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Gilson R, Nugent D, Bennett K, Doré CJ, Murray ML, Meadows J, Haddow LJ, Lacey C, Sandmann F, Jit M, Soldan K, Tetlow M, Caverly E, Nathan M, Copas AJ. Imiquimod versus podophyllotoxin, with and without human papillomavirus vaccine, for anogenital warts: the HIPvac factorial RCT. Health Technol Assess 2021; 24:1-86. [PMID: 32975189 DOI: 10.3310/hta24470] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The comparative efficacy, and cost-effectiveness, of imiquimod or podophyllotoxin cream, either alone or in combination with the quadrivalent HPV vaccine (Gardasil®, Merck Sharp & Dohme Corp., Merck & Co., Inc., Whitehouse Station, NJ, USA) in the treatment and prevention of recurrence of anogenital warts is not known. OBJECTIVE The objective was to compare the efficacy of imiquimod and podophyllotoxin creams to treat anogenital warts and to assess whether or not the addition of quadrivalent human papillomavirus vaccine increases wart clearance or prevention of recurrence. DESIGN A randomised, controlled, multicentre, partially blinded factorial trial. Participants were randomised equally to four groups, combining either topical treatment with quadrivalent human papillomavirus vaccine or placebo. Randomisation was stratified by gender, a history of previous warts and human immunodeficiency virus status. There was an accompanying economic evaluation, conducted from the provider perspective over the trial duration. SETTING The setting was 22 sexual health clinics in England and Wales. PARTICIPANTS Participants were patients with a first or repeat episode of anogenital warts who had not been treated in the previous 3 months and had not previously received quadrivalent human papillomavirus vaccine. INTERVENTIONS Participants were randomised to 5% imiquimod cream (Aldara®; Meda Pharmaceuticals, Takeley, UK) for up to 16 weeks or 0.15% podophyllotoxin cream (Warticon®; GlaxoSmithKlein plc, Brentford, UK) for 4 weeks, which was extended to up to 16 weeks if warts persisted. Participants were simultaneously randomised to quadrivalent human papillomavirus vaccine (Gardasil) or saline control at 0, 8 and 24 weeks. Cryotherapy was permitted after week 4 at the discretion of the investigator. MAIN OUTCOME MEASURES The main outcome measures were a combined primary outcome of wart clearance at week 16 and remaining wart free at week 48. Efficacy analysis was by logistic regression with multiple imputation for missing follow-up values; economic evaluation considered the costs per quality-adjusted life-year. RESULTS A total of 503 participants were enrolled and attended at least one follow-up visit. The mean age was 31 years, 66% of participants were male (24% of males were men who have sex with men), 50% had a previous history of warts and 2% were living with human immunodeficiency virus. For the primary outcome, the adjusted odds ratio for imiquimod cream versus podophyllotoxin cream was 0.81 (95% confidence interval 0.54 to 1.23), and for quadrivalent human papillomavirus vaccine versus placebo, the adjusted odds ratio was 1.46 (95% confidence interval 0.97 to 2.20). For the components of the primary outcome, the adjusted odds ratio for wart free at week 16 for imiquimod versus podophyllotoxin was 0.77 (95% confidence interval 0.52 to 1.14) and for quadrivalent human papillomavirus vaccine versus placebo was 1.30 (95% confidence interval 0.89 to 1.91). The adjusted odds ratio for remaining wart free at 48 weeks (in those who were wart free at week 16) for imiquimod versus podophyllotoxin was 0.98 (95% confidence interval 0.54 to 1.78) and for quadrivalent human papillomavirus vaccine versus placebo was 1.39 (95% confidence interval 0.73 to 2.63). Podophyllotoxin plus quadrivalent human papillomavirus vaccine had inconclusive cost-effectiveness compared with podophyllotoxin alone. LIMITATIONS Hepatitis A vaccine as control was replaced by a saline placebo in a non-identical syringe, administered by someone outside the research team, for logistical reasons. Sample size was reduced from 1000 to 500 because of slow recruitment and other delays. CONCLUSIONS A benefit of the vaccine was not demonstrated in this trial. The odds of clearance at week 16 and remaining clear at week 48 were 46% higher with vaccine, and consistent effects were seen for both wart clearance and recurrence separately, but these differences were not statistically significant. Imiquimod and podophyllotoxin creams had similar efficacy for wart clearance, but with a wide confidence interval. The trial results do not support earlier evidence of a lower recurrence with use of imiquimod than with use of podophyllotoxin. Podophyllotoxin without quadrivalent human papillomavirus vaccine is the most cost-effective strategy at the current vaccine list price. A further larger trial is needed to definitively investigate the effect of the vaccine; studies of the immune response in vaccine recipients are needed to investigate the mechanism of action. TRIAL REGISTRATION Current Controlled Trials. Current Controlled Trials ISRCTN32729817 and EudraCT 2013-002951-14. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 47. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Richard Gilson
- University College London Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK.,Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Diarmuid Nugent
- University College London Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK.,Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Kate Bennett
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Macey L Murray
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Jade Meadows
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Lewis J Haddow
- University College London Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, UK.,Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Charles Lacey
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, UK
| | - Frank Sandmann
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - Kate Soldan
- Statistics, Modelling and Economics Department, Public Health England, London, UK
| | - Michelle Tetlow
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Emilia Caverly
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Mayura Nathan
- Homerton Anogenital Neoplasia Service, Homerton University Hospital NHS Foundation Trust, London, UK
| | - Andrew J Copas
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK.,Medical Research Council Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, London, UK
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Pett SL, Spyer M, Haddow LJ, Nhema R, Benjamin LA, Najjuka G, Bilima S, Daud I, Musoro G, Kitabalwa J, Selemani G, Kandie S, Cornelius KM, Katemba C, Berkley JA, Hassan AS, Kityo C, Hakim J, Heyderman RS, Gibb DM, Walker AS. Benefits of enhanced infection prophylaxis at antiretroviral therapy initiation by cryptococcal antigen status. AIDS 2021; 35:585-594. [PMID: 33306556 PMCID: PMC7613319 DOI: 10.1097/qad.0000000000002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess baseline prevalence of cryptococcal antigen (CrAg) positivity; and its contribution to reductions in all-cause mortality, deaths from cryptococcus and unknown causes, and new cryptococcal disease in the REALITY trial. DESIGN Retrospective CrAg testing of baseline and week-4 plasma samples in all 1805 African adults/children with CD4+ cell count less than 100 cells/μl starting antiretroviral therapy who were randomized to receive 12-week enhanced-prophylaxis (fluconazole 100 mg/day, azithromycin, isoniazid, cotrimoxazole) vs. standard-prophylaxis (cotrimoxazole). METHODS Proportional hazards models were used to estimate the relative impact of enhanced-prophylaxis vs. standard-cotrimoxazole on all, cryptococcal and unknown deaths, and new cryptococcal disease, through 24 weeks, by baseline CrAg positivity. RESULTS Excluding 24 (1.4%) participants with active/prior cryptococcal disease at enrolment (all treated for cryptococcal disease), 133/1781 (7.5%) participants were CrAg-positive. By 24 weeks, 105 standard-cotrimoxazole vs. 78 enhanced-prophylaxis participants died. Of nine standard-cotrimoxazole and three enhanced-prophylaxis cryptococcal deaths, seven and two, respectively, were CrAg-positive at baseline. Among deaths of unknown cause, only 1/46 standard-cotrimoxazole and 1/28 enhanced-prophylaxis were CrAg-positive at baseline. There was no evidence that relative reductions in new cryptococcal disease associated with enhanced-prophylaxis varied between baseline CrAg-positives [hazard-ratio = 0.36 (95% confidence interval 0.13-0.98), incidence 19.5 vs. 56.5/100 person-years] and CrAg-negatives [hazard-ratio = 0.33 (0.03-3.14), incidence 0.3 vs. 0.9/100 person-years; Pheterogeneity = 0.95]; nor for all deaths, cryptococcal deaths or unknown deaths (Pheterogeneity > 0.3). CONCLUSION Relative reductions in cryptococcal disease/death did not depend on CrAg status. Deaths of unknown cause were unlikely to be cryptococcus-related; plausibly azithromycin contributed to their reduction. Findings support including 100 mg fluconazole in an enhanced-prophylaxis package at antiretroviral therapy initiation where CrAg screening is unavailable/impractical.
