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1.
J Rheumatol ; 2020 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32238510

RESUMO

OBJECTIVE: To examine the role of disease activity on organ damage over 5 years in patients with active systemic lupus erythematosus (SLE) despite standard of care. METHODS: This analysis of the University of Toronto Lupus Clinic cohort assessed organ damage [measured by Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI)] in patients with active SLE [SLE Disease Activity Index 2000 (SLEDAI-2K) ≥ 6], using Cox proportional time-independent hazard models. Subgroup analyses were conducted in patients with SLEDAI-2K 6 or 7, 8 or 9, and ≥ 10 at baseline, and in the overall study population by steroid dose at study entry (< 7.5 vs ≥ 7.5 mg/day). RESULTS: Among the overall study population (n = 649), SDI progression was observed in 209 (32.2%) patients over the 5-year follow-up period. Mean SDI change in patients with a score > 0 was generally consistent across all SLEDAI-2K subgroups. Multivariable analyses identified age at study start (HR 1.03, P < 0.0001), steroid dose (HR 2.03, P < 0.0001), immunosuppressants (HR 1.44, P = 0.021), and SLEDAI-2K (subgroup analyses HR 1.64-2.03, P = 0.0017 to < 0.0001) as the greatest risk factors for SDI progression, while a study start date after the year 2000 had a protective effect on SDI progression compared with a start date prior to the year 2000 (HR 0.65, P = 0.0004). CONCLUSION: Patients within the higher SLEDAI-2K subgroups at study entry or receiving high doses of steroids were more likely to have organ damage progression.

2.
Pediatr Infect Dis J ; 38(3): 253-257, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30763284

RESUMO

BACKGROUND: Invasive meningococcal disease (IMD) is associated with significant morbidity and mortality, thus remaining a concern for healthcare providers and the public. Evidence of the longitudinal burden of IMD and associated costs are scarce. Here we have evaluated the healthcare utilization and cost associated with hospitalized IMD cases in Ontario, Canada. METHODS: Observational cohort study utilizing the Ontario provincial claims databases, comprising: (1) individuals hospitalized with IMD between January 1995 and June 2012 and (2) age-, gender- and area-matched non-IMD controls (1:20 ratio). IMD cases were identified through diagnostic codes from hospitalization data and medical services claims. Costs are presented in Canadian dollars. RESULTS: Nine-hundred twelve IMD cases and 18,221 non-IMD controls were included. Over 5 years of follow-up, 27% of IMD cases (excluding initial hospitalization and 30-day acute phase) versus 15% of non-IMD controls (P < 0.001) were hospitalized. Compared with controls, IMD cases were more likely to receive alternative level of care (6.7% vs. 1.1%; P < 0.001) or visit the intensive care unit (49.2% vs. 2.4%; P < 0.001), and were associated with significantly higher mean hospitalization cost per case ($40,075 vs. $2827; P < 0.001). The hospitalization cost per case remained significantly higher when excluding the initial hospitalization and acute phase ($9867 vs. $3312; P < 0.001). The mean total cost per IMD case, including medications, hospitalization and medical services, was $45,768-$52,631 ($13,520-$23,789 excluding initial hospitalization and acute phase), for an overall cost (all cases during total follow-up) of $41,740,142-$47,999,289. CONCLUSIONS: In addition to its clinical burden, IMD is associated with significant economic burden to the public health system.


Assuntos
Custos de Cuidados de Saúde , Recursos em Saúde/economia , Infecções Meningocócicas/economia , Aceitação pelo Paciente de Cuidados de Saúde , Adolescente , Adulto , Estudos de Casos e Controles , Criança , Pré-Escolar , Feminino , Recursos em Saúde/estatística & dados numéricos , Custos Hospitalares , Hospitalização/economia , Humanos , Masculino , Infecções Meningocócicas/epidemiologia , Pessoa de Meia-Idade , Ontário/epidemiologia , Estudos Retrospectivos , Adulto Jovem
3.
J Clin Epidemiol ; 81: 96-100, 2017 01.
Artigo em Inglês | MEDLINE | ID: mdl-27693883

