Central Florida, Orlando, FL, USA
| | - Veerle Matheeussen
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine & Infectious Disease Institute, University of Antwerp, Antwerp, Belgium; Laboratory of Clinical Microbiology, Antwerp University Hospital, Edegem, Belgium
| | - Theo J Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
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14
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Prout HC, Barham A, Bongard E, Tudor-Edwards R, Griffiths G, Hamilton W, Harrop E, Hood K, Hurt CN, Nelson R, Porter C, Roberts K, Rogers T, Thomas-Jones E, Tod A, Yeo ST, Neal RD, Nelson A. Patient understanding and acceptability of an early lung cancer diagnosis trial: a qualitative study. Trials 2018; 19:419. [PMID: 30075741 PMCID: PMC6090834 DOI: 10.1186/s13063-018-2803-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 04/10/2017] [Accepted: 07/10/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The ELCID (Early Lung Cancer Investigation and Diagnosis) trial was a feasibility randomised controlled trial examining the effect on lung cancer diagnosis of lowering the threshold for referral for urgent chest x-ray for smokers and recent ex-smokers, aged over 60 years with new chest symptoms. The qualitative component aimed to explore the feasibility of individually randomising patients to an urgent chest x-ray or not and to investigate any barriers to patient recruitment and participation. We integrated this within the feasibility trial to inform the design of any future definitive trial, particularly in view of the lack of research exploring symptomatic patients' experiences of participating in diagnostic trials for possible/suspected lung cancer. Although previous studies contributed valuable information concerning screening for lung cancer and patient participation in trials, this paper is the first to explore issues relating to this specific patient group. METHODS Qualitative interviews were conducted with 21 patients, comprising 9 who had been randomised to receive an immediate chest x-ray, 10 who were randomised to receive the standard treatment according to the National Institute for Health and Care Excellence guidelines, and 2 who chose not to participate in the trial. Interviews were analysed using a framework approach. RESULTS The findings of this analysis showed that altruism, personal benefit and the reassurance of not having lung cancer were important factors in patient participation. However, patients largely believed that being in the intervention arm was more beneficial, highlighting a lack of understanding of clinical equipoise. Disincentives to participation in the trial included the stigmatisation of patients who smoked (given the inclusion criteria). Although the majority of patients reported that they were happy with the trial design, there was evidence of poor understanding. Last, for several patients, placing trust in health professionals was preferred to understanding the trial processes. CONCLUSIONS The integration of a qualitative study focusing on participant experience as a secondary outcome of a feasibility trial enabled exploration of patient response to participation and recruitment. The study demonstrated that although it is feasible to recruit patients to the ELCID trial, more work needs to be done to ensure an understanding of study principles and also of smoking stigmatisation. TRIAL REGISTRATION ClinicalTrials.gov, NCT01344005 . Registered on 27 April 2011.
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Affiliation(s)
- Hayley C. Prout
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Emily Bongard
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Emily Harrop
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerry Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Chris N. Hurt
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Rosie Nelson
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Kirsty Roberts
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Trevor Rogers
- Doncaster Royal Infirmary, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | | | - Angela Tod
- School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Richard D. Neal
- Academic Unit of Primary Care, Leeds Institute of Health Sciences, Worsley Building (Room 10.35), Clarendon Way, Leeds, LS2 9NL UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre, School of Medicine, Cardiff University, Cardiff, UK
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15
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Bongard E, van der Velden AW, Cook J, Saville B, Beutels P, Munck Aabenhus R, Brugman C, Chlabicz S, Coenen S, Colliers A, Davies M, De Paor M, De Sutter A, Francis NA, Glinz D, Godycki-ćwirko M, Goossens H, Holmes J, Ieven M, de Jong M, Lindbaek M, Little P, Martinón-Torres F, Moragas A, Pauer J, Pfeiferová M, Radzeviciene-Jurgute R, Sundvall PD, Torres A, Touboul P, Varthalis D, Verheij T, Butler CC. Antivirals for influenza-Like Illness? A randomised Controlled trial of Clinical and Cost effectiveness in primary CarE (ALIC 4 E): the ALIC 4 E protocol. BMJ Open 2018; 8:e021032. [PMID: 30002007 PMCID: PMC6089276 DOI: 10.1136/bmjopen-2017-021032] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 05/01/2018] [Accepted: 06/14/2018] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Effective management of seasonal and pandemic influenza is a high priority internationally. Guidelines in many countries recommend antiviral treatment for older people and individuals with comorbidity at increased risk of complications. However, antivirals are not often prescribed in primary care in Europe, partly because its