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Affiliation(s)
- Sarah L. Pett
- Institute for Global Health
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
- Kirby Institute for Infection and Immunity in Society, University of New South Wales, Sydney, New South Wales, Australia
| | - Moira Spyer
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | | | - Ruth Nhema
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Laura A. Benjamin
- Institute of Neurology, UCL, London
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | | | - Sithembile Bilima
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | - Godfrey Musoro
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | | | - George Selemani
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | | | | | | | | | | | - Cissy Kityo
- Joint Clinical Research Centre, Kampala, Uganda
| | - James Hakim
- University of Zimbabwe Clinical Research Centre, Harare, Zimbabwe
| | - Robert S. Heyderman
- Department/College of Medicine and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
- Division of Infection and Immunity, UCL, London, UK
| | - Diana M. Gibb
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
| | - Ann S. Walker
- MRC CTU at UCL, Institute of Clinical Trials and Methodology, UCL, London, UK
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Haddow LJ, Godi C, Sokolska M, Cardoso MJ, Oliver R, Winston A, Stöhr W, Clarke A, Chen F, Williams IG, Johnson M, Paton N, Arenas-Pinto A, Golay X, Jäger HR. Brain Perfusion, Regional Volumes, and Cognitive Function in Human Immunodeficiency Virus-positive Patients Treated With Protease Inhibitor Monotherapy. Clin Infect Dis 2020; 68:1031-1040. [PMID: 30084882 DOI: 10.1093/cid/ciy617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/30/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Protease inhibitor monotherapy (PIM) for human immunodeficiency virus (HIV) may exert suboptimal viral control in the central nervous system. We determined whether cerebral blood flow (CBF) and regional brain volumes were associated with PIM, and whether specific cognitive domains were associated with imaging biomarkers. METHODS Cognitive assessments and brain magnetic resonance imaging were performed after the final visit of a randomized HIV-treatment strategy trial. Participants were virologically suppressed on triple therapy at trial entry and followed for 3-5 years. We studied 37 patients randomized to ongoing triple therapy and 39 randomized to PIM. Resting CBF and normalized volumes were calculated for brain regions of interest, and correlated with treatment strategy and neuropsychological performance. RESULTS Mean age was 48.1 years (standard deviation 8.6 years), 63 male (83%), and 64 white (84%). Participants had median 8.1 years (interquartile range 6.4, 10.8) of antiretroviral therapy experience and CD4+ counts of median 640 cells/mm3 (interquartile range 490, 780). We found no difference between treatment arms in CBF or regional volumes. Regardless of treatment arm, poorer fine motor performance correlated with lower CBF in the caudate nucleus (P = .01), thalamus (P = .04), frontal cortex (P = .01), occipital cortex (P = .004), and cingulate cortex (P = .02), and was associated with smaller supratentorial white matter volume (decrease of 0.16 in Z-score per -1% of intracranial volume, 95% confidence interval 0.02-0.29; P = .023). CONCLUSIONS PIM does not confer an additional risk of neurological injury compared with triple therapy. There were correlations between fine motor impairment, grey matter hypoperfusion, and white matter volume loss. CLINICAL TRIALS REGISTRATION ISRCTN-04857074.
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Affiliation(s)
- Lewis J Haddow
- Institute of Global Health, University College London, United Kingdom
| | - Claudia Godi
- Institute of Neurology, University College London, United Kingdom.,Department of Neuroradiology, Ospedale San Raffaele, Milan, Italy
| | - Magdalena Sokolska
- Institute of Neurology, University College London, United Kingdom.,Department of Medical Physics and Biomedical Engineering, University College London Hospitals National Health Service (NHS) Foundation Trust, United Kingdom
| | - M Jorge Cardoso
- Centre for Medical Image Computing, University College London, United Kingdom
| | - Ruth Oliver
- Institute of Neurology, University College London, United Kingdom.,Department of Engineering, Macquarie University, Sydney, New South Wales, Australia
| | - Alan Winston
- Department of Medicine, Imperial College London, United Kingdom
| | - Wolfgang Stöhr
- The Medical Research Council Clinical Trials Unit at University College London, United Kingdom
| | - Amanda Clarke
- Elton John Centre, Brighton and Sussex University Hospital, United Kingdom
| | - Fabian Chen
- The Florey Sexual Health Clinic, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - Ian G Williams
- Institute of Global Health, University College London, United Kingdom
| | - Margaret Johnson
- Ian Charleson Day Centre, Royal Free London NHS Foundation Trust, United Kingdom
| | - Nick Paton
- The Medical Research Council Clinical Trials Unit at University College London, United Kingdom.,Department of Medicine, National University of Singapore
| | - Alejandro Arenas-Pinto
- Institute of Global Health, University College London, United Kingdom.,The Medical Research Council Clinical Trials Unit at University College London, United Kingdom
| | - Xavier Golay
- Institute of Neurology, University College London, United Kingdom
| | - Hans Rolf Jäger
- Institute of Neurology, University College London, United Kingdom.,Centre of Medical Imaging, University College London Hospitals NHS Foundation Trust, United Kingdom
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4
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Orbes-Arteaga M, Varsavsky T, Sudre CH, Eaton-Rosen Z, Haddow LJ, Sørensen L, Nielsen M, Pai A, Ourselin S, Modat M, Nachev P, Cardoso MJ. Multi-domain Adaptation in Brain MRI Through Paired Consistency and Adversarial Learning. Domain Adapt Represent Transf Med Image Learn Less Labels Imperfect Data (2019) 2019; 2019:54-62. [PMID: 34109324 PMCID: PMC7610933 DOI: 10.1007/978-3-030-33391-1_7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Supervised learning algorithms trained on medical images will often fail to generalize across changes in acquisition parameters. Recent work in domain adaptation addresses this challenge and successfully leverages labeled data in a source domain to perform well on an unlabeled target domain. Inspired by recent work in semi-supervised learning we introduce a novel method to adapt from one source domain to n target domains (as long as there is paired data covering all domains). Our multi-domain adaptation method utilises a consistency loss combined with adversarial learning. We provide results on white matter lesion hyperintensity segmentation from brain MRIs using the MICCAI 2017 challenge data as the source domain and two target domains. The proposed method significantly outperforms other domain adaptation baselines.