RESUMO

OBJECTIVE: To describe and summarize equity reporting in human immunodeficiency virus (HIV) systematic reviews and explore the extent to which equity issues are addressed and reported in HIV reviews using the PROGRESS Plus framework. STUDY DESIGN AND SETTING: Application of the PROGRESS Plus framework to a bibliometric analysis of HIV reviews in the Cochrane Database of Systematic Reviews. RESULTS: The analysis included 103 reviews published as of March 2014, with a median of five studies per review (first quartile; Q1 = 2; third quartile; Q3 = 11). Reporting of PROGRESS Plus factors was as follows: Place of residence (low, middle, and high income; 55.3%), place of residence (urban or rural; 24.3%), race or ethnicity (20.4%), occupation (10.7%), gender (65.0%), religion (1.9%), education (7.8%), socioeconomic position (10.7%), social networks and capital (1.0%), age (1.9%), and sexual orientation (3.8%). CONCLUSION: Gaps in the reporting of relevant equity indicators were identified within Cochrane HIV systematic review indicating that research is not consistently conducted through an equity lens. There is a need to incorporate PROGRESS Plus factors into both primary and secondary studies.


Assuntos
Infecções por HIV/epidemiologia , Equidade em Saúde/estatística & dados numéricos , Disparidades nos Níveis de Saúde , Literatura de Revisão como Assunto , Bibliometria , Feminino , Humanos , Masculino , Fatores Socioeconômicos
4.
Cochrane Database Syst Rev ; 12: CD004246, 2016 12 10.
Artigo em Inglês | MEDLINE | ID: mdl-27943261

RESUMO

BACKGROUND: The advent of highly active antiretroviral therapy (ART) has reduced the morbidity and mortality due to HIV infection. The World Health Organization (WHO) ART guidelines focus on three classes of antiretroviral drugs, namely nucleoside or nucleotide reverse transcriptase inhibitors (NRTI), non-nucleoside reverse transcriptase inhibitors (NNRTI) and protease inhibitors. Two of the most common medications given as first-line treatment are the NNRTIs, efavirenz (EFV) and nevirapine (NVP). It is unclear which NNRTI is more efficacious for initial therapy. This systematic review was first published in 2010. OBJECTIVES: To determine which non-nucleoside reverse transcriptase inhibitor, either EFV or NVP, is more effective in suppressing viral load when given in combination with two nucleoside reverse transcriptase inhibitors as part of initial antiretroviral therapy for HIV infection in adults and children. SEARCH METHODS: We attempted to identify all relevant studies, regardless of language or publication status, in electronic databases and conference proceedings up to 12 August 2016. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov to 12 August 2016. We searched LILACS (Latin American and Caribbean Health Sciences Literature) and the Web of Science from 1996 to 12 August 2016. We checked the National Library of Medicine (NLM) Gateway from 1996 to 2009, as it was no longer available after 2009. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) that compared EFV to NVP in people with HIV without prior exposure to ART, irrespective of the dosage or NRTI's given in combination.The primary outcome of interest was virological success. Other primary outcomes included mortality, clinical progression to AIDS, severe adverse events, and discontinuation of therapy for any reason. Secondary outcomes were change in CD4 count, treatment failure, development of ART drug resistance, and prevention of sexual transmission of HIV. DATA COLLECTION AND ANALYSIS: Two review authors assessed each reference for inclusion using exclusion criteria that we had established a priori. Two review authors independently extracted data from each included trial using a standardized data extraction form. We analysed data on an intention-to-treat basis. We performed subgroup analyses for concurrent treatment for tuberculosis and dosage of NVP. We followed standard Cochrane methodological procedures. MAIN RESULTS: Twelve RCTs, which included 3278 participants, met our inclusion criteria. None of these trials included children. The length of follow-up time, study settings, and NRTI combination drugs varied greatly. In five included trials, participants were receiving concurrent treatment for tuberculosis.There was little or no difference between EFV and NVP in virological success (RR 1.04, 95% CI 0.99 to 1.09; 10 trials, 2438 participants; high quality evidence), probably little or no difference in mortality (RR 0.84, 95% CI 0.59 to 1.19; 8 trials, 2317 participants; moderate quality evidence) and progression to AIDS (RR 1.23, 95% CI 0.72 to 2.11; 5 trials, 2005 participants; moderate quality evidence). We are uncertain whether there is a difference in all severe adverse events (RR 0.91, 95% CI 0.71 to 1.18; 8 trials, 2329 participants; very low quality evidence). There is probably little or no difference in discontinuation rate (RR 0.93, 95% CI 0.69 to 1.25; 9 trials, 2384 participants; moderate quality evidence) and change in CD4 count (MD -3.03; 95% CI -17.41 to 11.35; 9 trials, 1829 participants; moderate quality evidence). There may be little or no difference in treatment failure (RR 0.97, 95% CI 0.76 to 1.24; 5 trials, 737 participants; low quality evidence). Development of drug resistance is probably slightly less in the EFV arms (RR 0.76, 95% CI 0.60 to 0.95; 4 trials, 988 participants; moderate quality evidence). No studies were found that looked at sexual transmission of HIV.When we examined the adverse events individually, EFV probably is associated with more people with impaired mental function (7 per 1000) compared to NVP (2 per 1000; RR 4.46, 95% CI 1.65 to 12.03; 6 trials, 2049 participants; moderate quality evidence) but fewer people with elevated transaminases (RR 0.52, 95% CI 0.35 to 0.78; 3 trials, 1299 participants; high quality evidence), fewer people with neutropenia (RR 0.48, 95% CI 0.28 to 0.82; 3 trials, 1799 participants; high quality evidence), and probably fewer people withrash (229 per 100 with NVP versus 133 per 1000 with EFV; RR 0.58, 95% CI 0.34 to 1.00; 7 trials, 2277 participants; moderate quality evidence). We found that there may be little or no difference in gastrointestinal adverse events (RR 0.76, 95% CI 0.48 to 1.21; 6 trials, 2049 participants; low quality evidence), pyrexia (RR 0.65, 95% CI 0.15 to 2.73; 3 trials, 1799 participants; low quality evidence), raised alkaline phosphatase (RR 0.65, 95% CI 0.17 to 2.50; 1 trial, 1007 participants; low quality evidence), raised amylase (RR 1.40, 95% CI 0.72 to 2.73; 2 trials, 1071 participants; low quality evidence) and raised triglycerides (RR 1.10, 95% CI 0.39 to 3.13; 2 trials, 1071 participants; low quality evidence). There was probably little or no difference in serum glutamic oxaloacetic transaminase (SGOT; MD 3.3, 95% CI -2.06 to 8.66; 1 trial, 135 participants; moderate quality evidence), serum glutamic- pyruvic transaminase (SGPT; MD 5.7, 95% CI -4.23 to 15.63; 1 trial, 135 participants; moderate quality evidence) and raised cholesterol (RR 6.03, 95% CI 0.75 to 48.78; 1 trial, 64 participants; moderate quality evidence).Our subgroup analyses revealed that NVP slightly increases mortality when given once daily (RR 0.34, 95% CI 0.13 to 0.90; 3 trials, 678 participants; high quality evidence). There were little or no differences in the primary outcomes for patients who were concurrently receiving treatment for tuberculosis. AUTHORS' CONCLUSIONS: Both drugs have similar benefits in initial treatment of HIV infection when combined with two NRTIs. The adverse events encountered affect different systems, with EFV more likely to cause central nervous system adverse events and NVP more likely to raise transaminases, cause neutropenia and rash.