clinical and cost effectiveness has been insufficiently demonstrated by non-industry funded and pragmatic studies. METHODS AND ANALYSIS Antivirals for influenza-Like Illness? An rCt of Clinical and Cost effectiveness in primary CarE is a European multinational, multicentre, open-labelled, non-industry funded, pragmatic, adaptive-platform, randomised controlled trial. Initial trial arms will be best usual primary care and best usual primary care plus treatment with oseltamivir for 5 days. We aim to recruit at least 2500 participants ≥1 year presenting with influenza-like illness (ILI), with symptom duration ≤72 hours in primary care over three consecutive periods of confirmed high influenza incidence. Participant outcomes will be followed up to 28 days by diary and telephone. The primary objective is to determine whether adding antiviral treatment to best usual primary care is effective in reducing time to return to usual daily activity with fever, headache and muscle ache reduced to minor severity or less. Secondary objectives include estimating cost-effectiveness, benefits in subgroups according to age (<12, 12-64 and >64 years), severity of symptoms at presentation (low, medium and high), comorbidity (yes/no), duration of symptoms (≤48 hours/>48-72 hours), complications (hospital admission and pneumonia), use of additional prescribed medication including antibiotics, use of over-the-counter medicines and self-management of ILI symptoms. ETHICS AND DISSEMINATION Research ethics committee (REC) approval was granted by the NRES Committee South Central (Oxford B) and Clinical Trial Authority (CTA) approval by The Medicines and Healthcare products Regulatory Agency. All participating countries gained national REC and CTA approval as required. Dissemination of results will be through peer-reviewed scientific journals and conference presentations. TRIAL REGISTRATION NUMBER ISRCTN27908921; Pre-results.
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Affiliation(s)
- Emily Bongard
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alike W van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johanna Cook
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ben Saville
- Berry Consultants, Austin, Texas, USA
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | | | - Curt Brugman
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Slawomir Chlabicz
- Department of Family Medicine and Community Nursing, Medical University of Bialystok, Bialystok, Poland
| | - Samuel Coenen
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Annelies Colliers
- Centre for General Practice, Department of Primary and Interdisciplinary Care (ELIZA), University of Antwerp, Antwerp, Belgium
| | | | - Muireann De Paor
- Department of General Practice, Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland
| | - An De Sutter
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Nick A Francis
- Department of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Dominik Glinz
- University of Basel, Basel, Switzerland
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Maciek Godycki-ćwirko
- Department of Family and Community Medicine, Medical University of Lodz, Lodz, Poland
| | - Herman Goossens
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Menno de Jong
- Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Morten Lindbaek
- Department of General Practice, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Paul Little
- Primary Care and Population Science, University of Southampton, Southampton, UK
| | | | - Ana Moragas
- Primary Healthcare Centre Jaume I, Universitat Rovira i Virgili, Tarragona, Catalonia, Spain
| | | | - Markéta Pfeiferová
- Institute of General Practice, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | | | - Pär-Daniel Sundvall
- Närhälsan, Research and Development Primary Health Care, Region Västra Götaland, Research and Development Center Södra Älvsborg, Borås, Sweden
- Department of Public Health and Community Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Antoni Torres
- Department of Pulmonology, Hospital Clínic de Barcelona, Universitat de Barcelona and IDIBAPS, Barcelona, Spain
| | - Pia Touboul
- Department of Public Health, University Hospital of Nice, Nice, France
- Department of Teaching and Research in General Practice, University of Côte d’Azur, Nice, France
| | | | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher C Butler
- The Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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16
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Butler CC, Coenen S, Saville BR, Cook J, van der Velden A, Homes J, de Jong M, Little P, Goossens H, Beutels P, Ieven M, Francis N, Moons P, Bongard E, Verheij T. A trial like ALIC 4E: why design a platform, response-adaptive, open, randomised controlled trial of antivirals for influenza-like illness? ERJ Open Res 2018; 4:00046-2018. [PMID: 29761108 PMCID: PMC5938489 DOI: 10.1183/23120541.00046-2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 04/16/2018] [Indexed: 11/05/2022] Open
Abstract