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Affiliation(s)
- Mauricio Orbes-Arteaga
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Biomediq A/S, Copenhagen, Denmark
| | - Thomas Varsavsky
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Carole H. Sudre
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Medical Physics and Biomedical Engineering, UCL, London, UK
- Institute of Neurology, University College London, London, UK
| | - Zach Eaton-Rosen
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
- Department of Medical Physics and Biomedical Engineering, UCL, London, UK
| | - Lewis J. Haddow
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Lauge Sørensen
- Biomediq A/S, Copenhagen, Denmark
- Cereriu A/S, Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Mads Nielsen
- Biomediq A/S, Copenhagen, Denmark
- Cereriu A/S, Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Akshay Pai
- Biomediq A/S, Copenhagen, Denmark
- Cereriu A/S, Copenhagen, Denmark
- Department of Computer Science, University of Copenhagen, Copenhagen, Denmark
| | - Sébastien Ourselin
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | - Marc Modat
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
| | | | - M. Jorge Cardoso
- Biomedical Engineering and Imaging Sciences, King’s College London, London, UK
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5
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Haddow LJ, Sudre CH, Sokolska M, Gilson RC, Williams IG, Golay X, Ourselin S, Winston A, Sabin CA, Cardoso MJ, Jäger HR, Boffito M, Mallon P, Post F, Sabin C, Sachikonye M, Winston A, Anderson J, Asboe D, Boffito M, Garvey L, Mallon P, Post F, Pozniak A, Sabin C, Sachikonye M, Vera J, Williams I, Winston A, Post F, Campbell L, Yurdakul S, Okumu S, Pollard L, Williams I, Otiko D, Phillips L, Laverick R, Beynon M, Salz AL, Fisher M, Clarke A, Vera J, Bexley A, Richardson C, Mallon P, Macken A, Ghavani-Kia B, Maher J, Byrne M, Flaherty A, Babu S, Anderson J, Mguni S, Clark R, Nevin-Dolan R, Pelluri S, Johnson M, Ngwu N, Hemat N, Jones M, Carroll A, Whitehouse A, Burgess L, Babalis D, Winston A, Garvey L, Underwood J, Stott M, McDonald L, Boffito M, Asboe D, Pozniak A, Higgs C, Seah E, Fletcher S, Anthonipillai M, Moyes A, Deats K, Syed I, Matthews C, Fernando P, Sabin C, De Francesco D, Bagkeris E. Magnetic Resonance Imaging of Cerebral Small Vessel Disease in Men Living with HIV and HIV-Negative Men Aged 50 and Above. AIDS Res Hum Retroviruses 2019; 35:453-460. [PMID: 30667282 DOI: 10.1089/aid.2018.0249] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
We assessed whether HIV status was associated with white matter hyperintensities (WMH), a neuroimaging correlate of cerebral small vessel disease (CSVD), in men aged ≥50 years. A cross-sectional substudy was nested within a larger cohort study. Virologically suppressed men living with HIV (MLWH) and demographically matched HIV-negative men aged ≥50 underwent magnetic resonance imaging (MRI) at 3 Tesla. Sequences included volumetric three-dimensional (3D) T1-weighted, fluid-attenuated inversion recovery and pseudocontinuous arterial spin labeling. Regional segmentation by automated image processing algorithms was used to extract WMH volume (WMHV) and resting cerebral blood flow (CBF). The association between HIV status and WMHV as a proportion of intracranial volume (ICV; log-transformed) was estimated using a multivariable linear regression model. Thirty-eight MLWH [median age 59 years (interquartile range, IQR 55-64)] and 37 HIV-negative [median 58 years (54-63)] men were analyzed. MLWH had median CD4+ count 570 (470-700) cells/μL and a median time since diagnosis of 20 (14-24) years. Framingham 10-year risk of cardiovascular disease was 6.5% in MLWH and 7.4% in controls. Two (5%) MLWH reported a history of stroke or transient ischemic attack and five (13%) reported coronary heart disease compared with none of the controls. The total WMHV in MLWH was 1,696 μL (IQR 1,229-3,268 μL) or 0.10% of ICV compared with 1,627 μL (IQR 1,032-3,077 μL), also 0.10% of ICV in the HIV-negative group (p = .43). In the multivariable model, WMHV/ICV was not associated with HIV status (p = .86). There was an age-dependent decline in cortical CBF [-3.9 mL/100 mL/min per decade of life (95% confidence interval 1.1-6.7 mL)] but no association between CBF and HIV status (p > .2 in all brain regions analyzed). In conclusion, we found no quantitative MRI evidence of an increased burden of CSVD in MLWH aged 50 years and older.
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Affiliation(s)
- Lewis J. Haddow
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Carole H. Sudre
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Magdalena Sokolska
- Department of Medical Physics and Biomedical Engineering, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Richard C. Gilson
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Ian G. Williams
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
- Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Xavier Golay
- Research Department of Brain Repair and Rehabilitation, University College London, London, United Kingdom
| | - Sebastien Ourselin
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - Alan Winston
- Department of Medicine, Imperial College London, London, United Kingdom
| | - Caroline A. Sabin
- Centre for Clinical Research in Infection and Sexual Health, Institute for Global Health, University College London, London, United Kingdom
| | - M. Jorge Cardoso
- Centre for Medical Image Computing, University College London, London, United Kingdom
| | - H. Rolf Jäger
- Research Department of Brain Repair and Rehabilitation, University College London, London, United Kingdom
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Murray ML, Meadows J, Doré CJ, Copas AJ, Haddow LJ, Lacey C, Jit M, Soldan K, Bennett K, Tetlow M, Nathan M, Gilson R. Human papillomavirus infection: protocol for a randomised controlled trial of imiquimod cream (5%) versus podophyllotoxin cream (0.15%), in combination with quadrivalent human papillomavirus or control vaccination in the treatment and prevention of recurrence of anogenital warts (HIPvac trial). BMC Med Res Methodol 2018; 18:125. [PMID: 30400777 PMCID: PMC6220496 DOI: 10.1186/s12874-018-0581-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 10/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anogenital warts are the second most common sexually transmitted infection diagnosed in sexual health services in England. About 90% of genital warts are caused by human papillomavirus (HPV) types 6 or 11, and half of episodes diagnosed are recurrences. The best and most cost-effective treatment for patients with anogenital warts is unknown. The commonly used treatments are self-administered topical agents, podophyllotoxin (0.15% cream) or imiquimod (5% cream), or cryotherapy with liquid nitrogen. Quadrivalent HPV (qHPV) vaccination is effective in preventing infection, and disease, but whether it has any therapeutic effect is not known. METHODS AND DESIGN To investigate the efficacy of clearance and prevention of recurrence of external anogenital warts by topical treatments, podophyllotoxin 0.15% cream or imiquimod 5% cream, in combination with a three-dose regimen of qHPV or control vaccination. 500 adult patients presenting with external anogenital warts with either a first or subsequent episode of anogenital warts will be entered into this randomised, controlled partially blinded 2 × 2 factorial trial. DISCUSSION The trial is expected to provide the first high-quality evidence of the comparative efficacy and cost-effectiveness of the two topical treatments in current use, as well as investigate the potential benefit of HPV vaccination, in the management of anogenital warts. TRIAL REGISTRATION The trial was registered prior to starting recruitment under the following reference numbers: International Standard Randomized Controlled Trial Number (ISRCTN) Registry - ISRCTN32729817 (registered 25 July 2014); European Union Clinical Trials Register (EudraCT) - 2013-002951-14 (registered 26 June 2013).