Assuntos
Benzoxazinas/uso terapêutico , Infecções por HIV/tratamento farmacológico , Nevirapina/uso terapêutico , Inibidores da Transcriptase Reversa/uso terapêutico , Adulto , Alquinos , Fármacos Anti-HIV/uso terapêutico , Benzoxazinas/efeitos adversos , Ciclopropanos , Quimioterapia Combinada/métodos , Infecções por HIV/mortalidade , Infecções por HIV/virologia , Humanos , Nevirapina/efeitos adversos , Ensaios Clínicos Controlados Aleatórios como Assunto , Inibidores da Transcriptase Reversa/efeitos adversos , Carga Viral/efeitos dos fármacos
5.
J Clin Epidemiol ; 74: 66-72, 2016 06.
Artigo em Inglês | MEDLINE | ID: mdl-26582595

RESUMO

OBJECTIVES: To summarize the current gaps in human immunodeficiency virus (HIV) research evidence, describe the adequacy of reporting "implications for research," and map the number of studies that inform reviews with the prevalence of HIV for each country. STUDY DESIGN AND SETTING: A bibliometric analyses of HIV reviews in the Cochrane Database of Systematic Reviews with content analysis of the "implications for research" section. RESULTS: We analyzed 103 high-quality reviews published as of March 2014. They included a median of five studies (min 0 and max 44). Almost all the reviews recommended more trials (89.3%). Limitations in trial design, duration, setting, sample size, and choice of participants were also noted. Reporting of EPICOT+ items was as follows: evidence (35.9%), population (57.3%), intervention (71.8%), comparison (20.4%), outcomes (57.3%), time stamp (34.0%), and disease burden (13.6%). The primary studies were conducted in 67 countries. Six of the top 10 countries in which primary studies were conducted had a high HIV prevalence. CONCLUSION: Knowledge gaps were identified for research in younger participants, over longer periods, using more pragmatic interventions, conducted in resource-limited settings and incorporating economic evaluations. Implications for research are not always reported according to the EPICOT+ format. Not all countries with a high prevalence of HIV are contributing sufficiently to HIV research.