ALIC4E is the first publicly funded, multicountry, pragmatic study determining whether antivirals should be routinely prescribed for influenza-like illness in primary care. The trial aims to go beyond determining the average treatment effect in a population to determining effects in patients with combinations of participant characteristics (age, symptom duration, illness severity, and comorbidities). It is one of the first platform, response-adaptive, open trial designs implemented in primary care, and this article aims to provide an accessible description of key aspects of the study design. 1) The platform design allows the study to remain relevant to evolving circumstances, with the ability to add treatment arms. 2) Response adaptation allows the proportion of participants with key characteristics allocated to study arms to be altered during the course of the trial according to emerging outcome data, so that participants' information will be most useful, and increasing their chances of receiving the trial intervention that will be most effective for them. 3) Because the possibility of taking placebos influences participant expectations about their treatment, and determining effects of the interventions on patient help seeking and adherence behaviour in real-world care is critical to estimates of cost-effectiveness, ALIC4E is an open-label trial. A platform, response-adaptive, open trial design allows for flexibility and may enhance efficiency in determining cost-effectiveness of interventions for acute infectionshttp://ow.ly/NODY30jACb7
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Affiliation(s)
- Christopher C Butler
- Primary Care and Vaccines Collaborative Clinical Trials Unit, Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Samuel Coenen
- Dept of Epidemiology and Social Medicine (ESOC), University of Antwerpen, Antwerp, Belgium
| | - Benjamin R Saville
- Berry Consultants, LLC, Austin, TX, USA.,Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Johanna Cook
- Primary Care and Vaccines Collaborative Clinical Trials Unit, Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Alike van der Velden
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (STR 6.103), Utrecht, The Netherlands
| | - Jane Homes
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Menno de Jong
- Dept of Medical Microbiology at the Free University of Amsterdam Medical Centre, Amsterdam, The Netherlands
| | | | - Herman Goossens
- Dept of Medical Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Philippe Beutels
- Centre for Health Economics Research and Modelling Infectious Diseases (CHERMID), Vaccine and Infectious Disease Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Margareta Ieven
- Laboratory of Medical Microbiology, Vaccine and Infectious Diseases Institute (VAXINFECTIO), University of Antwerp, Antwerp, Belgium
| | - Nick Francis
- Dept of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
| | - Pieter Moons
- Dept of Medical Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Emily Bongard
- Primary Care and Vaccines Collaborative Clinical Trials Unit, Nuffield Dept of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Theo Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht (STR 6.103), Utrecht, The Netherlands
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17
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Murphy ME, Phillips PPJ, Mendel CM, Bongard E, Bateson ALC, Hunt R, Murthy S, Singh KP, Brown M, Crook AM, Nunn AJ, Meredith SK, Lipman M, McHugh TD, Gillespie SH. Spot sputum samples are at least as good as early morning samples for identifying Mycobacterium tuberculosis. BMC Med 2017; 15:192. [PMID: 29073910 PMCID: PMC5658986 DOI: 10.1186/s12916-017-0947-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 09/25/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The use of early morning sputum samples (EMS) to diagnose tuberculosis (TB) can result in treatment delay given the need for the patient to return to the clinic with the EMS, increasing the chance of patients being lost during their diagnostic workup. However, there is little evidence to support the superiority of EMS over spot sputum samples. In this new analysis of the REMoxTB study, we compare the diagnostic accuracy of EMS with spot samples for identifying Mycobacterium tuberculosis pre- and post-treatment. METHODS Patients who were smear positive at screening were enrolled into the study. Paired sputum samples (one EMS and one spot) were collected at each trial visit pre- and post-treatment. Microscopy and culture on solid LJ and liquid MGIT media were performed on all samples; those missing corresponding paired results were excluded from the analyses. RESULTS Data from 1115 pre- and 2995 post-treatment paired samples from 1931 patients enrolled in the REMoxTB study were analysed. Patients were recruited from South Africa (47%), East Africa (21%), India (20%), Asia (11%), and North America (1%); 70% were male, median age 31 years (IQR 24-41), 139 (7%) co-infected with HIV with a median CD4 cell count of 399 cells/μL (IQR 318-535). Pre-treatment spot samples had a higher yield of positive Ziehl-Neelsen smears (98% vs. 97%, P = 0.02) and LJ cultures (87% vs. 82%, P = 0.006) than EMS, but there was no difference for positivity by MGIT (93% vs. 95%, P = 0.18). Contaminated and false-positive MGIT were found more often with EMS rather than spot samples. Surprisingly, pre-treatment EMS had a higher smear grading and shorter time-to-positivity, by 1 day, than spot samples in MGIT culture (4.5 vs. 5.5 days, P < 0.001). There were no differences in time to positivity in pre-treatment LJ culture, or in post-treatment MGIT or LJ cultures. Comparing EMS and spot samples in those with unfavourable outcomes, there were no differences in smear or culture results, and positive results were not detected earlier in Kaplan-Meier analyses in either EMS or spot samples. CONCLUSIONS Our data do not support the hypothesis that EMS samples are superior to spot sputum samples in a clinical trial of patients with smear positive pulmonary TB. Observed small differences in mycobacterial burden are of uncertain significance and EMS samples do not detect post-treatment positives any sooner than spot samples.