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Affiliation(s)
- Macey L Murray
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Jade Meadows
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Andrew J Copas
- UCL Centre for Clinical Research in Infection and Sexual Health, The Mortimer Market Centre, Institute for Global Health, University College London, London, WC1E 6JB, UK
| | - Lewis J Haddow
- UCL Centre for Clinical Research in Infection and Sexual Health, The Mortimer Market Centre, Institute for Global Health, University College London, London, WC1E 6JB, UK
| | - Charles Lacey
- Centre for Immunology and Infection, Hull York Medical School, University of York, York, YO10 5DD, UK
| | - Mark Jit
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.,Public Health England, London, NW9 5EQ, UK
| | | | - Kate Bennett
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Michelle Tetlow
- Comprehensive Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, Gower Street, London, WC1E 6BT, UK
| | - Mayura Nathan
- Homerton Anal Neoplasia Service, Homerton University Hospital NHS Foundation Trust, London, E9 6SR, UK
| | - Richard Gilson
- UCL Centre for Clinical Research in Infection and Sexual Health, The Mortimer Market Centre, Institute for Global Health, University College London, London, WC1E 6JB, UK.
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7
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Haddow LJ, Laverick R, Daskalopoulou M, McDonnell J, Lampe FC, Gilson R, Speakman A, Antinori A, Balestra P, Bruun T, Gerstoft J, Nielsen L, Vassilenko A, Collins S, Rodger AJ. Multicenter European Prevalence Study of Neurocognitive Impairment and Associated Factors in HIV Positive Patients. AIDS Behav 2018; 22:1573-1583. [PMID: 28144792 PMCID: PMC5902513 DOI: 10.1007/s10461-017-1683-z] [Citation(s) in RCA: 24] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We conducted a cross-sectional study in 448 HIV positive patients attending five European outpatient clinics to determine prevalence of and factors associated with neurocognitive impairment (NCI) using computerized and pen-and-paper neuropsychological tests. NCI was defined as a normalized Z score ≤-1 in at least 2 out of 5 cognitive domains. Participants' mean age was 45.8 years; 84% male; 87% white; 56% university educated; median CD4 count 550 cells/mm3; 89% on antiretroviral therapy. 156 (35%) participants had NCI, among whom 26 (17%; 5.8% overall) reported a decline in activities of daily living. Prevalence of NCI was lower in those always able to afford basic needs (adjusted prevalence ratio [aPR] 0.71, 95% confidence interval [CI] 0.54-0.94) or with a university education (aPR 0.72, 95% CI 0.54-0.97) and higher in those with severe depressive symptoms (aPR 1.53, 95% CI 1.09-2.14) or a significant comorbid condition (aPR 1.40, 95% CI 1.03-1.90).
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Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK.
| | - Rosanna Laverick
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Marina Daskalopoulou
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | | | - Fiona C Lampe
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Richard Gilson
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Andrew Speakman
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
| | - Andrea Antinori
- National Institute for Infectious Diseases, Lazzaro Spallanzani, Rome, Italy
| | - Pietro Balestra
- National Institute for Infectious Diseases, Lazzaro Spallanzani, Rome, Italy
| | - Tina Bruun
- Department of Infectious Diseases, Rigshospitalet, Centre for Health & Infectious Disease Research (CHIP), University of Copenhagen, Copenhagen, Denmark
| | - Jan Gerstoft
- Department of Infectious Diseases, Rigshospitalet, Centre for Health & Infectious Disease Research (CHIP), University of Copenhagen, Copenhagen, Denmark
| | - Lars Nielsen
- Infektionsmedicinsk Afdeling, Nordsjællands Hospital, Hillerød, Denmark
| | | | | | - Alison J Rodger
- Research Department of Infection and Population Health, Mortimer Market Centre, University College London, Capper Street, London, WC1E 6JB, UK
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Kugathasan R, Collier DA, Haddow LJ, El Bouzidi K, Edwards SG, Cartledge JD, Miller RF, Gupta RK. Diffuse White Matter Signal Abnormalities on Magnetic Resonance Imaging Are Associated With Human Immunodeficiency Virus Type 1 Viral Escape in the Central Nervous System Among Patients With Neurological Symptoms. Clin Infect Dis 2017; 64:1059-1065. [PMID: 28329096 PMCID: PMC5439343 DOI: 10.1093/cid/cix035] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/16/2017] [Indexed: 01/15/2023] Open
Abstract
Background. Human immunodeficiency virus type 1 (HIV-1) can replicate independently in extravascular compartments such as the central nervous system, resulting in either cerebrospinal fluid (CSF) discordance (viral load [VL] in CSF 0.5 log10 copies HIV-1 RNA greater than plasma VL) or escape (detection of HIV VL >50 copies/mL in CSF in patients with suppressed plasma VL <50 copies/mL). Both discordance and escape may be associated with neurological symptoms. We explored risk factors for CSF discordance and escape in patients presenting with diverse neurological problems. Methods. HIV-infected adult patients undergoing diagnostic lumbar puncture (LP) at a single center between 2011 and 2015 were included in the analysis. Clinical and neuroimaging variables associated with CSF discordance/escape were identified using multivariate logistic regression. Results. One hundred forty-six patients with a median age of 45.3 (interquartile range [IQR], 39.6–51.5) years underwent 163 LPs. Median CD4 count was 430 (IQR, 190–620) cells/µL. Twenty-four (14.7%) LPs in 22 patients showed CSF discordance, of which 10 (6.1%) LPs in 9 patients represented CSF escape. In multivariate analysis, both CSF discordance and escape were associated with diffuse white matter signal abnormalities (DWMSAs) on cranial magnetic resonance imaging (adjusted odds ratio, 10.3 [95% confidence interval {CI}, 2.3–45.0], P = .007 and 56.9 [95% CI, 4.0–882.8], P = .01, respectively). All 7 patients with CSF escape (10 LPs) had been diagnosed with HIV >7 years prior to LP, and 6 of 6 patients with resistance data had documented evidence of drug-resistant virus in plasma. Conclusions. Among patients presenting with diverse neurological problems, CSF discordance or escape was observed in 15%, with treatment-experienced patients dominating the escape group. DWMSAs in HIV-infected individuals presenting with neurological problems should raise suspicion of possible CSF discordance/escape.