Assuntos
Bibliometria , Infecções por HIV/epidemiologia , Humanos
6.
BMC Health Serv Res ; 15: 33, 2015 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-25609559

RESUMO

BACKGROUND: Strong international commitment and the widespread use of antiretroviral therapy have led to higher longevity for people living with human immune deficiency virus (HIV). Text messaging interventions have been shown to improve health outcomes in people living with HIV. The objectives of this overview were to: map the state of the evidence of text messaging interventions, identify knowledge gaps, and develop a framework for the transfer of evidence to other chronic diseases. METHODS: We conducted a systematic review of systematic reviews on text messaging interventions to improve health or health related outcomes. We conducted a comprehensive search of PubMed, EMBASE (Exerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), PsycINFO, Web of Science (WoS) and the Cochrane Library on the 17th April 2014. Screening, data extraction and assessment of methodological quality were done in duplicate. Our findings were used to develop a conceptual framework for transfer. RESULTS: Our search identified 135 potential systematic reviews of which nine were included, reporting on 37 source studies, conducted in 19 different countries. Seven of nine (77.7%) of these reviews were high quality. There was some evidence for text messaging as a tool to improve adherence to antiretroviral therapy. Text messages also improved attendance at appointments and behaviour change outcomes. The findings were inconclusive for self-management of illness, treatment of tuberculosis and communicating results of medical investigations. The geographical distribution of text messaging research was limited to specific regions of the world. Prominent knowledge gaps included the absence of data on long term outcomes, patient satisfaction, and economic evaluations. The included reviews also identified methodological limitations in many of the primary studies. CONCLUSIONS: Global evidence supports the use of text messaging as a tool to improve adherence to medication and attendance at scheduled appointments. Given the similarities between HIV and other chronic diseases (long-term medications, life-long care, strong link to behaviour and the need for home-based support) evidence from HIV may be transferred to these diseases using our proposed framework by integration of HIV and chronic disease services or direct transfer.


Assuntos
Antirretrovirais/uso terapêutico , Telefone Celular/estatística & dados numéricos , Doença Crônica/terapia , Infecções por HIV/tratamento farmacológico , Satisfação do Paciente/estatística & dados numéricos , Sistemas de Alerta , Envio de Mensagens de Texto/estatística & dados numéricos , Agendamento de Consultas , Promoção da Saúde/métodos , Humanos , Adesão à Medicação/estatística & dados numéricos , Autocuidado/métodos
7.
Evolution ; 67(2): 403-16, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23356613

RESUMO

Through the course of an adaptive radiation, the evolutionary speed of cladogenesis and ecologically relevant trait evolution are expected to slow as species diversity increases, niches become occupied, and ecological opportunity declines. We develop new likelihood-based models to test diversity-dependent evolution in the auks, one of only a few families of seabirds adapted to underwater "flight," and which exhibit a large variety of bill sizes and shapes. Consistent with the expectations of adaptive radiation, we find both a decline in rates of cladogenesis (a sixfold decline) and bill shape (a 64-fold decline) evolution as diversity increased. Bill shape diverged into two clades at the basal cladogenesis event with one clade possessing mostly long, narrow bills used to forage primarily on fish, and the other with short thick bills used to forage primarily on plankton. Following this initial divergence in bill shape, size, a known correlate of both prey size and maximum diving depth, diverged rapidly within each of these clades. These results suggest that adaptive radiation in foraging traits underwent initial divergence in bill shape to occupy different food resources, followed by size differentiation to subdivide each niche along the depth axis of the water column.


Assuntos
Adaptação Biológica/genética , Bico/anatomia & histologia , Charadriiformes/genética , Evolução Molecular , Filogenia , Animais , Charadriiformes/anatomia & histologia , Especiação Genética , Variação Genética , Modelos Genéticos , Modelos Estatísticos , Tamanho do Órgão/genética , Comportamento Predatório
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