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Affiliation(s)
- Michael E Murphy
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.
| | - Patrick P J Phillips
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Carl M Mendel
- Global Alliance for Tuberculosis Drug Development, New York, NY, 10005, USA
| | - Emily Bongard
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Anna L C Bateson
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Robert Hunt
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Saraswathi Murthy
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Kasha P Singh
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Michael Brown
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Angela M Crook
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Andrew J Nunn
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Sarah K Meredith
- Medical Research Council UK Clinical Trials Unit at University College London, Aviation House, 125 Kingsway, London, WC2B 6NH, UK
| | - Marc Lipman
- UCL Respiratory, Division of Medicine, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Timothy D McHugh
- UCL Centre for Clinical Microbiology, Department of Infection, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Stephen H Gillespie
- School of Medicine, Medical and Biological Sciences, University of St Andrews, North Haugh, St Andrews, KY16 9TF, UK.
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18
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Neal RD, Barham A, Bongard E, Edwards RT, Fitzgibbon J, Griffiths G, Hamilton W, Hood K, Nelson A, Parker D, Porter C, Prout H, Roberts K, Rogers T, Thomas-Jones E, Tod A, Yeo ST, Hurt CN. Immediate chest X-ray for patients at risk of lung cancer presenting in primary care: randomised controlled feasibility trial. Br J Cancer 2017; 116:293-302. [PMID: 28072761 PMCID: PMC5294478 DOI: 10.1038/bjc.2016.414] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 10/31/2016] [Accepted: 11/16/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Achieving earlier stage diagnosis is one option for improving lung cancer outcomes in the United Kingdom. Patients with lung cancer typically present with symptoms to general practitioners several times before referral or investigation. METHODS We undertook a mixed methods feasibility individually randomised controlled trial (the ELCID trial) to assess the feasibility and inform the design of a definitive, fully powered, UK-wide, Phase III trial of lowering the threshold for urgent investigation of suspected lung cancer. Patients over 60, with a smoking history, presenting with new chest symptoms to primary care, were eligible to be randomised to intervention (urgent chest X-ray) or usual care. RESULTS The trial design and materials were acceptable to GPs and patients. We randomised 255 patients from 22 practices, although the proportion of eligible patients who participated was lower than expected. Survey responses (89%), and the fidelity of the intervention (82% patients X-rayed within 3 weeks) were good. There was slightly higher anxiety and depression in the control arm in participants aged >75. Three patients (1.2%) were diagnosed with lung cancer. CONCLUSIONS We have demonstrated the feasibility of individually randomising patients at higher risk of lung cancer, to a trial offering urgent investigation or usual care.
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Affiliation(s)
- Richard D Neal
- Leeds Institute for Health Sciences, University of Leeds, Leeds LS2 9NL, UK
| | | | - Emily Bongard
- MRC Lifecourse Epidemiology Unit, University of Southampton, Southampton, UK
| | | | | | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton, UK
| | | | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Annmarie Nelson
- Marie Curie Palliative Care Research Centre School of Medicine, Cardiff University, Cardiff, UK
| | - David Parker
- Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital, Wrexham, UK
| | - Cath Porter
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Hayley Prout
- Marie Curie Palliative Care Research Centre School of Medicine, Cardiff University, Cardiff, UK
| | - Kirsty Roberts
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Trevor Rogers
- Doncaster Royal Infirmary, Doncaster and Bassetlaw NHS Foundation Trust, Doncaster, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Seow Tien Yeo
- Centre for Health Economics and Medicines Evaluation, Bangor University, Gwynedd, UK
| | - Chris N Hurt
- Wales Cancer Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
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19
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Bongard E, Frimodt-Møller N, Gal M, Wootton M, Howe R, Francis N, Goossens H, Butler CC. Analytic laboratory performance of a point of care urine culture kit for diagnosis and antibiotic susceptibility testing. Eur J Clin Microbiol Infect Dis 2015; 34:2111-9. [PMID: 26245946 DOI: 10.1007/s10096-015-2460-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/16/2015] [Indexed: 11/24/2022]
Abstract
Currently available point-of-care (POC) diagnostic tests for managing urinary tract infections (UTIs) in general practice are limited by poor performance characteristics, and laboratory culture generally provides results only after a few days. This laboratory evaluation compared the analytic performance of the POC UK Flexicult(™) (Statens Serum Institut) (SSI) urinary kit for quantification, identification and antibiotic susceptibility testing and routine UK National Health Service (NHS) urine processing to an advanced urine culture method. Two hundred urine samples routinely submitted to the Public Health Wales Microbiology Laboratory were divided and: (1) analysed by routine NHS microbiological tests as per local laboratory standard operating procedures, (2) inoculated onto the UK Flexicult(™) SSI urinary kit and (3) spiral plated onto Colorex Orientation UTI medium (E&O Laboratories Ltd). The results were evaluated between the NHS and Flexicult(™ )methods, and discordant results were compared to the spiral plating method. The UK Flexicult(™) SSI urinary kit was compared to routine NHS culture for identification of a pure or predominant uropathogen at ≥ 10(5) cfu/mL, with a positive discordancy rate of 13.5% and a negative discordancy rate of 3%. The sensitivity and specificity were 86.7% [95% confidence interval (CI) 73.8-93.7] and 82.6% (95% CI 75.8-87.7), respectively. The UK Flexicult(™) SSI urinary kit was comparable to routine NHS urine processing in identifying microbiologically positive UTIs in this laboratory evaluation. However, the number of false-positive samples could lead to over-prescribing of antibiotics in clinical practice. The Flexicult(™) SSI kit could be useful as a POC test for UTIs in primary care but further pragmatic evaluations are necessary.