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Affiliation(s)
| | - Dami A Collier
- Division of Infection and Immunity, University College London, United Kingdom
| | - Lewis J Haddow
- Central and North West London NHS Foundation Trust, United Kingdom.,Research Department of Infection and Population Health, University College London, United Kingdom
| | - Kate El Bouzidi
- Division of Infection and Immunity, University College London, United Kingdom
| | - Simon G Edwards
- Central and North West London NHS Foundation Trust, United Kingdom
| | | | - Robert F Miller
- Central and North West London NHS Foundation Trust, United Kingdom.,Research Department of Infection and Population Health, University College London, United Kingdom.,Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Ravindra K Gupta
- Division of Infection and Immunity, University College London, United Kingdom
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10
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Haddow LJ, Herbert S. Clinical round-up. Sex Transm Infect 2016; 91:621. [PMID: 26900616 DOI: 10.1136/sextrans-2015-052257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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11
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Haddow LJ, Herbert S. Clinical round-up. Br J Vener Dis 2016. [DOI: 10.1136/sextrans-2015-052366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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12
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Haddow LJ, Pierce KJ, Daskalopoulou M, Lampe F, Rodger AJ. Neurocognitive change observed in the CHARTER HIV cohort could be due to chance, and may be a cause as well as a consequence of detectable viremia. Clin Infect Dis 2015; 60:1441-2. [PMID: 25645215 DOI: 10.1093/cid/civ043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, University College London
| | - Katherine J Pierce
- Community Neurology and Stroke Service, Central and North West London NHS Foundation Trust, United Kingdom
| | - Marina Daskalopoulou
- Research Department of Infection and Population Health, University College London
| | - Fiona Lampe
- Research Department of Infection and Population Health, University College London
| | - Alison J Rodger
- Research Department of Infection and Population Health, University College London
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13
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Haddow LJ, Dudau C, Chandrashekar H, Cartledge JD, Hyare H, Miller RF, Jäger HR. Cross-sectional study of unexplained white matter lesions in HIV positive individuals undergoing brain magnetic resonance imaging. AIDS Patient Care STDS 2014; 28:341-9. [PMID: 24785779 DOI: 10.1089/apc.2013.0230] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
White matter (WM) abnormalities are frequently seen on brain MRI of HIV positive (HIV+) patients. We aimed to determine the prevalence of unexplained WM abnormalities and their associations with HIV disease and cardiovascular risk factors. We conducted a retrospective, cross-sectional study of brain MRI of HIV+ patients conducted between 2004 and 2009 at our center. Clinical and laboratory data were compiled, and images were independently reviewed for WM lesions. Images were obtained from 254 patients: 70% male, 53% white, 40% black, mean age 42 years, median current CD4 count 240 cells/mm(3), and 41% not taking antiretroviral therapy (ART). Hyperintense WM lesions were present in 161 patients (63.4%): 89 scans (35.0%) showed diffuse WM signal abnormality (DWMSA), 61 (24.0%) were consistent with small vessel disease (SVD, graded by Fazekas' scale), and 37 (14.6%) showed large asymmetrical focal WM lesions. SVD changes were associated with age and cardiovascular risk factors, and while cerebral SVD may be related to HIV infection, the MRI findings were not associated with HIV-related factors. The only risk factor for DWMSA was black race, and no correlation with cardiovascular risk factors, CD4 count, or clinical presentation was identified. DWMSA are therefore of uncertain neurological significance in HIV+ patients and could represent more than one clinicopathological entity.
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Affiliation(s)
- Lewis J. Haddow
- Research Department of Infection and Population Health, Institute of Epidemiology and Health Care, Institute of Neurology, University College London, London, United Kingdom
- Department of Genitourinary Medicine, Central and North West London NHS Foundation Trust, London, United Kingdom
| | - Cristina Dudau
- Department of Imaging, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Hoskote Chandrashekar
- Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Jonathan D. Cartledge
- Department of Genitourinary Medicine, Central and North West London NHS Foundation Trust, London, United Kingdom
- Department of Infection, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Harpreet Hyare
- Department of Imaging, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Neurodegenerative Disease, Institute of Neurology, University College London, London, United Kingdom
| | - Robert F. Miller
- Research Department of Infection and Population Health, Institute of Epidemiology and Health Care, Institute of Neurology, University College London, London, United Kingdom
- Department of Infection, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - H. Rolf Jäger
- Department of Imaging, University College London Hospitals NHS Foundation Trust, London, United Kingdom
- Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, London, United Kingdom
- Research Department of Brain Repair and Rehabilitation, Institute of Neurology, University College London, London, United Kingdom
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Abstract
The field of HIV medicine has changed rapidly in the last two decades since effective and tolerable antiretroviral treatment became available. As a result, although classical opportunistic infections of the brain have become less common, clinicians need to be aware of a wider range of acute and chronic complications of HIV and its treatment. In this article, we summarise major opportunistic infections, immune reconstitution inflammatory syndrome, HIV-associated neurocognitive disorders, and cerebrovascular disease in HIV positive patients. We also emphasise the preventability and reversibility of most of the central nervous system complications of HIV, and hence the importance of early diagnosis of HIV and involvement of clinicians with special expertise in HIV medicine.
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Affiliation(s)
- Lewis J Haddow
- Research Department of Infection and Population Health, University College London, UK
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15
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Oliver BG, Haddow LJ, Agarwal U, Kumar M, Easterbrook PJ, Moosa MY, Singh S, Price P. Pre-antiretroviral therapy plasma levels of CCL2 may aid in the prediction of tuberculosis-associated immune reconstitution inflammatory syndrome in HIV patients after they commence antiretroviral therapy. J Acquir Immune Defic Syndr 2013; 63:e72-4. [PMID: 23666138 DOI: 10.1097/qai.0b013e31828e6182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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16
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Haddow LJ, Accoroni A, Cartledge JD, Manji H, Benn P, Gilson RJC. Routine detection and management of neurocognitive impairment in HIV-positive patients in a UK centre. Int J STD AIDS 2013; 24:217-9. [PMID: 23535355 PMCID: PMC4138002 DOI: 10.1177/0956462412472452] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We estimated the burden of HIV-associated neurocognitive disorders (HAND) in a UK clinic. From a random sample, and referrals to specialist services over one year (neurology, clinical psychology, hospital admissions), we determined whether patients were diagnosed with HIV-associated dementia (HAD) and whether they reported symptoms suggesting neurocognitive impairment (NCI). In the first sample, 2/150 (prevalence 1.3%; 95% confidence interval [CI] 0.2–4.7%) had documented HAD. Eleven patients (7.3%; CI 3.7–12.7%) reported recent symptoms suggesting NCI; most of these individuals were diagnosed with a psychiatric or substance-use disorder. Among specialist referrals with symptoms suggesting NCI, 11 were diagnosed with HAD from a clinic population of 3129 individuals (annual incidence 0.4%; CI 0.2–0.6%). No patients with mildly symptomatic or asymptomatic HAND were identified in either sample, suggesting that such patients remain undetected in current clinical practice. Evidence-based screening for HAND in HIV clinics may be needed.