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Affiliation(s)
| | | | - M Gal
- Cardiff University, Cardiff, Wales
| | | | - R Howe
- Public Health Wales, Cardiff, Wales
| | | | - H Goossens
- University of Antwerp, Antwerpen, Belgium
| | - C C Butler
- Cardiff University, Cardiff, Wales.,University of Oxford, Oxford, England
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20
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Bates J, Thomas-Jones E, Kirby N, Pickles T, Thomas R, Bongard E, Gal M, Little P, Verheij T, Llor C, Cohen D, Francis N, Hood K, Butler C. Effects of an optimised POCT guided diagnostic and treatment strategy for symptoms of uncomplicated UTI on use of appropriate antibiotics and uptake into primary care practice. Trials 2013. [PMCID: PMC3981514 DOI: 10.1186/1745-6215-14-s1-p10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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21
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Ellis GL, Amewu R, Sabbani S, Stocks PA, Shone A, Stanford D, Gibbons P, Davies J, Vivas L, Charnaud S, Bongard E, Hall C, Rimmer K, Lozanom S, Jesús M, Gargallo D, Ward SA, O'Neill PM. Two-step synthesis of achiral dispiro-1,2,4,5-tetraoxanes with outstanding antimalarial activity, low toxicity, and high-stability profiles. J Med Chem 2008; 51:2170-7. [PMID: 18341274 DOI: 10.1021/jm701435h] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A rapid, two-step synthesis of a range of dispiro-1,2,4,5-tetraoxanes with potent antimalarial activity both in vitro and in vivo has been achieved. These 1,2,4,5-tetraoxanes have been proven to be superior to 1,2,4-trioxolanes in terms of stability and to be superior to trioxane analogues in terms of both stability and activity. Selected analogues have in vitro nanomolar antimalarial activity and good oral activity and are nontoxic in screens for both cytotoxicity and genotoxicity. The synthesis of a fluorescent 7-nitrobenza-2-oxa-1,3-diazole (NBD) tagged tetraoxane probe and use of laser scanning confocal microscopy techniques have shown that tagged molecules accumulate selectively only in parasite infected erythrocytes and that intraparasitic formation of adducts could be inhibited by co-incubation with the iron chelator desferrioxamine (DFO).
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Affiliation(s)
- Gemma L Ellis
- Department of Chemistry, University of Liverpool, Liverpool, U.K
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22
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Vivas L, Rattray L, Stewart L, Bongard E, Robinson BL, Peters W, Croft SL. Anti-malarial efficacy of pyronaridine and artesunate in combination in vitro and in vivo. Acta Trop 2008; 105:222-8. [PMID: 18279817 DOI: 10.1016/j.actatropica.2007.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 10/13/2007] [Accepted: 12/16/2007] [Indexed: 10/22/2022]
Abstract
Pyronaridine is a Mannich base anti-malarial with demonstrated efficacy against drug resistant Plasmodium falciparum, P. vivax, P. ovale and P. malariae. However, resistance to pyronaridine can develop quickly when it is used alone but can be considerably delayed when it is administered with artesunate in rodent malaria models. The aim of this study was to evaluate the efficacy of pyronaridine in combination with artesunate against P. falciparum in vitro and in rodent malaria models in vivo to support its clinical application. Pyronaridine showed consistently high levels of in vitro activity against a panel of six P. falciparum drug-sensitive and resistant strains (Geometric Mean IC50=2.24 nM, 95% CI=1.20-3.27). In vitro interactions between pyronaridine and artesunate showed a slight antagonistic trend, but in vivo compared to pyronaridine and artesunate administered alone, the 3:1 ratio of the combination, reduced the ED90 of artesunate by approximately 15.6-fold in a pyronaridine-resistant P. berghei line and by approximately 200-fold in an artesunate-resistant line of P. berghei. Complete cure rates were achieved with doses of the combination above or equal to 8 mg/kg per day against P. chabaudi AS. These results indicate that the combination had an enhanced effect over monotherapy and lower daily doses of artesunate could be used to obtain a curative effect. The data suggest that the combination of pyronaridine and artesunate should have potential in areas of multi-drug resistant malaria.
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23
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Too K, Brown DM, Loakes D, Bongard E, Vivas L. In vitro anti-malarial activity of N6-modified purine analogs. Nucleosides Nucleotides Nucleic Acids 2008; 26:579-83. [PMID: 18066859 DOI: 10.1080/15257770701490134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
A library of N6-hydroxy-, methoxy-, or amino-adenosine analogs was prepared and screened for anti-malarial properties. We found three compounds that possess anti-plasmodial activity in the low micromolar range against the multi-drug resistant VS1 strain, namely N6-hydroxy-9H-purin-6-amine (IC50 5.57 micro M), 2-amino-N6-amino-adenosine (IC50 12.2 micro M), and 2-amino-N6-amino-N6-methyladenosine (IC50 0.29 micro M). More importantly, the compounds were non-toxic, with 2-amino-N6-amino-N6-methyladenosine showing a selectivity index of 5008.
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Affiliation(s)
- Kathleen Too
- Medical Research Council, Laboratory of Molecular Biology, Cambridge, UK
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24
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Vicente E, Lima LM, Bongard E, Charnaud S, Villar R, Solano B, Burguete A, Perez-Silanes S, Aldana I, Vivas L, Monge A. Synthesis and structure-activity relationship of 3-phenylquinoxaline 1,4-di-N-oxide derivatives as antimalarial agents. Eur J Med Chem 2008. [PMID: 18215443 DOI: 10.1016/j.ejmech.2007.11.024.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
As a continuation of our research and with the aim of obtaining new antimalarial agents, new series of 3-phenylquinoxaline 1,4-di-N-oxide derivatives have been synthesized following the classical Beirut reaction. Antiplasmodial activity was evaluated in vitro against Plasmodium falciparum by the incorporation of [3H]-hypoxanthine. Cytotoxicity was tested in KB cells by AlamarBlue assay. Twenty-one of the 60 compounds that were assayed against 3D7 (CQ-sensitive) showed enough activity to be also evaluated against K1 (CQ-resistant) strain. Ten of them were shown to be more active than chloroquine in the resistant strain. The most interesting compounds are 7-(methyl or methoxy)-3-(4'-fluoro or chloro)phenylquinoxaline-2-carbonitrile 1,4-di-N-oxides because of their low IC50 and their high SI shown for the K1 strain, making them valid new leads.
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Affiliation(s)
- Esther Vicente
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, C/Irunlarrea s/n, 31080 Pamplona, Spain
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25
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Vicente E, Charnaud S, Bongard E, Villar R, Burguete A, Solano B, Ancizu S, Pérez-Silanes S, Aldana I, Vivas L, Monge A. Synthesis and antiplasmodial activity of 3-furyl and 3-thienylquinoxaline-2-carbonitrile 1,4-di-N-oxide derivatives. Molecules 2008; 13:69-77. [PMID: 18259130 PMCID: PMC6245472 DOI: 10.3390/molecules13010069] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2007] [Accepted: 01/11/2008] [Indexed: 11/16/2022] Open
Abstract
The aim of this study was to identify new compounds active against Plasmodium falciparum based on our previous research carried out on 3-phenyl-quinoxaline-2-carbonitrile 1,4-di-N-oxide derivatives. Twelve compounds were synthesized and evaluated for antimalarial activity. Eight of them showed an IC(50) less than 1 microM against the 3D7 strain. Derivative 1 demonstrated high potency (IC(50)= 0.63 microM) and good selectivity (SI=10.35), thereby becoming a new lead-compound.