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Affiliation(s)
- L J Haddow
- Centre for Sexual Health and HIV Research, Research Department of Infection and Population Health, University College London
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17
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Price P, Haddow LJ, Affandi J, Agarwal U, Easterbrook PJ, Elliott J, French M, Kumar M, Moosa MYS, Oliver B, Singh S, Sola M, Saphonn V, Vun MC. Short communication: Plasma levels of vitamin D in HIV patients initiating antiretroviral therapy do not predict immune restoration disease associated with Mycobacterium tuberculosis. AIDS Res Hum Retroviruses 2012; 28:1216-9. [PMID: 22280097 DOI: 10.1089/aid.2011.0272] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Immune restoration disease associated with Mycobacterium tuberculosis (TB IRD) is clinically important among HIV patients commencing antiretroviral therapy in countries where tuberculosis is endemic. Vitamin D affects dendritic cell and T cell function and the antimicrobial activity of monocytes. Plasma levels of vitamin D and polymorphisms in the vitamin D receptor may affect tuberculosis, and HIV infection associates with vitamin D deficiency. Here we assess whether plasma vitamin D levels may predict TB IRD. Samples were available from prospective studies of TB IRD in Cambodia (26 cases), India (19 cases), and South Africa (29 cases). IRD cases and controls from each site were similar in age and baseline CD4(+) T cell count. Plasma samples were assessed using 25(OH) vitamin D immunoassay plates. DNA samples were available from a subset of patients and were genotyped for the VDR FokI (F/f) [C/T, rs10735810] SNP. When data from each cohort were pooled to assess ethnic/geographic differences, 25(OH)D levels were higher in Cambodian than Indian or South African patients (p<0.0001) and higher in South African than Indian patients (p<0.0001). TB IRD was not associated with differences in levels of 25(OH)D in any cohort (p=0.36-0.82), irrespective of the patients' prior TB diagnoses/treatment. Carriage of the minor allele of VDR FokI (F/f) was marginally associated with TB IRD in Indian patients (p=0.06) with no association in Cambodians. Neither plasma levels of vitamin D nor the vitamin D allele will usefully predict TB IRD in diverse populations from TB endemic regions.
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Affiliation(s)
- Patricia Price
- School of Pathology and Laboratory Medicine, University of Western Australia, Nedlands, Australia.
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Haddow LJ, Easterbrook PJ, Mosam A, Khanyile NG, Parboosing R, Moodley P, Moosa MYS. Defining immune reconstitution inflammatory syndrome: evaluation of expert opinion versus 2 case definitions in a South African cohort. Clin Infect Dis 2009; 49:1424-32. [PMID: 19788360 DOI: 10.1086/630208] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND There is no validated case definition for human immunodeficiency virus-associated immune reconstitution inflammatory syndrome (IRIS). We measured the level of agreement of 2 published case definitions (hereafter referred to as CD1 and CD2) with expert opinion in a prospective cohort of patients who were starting antiretroviral therapy in South Africa. METHODS A total of 498 adult patients were monitored for the first 6 months of antiretroviral therapy. All new or worsening clinical events were reviewed by 2 investigators and classified on the basis of expert opinion, CD1, and CD2. Events were categorized according to whether they were paradoxical or unmasking in presentation. We measured positive, negative, and chance-corrected agreement (kappa) with expert opinion for CD1 and CD2, and reviewed areas of disagreement. RESULTS A total of 620 clinical events were recorded, of which, on the basis of expert opinion, 144 (23.2%) were defined as probable IRIS and 112 (18.1%) were defined as possible IRIS. Of the 144 probable IRIS events, 93 (64.6%) were unmasking in presentation, 99 (68.8%) were associated with dermatological or orogenital disease, and 45 (31.3%) were associated with tuberculosis or major opportunistic infections. Of the 620 clinical events recorded, 41 (6.6%) were classified as IRIS on the basis of CD1, and 156 (25.2%) were classified as IRIS on the basis of CD2. Positive agreement between CD1 and expert opinion was low for both unmasking (17.2%; kappa = 0.24) and paradoxical events (37.3%; kappa = 0.43), mainly because 1 major criterion requires IRIS to be atypical and either an opportunistic infection or a tumor, although negative agreement was >98%. In contrast, CD2 had good positive agreement (>75% for most event types), with a kappa value of 0.75 for paradoxical and 0.62 for unmasking. CONCLUSIONS CD2 agreed well with expert opinion, with additional clinical events, such as arthropathy and inflammatory dermatoses, being classified as IRIS and added to CD2. We propose revised case definitions for both paradoxical and unmasking IRIS.
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Affiliation(s)
- Lewis J Haddow
- Department of HIV and Genitourinary Medicine, King's College London, London, UK
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Haddow LJ, Wood CW, Ainsworth JG. Discontinuation of non-nucleoside reverse transcriptase inhibitor-based highly active antiretroviral therapy due to nucleoside analogue reverse transcriptase inhibitor-related metabolic toxicity. Int J STD AIDS 2007; 18:343-6. [PMID: 17524198 DOI: 10.1258/095646207780749790] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We aimed to evaluate the reasons for, and timing of, treatment changes in a cohort of treatment-naïve patients initiating non-nucleoside reverse transcriptase inhibitor (NNRTI)-containing highly active antiretroviral therapy (HAART). All 268 patients initiating these regimens between January 1998 and September 2003 were included. Median follow up was 103 weeks. The median baseline CD4 count was 150 cells/microL. Seven patients (3%) died and 155 patients (58%) experienced a change in their HAART regimen. The reasons drugs were discontinued included toxicity in 106 patients (40%), virological failure in 21 (8%), other reasons in 23 (9%) and unknown reasons in five (2%). Fifty-one patients (19%) stopped NRTIs due to peripheral neuropathy, hyperlactataemia, lipoatrophy, lipodystrophy or myelosuppression, and these events were more likely in patients with baseline CD4 count below the median (P = 0.039). The findings in this cohort show that discontinuation of HAART was commonly due to toxicity, especially metabolic or mitochondrial toxicity in those with lower baseline CD4 count.
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Affiliation(s)
- L J Haddow
- Coleridge Unit, North Middlesex University Hospital NHS Trust, Silver Street, Edmonton, London N18 1QX, UK
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Haddow LJ, Sullivan EA, Taylor J, Abel M, Cunningham AL, Tabrizi S, Mindel A. Herpes simplex virus type 2 (HSV-2) infection in women attending an antenatal clinic in the South Pacific island nation of Vanuatu. Sex Transm Dis 2007; 34:258-61. [PMID: 16940899 DOI: 10.1097/01.olq.0000237774.29010.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to estimate the prevalence and correlates of herpes simplex virus type 2 infection in women in an antenatal clinic in the South Pacific island nation of Vanuatu. STUDY DESIGN A prevalence survey of sexually transmitted infections of pregnant women attending an antenatal clinic at Vila Central Hospital was conducted in 1999-2000. Serum samples were tested for HSV-1 and HSV-2 antibodies by enzyme-linked immunosorbent assay. Results for other sexually transmitted infections and demographic and obstetric variables were analyzed for their association with HSV-2 serostatus. RESULTS HSV-2 serum antibody results were obtained on 535 women and HSV-1 results on 134. The seroprevalence of HSV-2 was 30% and HSV-1 was 100%. On multivariate analysis, the independent predictors of HSV-2 infection were age, marital status, and trichomoniasis. CONCLUSIONS HSV-2 was common in this sample of sexually active women in Vanuatu. This is the first study of HSV in Vanuatu and one of very few studies in the Pacific region.