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Affiliation(s)
- Esther Vicente
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
| | - Sarah Charnaud
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
| | - Emily Bongard
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
| | - Raquel Villar
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
| | - Asunción Burguete
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
| | - Beatriz Solano
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
| | - Saioa Ancizu
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
| | - Silvia Pérez-Silanes
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
| | - Ignacio Aldana
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
- Author to whom correspondence should be addressed. E-mail:
| | - Livia Vivas
- Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine (LSHTM), Keppel Street, London WC1E 7HT, United Kingdom
| | - Antonio Monge
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, 31080 Pamplona, Spain
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26
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Vicente E, Lima LM, Bongard E, Charnaud S, Villar R, Solano B, Burguete A, Perez-Silanes S, Aldana I, Vivas L, Monge A. Synthesis and structure-activity relationship of 3-phenylquinoxaline 1,4-di-N-oxide derivatives as antimalarial agents. Eur J Med Chem 2007; 43:1903-10. [PMID: 18215443 DOI: 10.1016/j.ejmech.2007.11.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Revised: 11/23/2007] [Accepted: 11/27/2007] [Indexed: 11/26/2022]
Abstract
As a continuation of our research and with the aim of obtaining new antimalarial agents, new series of 3-phenylquinoxaline 1,4-di-N-oxide derivatives have been synthesized following the classical Beirut reaction. Antiplasmodial activity was evaluated in vitro against Plasmodium falciparum by the incorporation of [3H]-hypoxanthine. Cytotoxicity was tested in KB cells by AlamarBlue assay. Twenty-one of the 60 compounds that were assayed against 3D7 (CQ-sensitive) showed enough activity to be also evaluated against K1 (CQ-resistant) strain. Ten of them were shown to be more active than chloroquine in the resistant strain. The most interesting compounds are 7-(methyl or methoxy)-3-(4'-fluoro or chloro)phenylquinoxaline-2-carbonitrile 1,4-di-N-oxides because of their low IC50 and their high SI shown for the K1 strain, making them valid new leads.
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Affiliation(s)
- Esther Vicente
- Unidad de Investigación y Desarrollo de Medicamentos, Centro de Investigación en Farmacobiología Aplicada (CIFA), University of Navarra, C/Irunlarrea s/n, 31080 Pamplona, Spain
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27
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Metzger WG, Vivas-Martínez S, Rodriguez I, Gonçalves J, Bongard E, Fanello CI, Vivas L, Magris M. Malaria diagnosis under field conditions in the Venezuelan Amazon. Trans R Soc Trop Med Hyg 2007; 102:20-4. [PMID: 17919672 DOI: 10.1016/j.trstmh.2007.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2007] [Revised: 08/28/2007] [Accepted: 08/28/2007] [Indexed: 10/22/2022] Open
Abstract
To improve practical, accurate diagnosis of malaria in the Amazon rainforest of Venezuela, two rapid diagnostic tests (RDT) (OptiMAL-IT) and FalciVax) and a laboratory light microscope, used in the field with a battery-operated head lamp as an external light source, were evaluated against the standard laboratory microscope procedure for malaria detection. One hundred and thirty-six Yanomami patients were studied for the presence of malaria parasites. Thirty-three patients (24%) were positive for malaria (Plasmodium falciparum, P. vivax, P. malariae). Twenty-one (64%) of the positive patients had <100 parasites/microl. Both RDTs showed poor sensitivity (24.2% for OptiMAL-IT) and 36.4% for FalciVax) but good specificity (99% both for OptiMAL-IT) and FalciVax). Field and laboratory microscopy showed sensitivities of 94% and 91%, respectively. The kappa coefficient was 0.90, indicating a high agreement between field and laboratory microscopy. We conclude that (i) adequate slide reading cannot be substituted by either of the two RDTs in the Venezuelan Amazon and (ii) the use of a light source such as that described above makes slide reading more feasible than hitherto in remote areas without electricity.
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Affiliation(s)
- W G Metzger
- Centro Amazónico de Investigación y Control de Enfermedades Tropicales Simon Bolivar (CAICET), Puerto Ayacucho, Venezuela
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28
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Khan S, Chatfield S, Stratford R, Bedwell J, Bentley M, Sulsh S, Giemza R, Smith S, Bongard E, Cosgrove C, Johnson J, Dougan G, Griffin G, Makin J, Lewis D. Ability of SPI2 mutant of S. typhi to effectively induce antibody responses to the mucosal antigen enterotoxigenic E. coli heat labile toxin B subunit after oral delivery to humans. Vaccine 2007; 25:4175-82. [PMID: 17412462 PMCID: PMC2652036 DOI: 10.1016/j.vaccine.2007.03.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2005] [Revised: 03/05/2007] [Accepted: 03/05/2007] [Indexed: 12/01/2022]
Abstract
We have evaluated an oral vaccine based on an Salmonella enteric serovar typhi (S. typhi) Ty2 derivative TSB7 harboring deletion mutations in ssaV (SPI-2) and aroC together with a chromosomally integrated copy of eltB encoding the B subunit of enterotoxigenic Escherichia coli heat labile toxin (LT-B) in volunteers. Two oral doses of 10(8) or 10(9)CFU were administered to two groups of volunteers and both doses were well tolerated, with no vaccinemia, and only transient stool shedding. Immune responses to LT-B and S. typhi lipopolysaccharide were demonstrated in 67 and 97% of subjects, respectively, without evidence of anti-carrier immunity preventing boosting of LT-B responses in many cases. Further development of this salmonella-based (spi-VEC) system for oral delivery of heterologous antigens appears warranted.
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Affiliation(s)
- S. Khan
- Microscience, Wokingham Berkshire RG41 5TU, UK
| | | | | | - J. Bedwell
- Microscience, Wokingham Berkshire RG41 5TU, UK
| | - M. Bentley
- Microscience, Wokingham Berkshire RG41 5TU, UK
| | - S. Sulsh
- Microscience, Wokingham Berkshire RG41 5TU, UK
| | - R. Giemza
- St. George's Vaccine Institute, London SW17 0RE, UK
| | - S. Smith
- St. George's Vaccine Institute, London SW17 0RE, UK
| | - E. Bongard
- St. George's Vaccine Institute, London SW17 0RE, UK
| | | | - J. Johnson
- St. George's Vaccine Institute, London SW17 0RE, UK
| | - G. Dougan
- The Wellcome Trust Sanger Institute, Genome Campus, Cambridge CB10 1SA, UK
| | - G.E. Griffin
- St. George's Vaccine Institute, London SW17 0RE, UK
| | - J. Makin
- Microscience, Wokingham Berkshire RG41 5TU, UK
| | - D.J.M. Lewis
- St. George's Vaccine Institute, London SW17 0RE, UK
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Too K, Brown DM, Bongard E, Yardley V, Vivas L, Loakes D. Anti-malarial activity of N6-modified purine analogues. Bioorg Med Chem 2007; 15:5551-62. [PMID: 17548196 DOI: 10.1016/j.bmc.2007.05.038] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [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] [Received: 02/21/2007] [Revised: 05/10/2007] [Accepted: 05/15/2007] [Indexed: 11/16/2022]
Abstract
Plasmodium falciparum causes one of the deadliest forms of malaria and resistance to the currently available drugs makes it imperative to develop new, safe and potent drugs. Parasites such as P. falciparum are unable to synthesise purines de novo and to this end often have multiple purine uptake and salvage systems. With this in mind, we have designed and synthesised libraries of purine analogues as potential anti-malarial agents. Herein, we report three compounds with promising activity against the highly chloroquine-resistant VS1 P. falciparum namely: N(6)-hydroxyadenine (1c), 2-amino-N(6)-aminoadenosine (2b) and 2-amino-N(6)-amino-N(6)-methyladenosine (4b).
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Affiliation(s)
- Kathleen Too
- Medical Research Council, Laboratory of Molecular Biology, Hills Road, Cambridge CB2 2QH, UK
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Gosling RD, Uiso LO, Sam NE, Bongard E, Kanduma EG, Nyindo M, Morris RW, Gillespie SH. The bactericidal activity of moxifloxacin in patients with pulmonary tuberculosis. Am J Respir Crit Care Med 2003; 168:1342-5. [PMID: 12917230 DOI: 10.1164/rccm.200305-682oc] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Patients in whom acid-fast bacilli smear-positive pulmonary tuberculosis was newly diagnosed were randomized to receive 400 mg moxifloxacin, 300 mg isonaizid, or 600 mg rifampin daily for 5 days. Sixteen-hour overnight sputa collections were made for the 2 days before and for 5 days of monotherapy. Bactericidal activity was estimated by the time taken to kill 50% of viable bacilli (vt50) and the fall in sputum viable count during the first 2 days designated as the early bactericidal activity (EBA). The mean vt50 of moxifloxacin was 0.88 days (95% confidence interval [CI], 0.43-1.33 days) and the mean EBA was 0.53 (95% CI 0.28-0.79). For the isoniazid group, the mean vt50 was 0.46 days (95% CI, 0.31-0.61 days) and the mean EBA was 0.77 (95% CI, 0.54-1.00). For rifampin, the mean vt50 was 0.71 days (95% CI, 0.48-0.95 days) and the mean EBA was 0.28 (95% CI, 0.15-0.41). Using the EBA method, isoniazid was significantly more active than rifampin (p < 0.01) but not moxifloxacin. Using the vt50 method, isoniazid was more active than both rifampin and moxifloxacin (p = 0.03). Moxifloxacin has an activity similar to rifampin in human subjects with pulmonary tuberculosis, suggesting that it should undergo further assessment as part of a short course regimen for the treatment of drug-susceptible tuberculosis.
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Affiliation(s)
- Roly D Gosling
- Department of Medical Microbiology, Royal Free and University London College Medical Schools, Royal Free Campus, London, UK
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