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Affiliation(s)
- Lewis J Haddow
- Sexually Transmitted Infections Research Centre, Westmead, New South Wales, Australia
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McCarthy M, Haddow LJ, Furner V, Mindel A. Contact tracing for sexually transmitted infections in New South Wales, Australia. Sex Health 2007; 4:21-5. [PMID: 17382033 DOI: 10.1071/sh06019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2006] [Accepted: 10/13/2006] [Indexed: 11/23/2022]
Abstract
Background: Contact tracing is an important strategy in the control of sexually transmitted infections (STI) because it encourages individuals who may be unaware they have been exposed to an infection to be tested and treated. The aim of this study was to review STI contact tracing procedures in NSW by sexual health clinics (SHC), public health units (PHU) and general practitioners (GP). Methods: A questionnaire study carried out in 2004–2005 of SHC, PHU and a random sample of GP in NSW. SHC and PHU participated in structured interviews and GP completed questionnaires at educational workshops or through a mail-out. Interviews and questionnaires addressed current contact tracing practice and methods of improving the service. Results: All 35 SHC, 6/18 (33%) PHU and 172/212 (81%) of the GP who responded to the survey undertook contact tracing for STI. Chlamydia was the STI most commonly traced by SHC (34/35, 97%) and GP (165/172, 96%). HIV was the STI most commonly traced by PHU (5/6, 83%). Only 23/172 (13%) GP were familiar with the ‘Australasian contact tracing manual’. The commonest barriers to tracing for SHC and GP included patient reluctance (SHC 60%, GP 71%), and the lack of contact details for partners (SHC 46%, GP 60%). GP identified the availability of information for patients (82%) and more training (55%) as necessary resources for optimal contact tracing. Conclusions: SHC and GP frequently undertook contact tracing for some STI; PHU do so less frequently. Barriers to contact tracing are similar for all health-care providers. For GP, there is a need for increased training and the development of written policies and agreed pathways for referral.
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Affiliation(s)
- Melissa McCarthy
- Sexually Transmitted Infections Research Centre and University of Sydney, Marian Villa, Westmead Hospital, Westmead, NSW 2145, Australia
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Haddow LJ, Dave B, Mindel A, McPhie KA, Chung C, Marks C, Dwyer DE. Increase in rates of herpes simplex virus type 1 as a cause of anogenital herpes in western Sydney, Australia, between 1979 and 2003. Sex Transm Infect 2006; 82:255-9. [PMID: 16731681 PMCID: PMC2564751 DOI: 10.1136/sti.2005.018176] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [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: 11/03/2022] Open
Abstract
BACKGROUND/OBJECTIVE Recent studies suggest that herpes simplex virus type 1 (HSV-1) is becoming more common as a cause for genital herpes, relative to HSV-2. We aimed to calculate trends in HSV type from isolates and serology samples sent to a reference virology laboratory in New South Wales (NSW), Australia. METHODS We compared the proportions of HSV-1 and HSV-2 positive samples, adjusting for age and sex of source patient, in three datasets: anogenital isolates from 1979 to 1988; anogenital isolates from 1989 to 2003; and HSV type specific IgM seropositivity from 1994 to 2003. RESULTS The number of specimens in each analysis was 17 512, 4359, and 497, respectively. There was a progressive rise in the proportions of typed specimens being HSV-1 in all analyses. The proportion of isolates that were HSV-1 ranged from 3% in 1980 to 41% in 2001. Female sex and age under 25 were associated with a greater proportion of HSV-1 isolates in both time periods. In the period 1979-88, comparing the proportions of HSV-1 and HSV-2 gave an odds ratio (OR) per additional year of 1.24 (95% confidence interval (CI) 1.20 to 1.27; p<0.005) after adjustment for age and sex. In the period 1989-2003 there was a steeper rise in the proportion of isolates that were HSV-1 in samples from younger individuals (OR per year 1.17, 1.12 to 1.22) compared to those over 25 (OR per year 1.06, 1.03 to 1.08). The rise in the proportion of IgM seropositive results reactive for HSV-1 compared to HSV-2 gave an OR of 1.36 per year (1.26 to 1.47; p<0.005). CONCLUSIONS These data suggest that HSV-1 has become more common as a cause of anogenital herpes in NSW.
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Affiliation(s)
- L J Haddow
- Sexually Transmitted Infections Research Centre, Westmead Hospital, Westmead, New South Wales 2145, Australia
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Abstract
The high prevalence of herpes simplex virus infections in many communities, its numerous serious physical and psychological complications and its importance in enhancing the transmission of HIV make this virus an obvious target for prevention by vaccination. Randomised clinical trials of only one genital herpes vaccine has shown efficacy so far. Analysis of clinical results is complicated by the difference between disease and infection, different results for males and females and the interaction between HSV-1 and HSV-2 immunity.
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Haddow LJ, Bunn A, Copas AJ, Gilson R, Prince M, Ridgway GL, Sadiq ST. Polymorph count for predicting non-gonococcal urethral infection: a model using Chlamydia trachomatis diagnosed by ligase chain reaction. Sex Transm Infect 2004; 80:198-200. [PMID: 15170002 PMCID: PMC1744835 DOI: 10.1136/sti.2003.006924] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND/OBJECTIVES The criteria for the diagnosis of non-gonococcal urethritis (NGU) on a Gram stained urethral smear are derived from previous studies which used culture as a diagnostic test for Chlamydia trachomatis. Our objectives were (1). to re-assess the relation between urethral polymorph count and C trachomatis infection, using ligase chain reaction (LCR) as the diagnostic test; and (2). to assess other possible predictors of C trachomatis infection such as symptoms, signs, demographic and behavioural variables. METHODS We collected data from 363 men consecutively attending a genitourinary medicine clinic (excluding those with gonorrhoea and follow up visits) who had a urethral smear and a urethral LCR test for C trachomatis. The sensitivity and specificity of a discrete cut off in urethral polymorphonuclear leucocyte (PMNL) count as a diagnostic test for chlamydia urethritis were calculated. The associations between other variables, such as age and symptoms, and this infection were also estimated. RESULTS 8% of men had C trachomatis infection and 26% of men had a PMNL count of 5 or more. Of those men with chlamydia 37% did not have NGU; 20% of men with NGU had chlamydia. Adjusted odds ratios for risk of chlamydial infection were significant for age less than 30 relative to 40 years and over (adj OR 13.6; 95% confidence interval 1.69 to 110), a PMNL count of 20 or more (6.56; 2.15 to 20.0), a PMNL count of 5-19 (3.59; 1.41 to 9.15), and the symptom of dysuria (3.27; 1.32 to 8.08). However a PMNL count of 5 or more was only 63% sensitive and 77% specific for C trachomatis infection. No association between sexual behaviour and chlamydial infection was found in this setting. CONCLUSIONS The PMNL count is associated with presence of chlamydial infection but a large proportion of men with chlamydia have PMNL counts below the recommended cut off for a diagnosis of NSU. Lower age and the presence of symptoms may be as predictive as the urethral polymorph count for chlamydial urethritis and possibly for other urethral infections.
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Affiliation(s)
- L J Haddow
- Department of Genitourinary Medicine, Camden Primary Care Trust, Mortimer Market Centre, London WC1E 6AU, UK
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Buckingham SJ, Haddow LJ, Shaw PJ, Miller RF. Immune reconstitution inflammatory syndrome in HIV-infected patients with mycobacterial infections starting highly active anti-retroviral therapy. Clin Radiol 2004; 59:505-13. [PMID: 15145720 DOI: 10.1016/j.crad.2003.12.002] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2003] [Revised: 11/24/2003] [Accepted: 12/03/2003] [Indexed: 10/26/2022]
Abstract
AIM To describe the radiological appearances of immune reconstitution inflammatory syndrome (IRIS) in human immunodeficiency virus (HIV)-infected patients with mycobacterial infections starting highly active anti-retroviral therapy (HAART). MATERIALS AND METHODS Five consecutive HIV infected patients with IRIS due to mycobacterial infection were studied. Intercurrent infection and poor drug compliance were excluded as causes of presentation. The chest radiological appearances at the time of starting HAART and at the time of diagnosis of IRIS were compared. RESULTS In these five patients there was clinical and radiological deterioration, occurring between 10 days and 7 months after starting HAART, leading to unmasking of previously undiagnosed mycobacterial infection or to worsening of mycobacterial disease. All five patients had HAART-induced increases in CD4+ T lymphocyte counts and reductions in peripheral blood HIV "viral load". Chest radiographic abnormalities due to IRIS included marked mediastinal lymphadenopathy in three patients-severe enough to produce tracheal compression in two patients (one of whom had stridor)-and was associated with new pulmonary infiltrates in two patients. The other two patients had new infiltrates, which in one patient was associated with a pleural effusion. CONCLUSION These cases illustrate the diverse chest radiographic appearances of IRIS occurring after HAART in patients with mycobacterial and HIV co-infection. Marked mediastinal lymphadenopathy occurred in three of these five patients (with associated tracheal narrowing in two patients); four patients developed pulmonary infiltrates and one had an effusion. The cases further highlight that the onset of IRIS may be delayed for several months after HAART is started.
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Affiliation(s)
- S J Buckingham
- Department of Imaging, University College London Hospitals NHS Trust, London, UK
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Abstract
We describe a case of infective endocarditis due to Neisseria elongata, and review the literature. N. elongata is a constituent of the normal oral flora and a rare cause of infective endocarditis. Unfamiliarity with the organism and its rod-shaped morphology may lead to a delay in microbiological diagnosis. Although the organism is relatively sensitive to antibiotics, our experience in the management of the described case and a review of previous reports suggest that antibiotic therapy alone may not be sufficient. It is likely that patients with N. elongata endocarditis will require surgery.
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Affiliation(s)
- L J Haddow
- Department of Microbiology, University Hospital Lewisham, Lewisham High Street, London SE13 6LH London, UK
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Haddow LJ, Chandra Sekhar M, Hajela V, Gopal Rao G. Spontaneous Achilles tendon rupture in patients treated with levofloxacin. J Antimicrob Chemother 2003; 51:747-8. [PMID: 12615887 DOI: 10.1093/jac/dkg081] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
An HIV-1 antibody positive black African man with plasma cell variant Castleman's disease and cutaneous Kaposi's sarcoma, despite receiving chemotherapy, had progressive disease. In addition, he developed pain and swelling behind the right knee. Histology of an ultrasound guided biopsy showed Kaposi's sarcoma infiltrating the head of gastrocnemius.
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Affiliation(s)
- L J Haddow
- Patrick Manson Unit, University College London Hospitals, London, UK
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Ribchester RR, Thomson D, Haddow LJ, Ushkaryov YA. Enhancement of spontaneous transmitter release at neonatal mouse neuromuscular junctions by the glial cell line-derived neurotrophic factor (GDNF). J Physiol 1998; 512 ( Pt 3):635-41. [PMID: 9769409 PMCID: PMC2231231 DOI: 10.1111/j.1469-7793.1998.635bd.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [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: 05/06/1998] [Accepted: 07/29/1998] [Indexed: 11/30/2022] Open
Abstract
1. The acute effects of neurotrophic factors on the frequency of spontaneous transmitter release (miniature endplate potentials (MEPPs)) from motor nerve terminals has been examined in skeletal muscles of neonatal mice aged between 9 and 20 days. The following factors were tested at a concentration of 50 ng ml-1: brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), neurotrophin-4 (NT-4), ciliary neuronotrophic factor (CNTF), leukaemia inhibitory factor (LIF), insulin-like growth factors 1 and 2 (IGF-1 and IGF-2), and glial cell line-derived neurotrophic factor (GDNF). In some experiments, the responses to 2 microM LaCl3 and 10 mM K+, or to 2-5 nM purified alpha-latrotoxin (alpha-LTX) were also measured. 2. Neither BDNF, NT-3, NT-4, LIF, IGF-1 or IGF-2 - singly or in combination - caused any significant change in MEPP frequency. GDNF, however, produced a highly significant, 2-fold increase in neurotransmitter release that was reproduced in fourteen muscles. 3. Potentiation of MEPP frequency in GDNF was of the same order as that induced by tetanic stimulation or substitution of the bathing medium with hypertonic saline; but substantially less than that induced either by lanthanum ions or alpha-latrotoxin. 4. The data suggest that concentrations of GDNF that produce maximal enhancement of motoneurone survival in vitro and in vivo also produce acute, non-saturating enhancement in transmitter release at immature mammalian neuromuscular synapses. Taken together with other reports, these findings suggest that GDNF may mediate both functional and structural plasticity of neonatal neuromuscular junctions.
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Affiliation(s)
- R R Ribchester
- Department of Physiology, University Medical School, Teviot Place, Edinburgh EH8 9AG, UK.
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Abstract
Unilateral ventrolateral (VL) thalamotomy for medically refractory tremorigenic movement disorders (MD) was performed in 9 patients with established multiple sclerosis. All patients had abolition of their coarse action/kinetic tremor with improvement in arm and hand function. In two patients some intention tremor either remained or was unmasked. Target coordinates ranged from 2 to -5 mm relative to the intercommissural line and from 8 to 16 mm lateral to the midline. There were no permanent surgical complications and the one stage procedure under local anesthetic was well tolerated. Although there were also improvements in posture and speech in some patients the overall and longer term functional impact of surgery was, except in two patients, disappointing. Since multiple sclerosis is a spectrum of disease entities, and tremor may be only one manifestation of the disease, clinical studies that use comprehensive patient assessments and objective criteria may allow prediction of longer term functional outcome in specific patient subgroups. The specific aims of the stereotactic procedure in severely disabled patients with MS and MD must also be clear.
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Affiliation(s)
- I R Whittle
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, Scotland, U.K
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