Cost-effectiveness of laboratory monitoring for management of HIV treatment in sub-Saharan Africa: a model-based analysis.

OBJECTIVE: To compare the cost-effectiveness of three different strategies for long-term monitoring of antiretroviral therapy (ART) failure and regimen switching in sub-Saharan Africa: a symptom-based approach, or monitoring of either CD4 cell counts or plasma viral load (pVL). DESIGN: Markov model. SETTING AND PARTICIPANTS: Hypothetical HIV-infected adult population who began first-line ART and subsequently had up to 6 years of follow-up. MAIN OUTCOME MEASURES: Total cost, life expectancy and incremental cost-effectiveness ratio (ICER). RESULTS: A symptom-based approach yielded a life expectancy of 64.0 months at a total cost of US$ 4028 per person. All laboratory-based strategies, at testing intervals of 6 or 12 months, were cost-saving and improved life expectancy, compared with a symptom-based approach. The life-expectancy gain was larger for pVL than for CD4 strategies at 6-monthly (2.3 and 0.9 months, respectively) and 12-monthly testing (2.0 and 0.8 months, respectively). Cost-savings of 6-monthly pVL or CD4 testing were similar (US$ 630 and 621, respectively), whereas 12-monthly CD4 cell counts were more cost-saving than 12-monthly pVL (US$ 1132 and 880, respectively). Testing every 12 months - rather than every 6 months - decreased the ICER by 102% for CD4 cell count and 67% for pVL. These findings were robust to a wide range of deterministic sensitivity analyses, but were sensitive to the specificity and costs of diagnostic tests. CONCLUSION: Additional diagnostic costs are balanced by cost-savings from avoiding unnecessary switching due to misdiagnosis of ART failure. Routine pVL monitoring may be preferred as a replacement for CD4 cell counts because of its additional public-health advantages in preventing drug-resistance, supporting adherence and reducing HIV transmission.

Moderate to heavy infections of Trichuris trichiura affect cognitive function in Jamaican school children.

A double-blind placebo trial was conducted to determine the effect of moderate to high loads of Trichuris trichiura (whipworm) infection on the cognitive functions of 159 school children (age 9-12 years) in Jamaica. Infected children were randomly assigned to Treatment or Placebo groups. A third group of randomly selected uninfected children were assigned to a Control for comparative purposes. The improvement in cognitive function was evaluated using a stepwise multiple linear regression, designed to control for any confounding variables. The expulsion of worms led to a significant improvement in tests of auditory short-term memory (P less than 0.02; P less than 0.01), and a highly significant improvement in the scanning and retrieval of long-term memory (P less than 0.001). After 9 weeks, treated children were no longer significantly different from an uninfected Control group in these three tests of cognitive function. The removal of T. trichiura was more important than Ascaris lumbricoides in determining this improvement. The results suggest that whipworm infection has an adverse effect on certain cognitive functions which is reversible by therapy.

Moderate to heavy infections of Trichuris trichiura affect cognitive function in Jamaican school children

In Mandeville, Jamaica, researchers compared cognitive function test results of 62 male school children (9-12 years old) infected with 1 of 3 helminths (Trichuris trichiura [whipworm], Ascaris lumbricoides [roundworm], or Necator americanus [roundworm]) who received 3 doses of 400 mg of the broad spectrum anthelmintic, albendazole (Zental), each day with those of 41 male school children also infected with a helminth but who received instead a placebo and those of 22 uninfected male school children who also received the placebo to determine wether a causal relationship existed between moderate to heavy loads of Trichuris trichiura and cognitive function. Anthelmintic treatment infected children significantly improved auditory short-term memory (p<0.02;p<0.01) and especially scanning and retrieval of longterm memory (p<0.001). Most of this improvement was a result of removal of T. trichiura. These children had even improved significantly more than the uninfected children (controls) in the same cognitive functions (p<0.05; p<0.01 and p<0.003, respectively). Thus treatment eliminated the significant differences between the treatment children and uninfected control children. The treatment restored cognitive functions in a relatively short time span (9 weeks). Treatment reduced fecal egg density of 99 percent of all 3 parasites (p<0.0001) and prevalence of infection. This anthelmintic treatment greatly reduced whipworm infection which in turn significantly improved cognitive functions. (AU)

Moderate to heavy infections of trichuris trichiura affect cognitive function in Jamaican school children - abstract

A double blind placebo-controlled clinical trial was conducted to determine the effect of moderate to high loads of Trichuris trichiuria infection on the cognitive functions of 159 school children (age 9-12 years) in Jamaica. Infected children were randomly assigned to treatment or placebo groups. A third group of randomly uninfected children were assigned to a control for comparitive purposes. Cognitive tests were performed pre-intervention and repeated approximately 9 weeks later. The baseline characteristics (age, sex, anthropometry, iron status, IQ, socioeconomic status

Parasitic helminth infection and cognitive function in school children.

The study examines the effect of moderate to high worm burdens of Trichuris trichiura infection on the cognitive functions of 159 school children (age 9-12 years) in Jamaica, using a double-blind placebo-controlled protocol. Results were evaluated by using a forward-stepwise multiple linear regression. Removal of worms led to a significant improvement in tests of auditory short-term memory (p less than 0.017; p less than 0.013), and scanning and retrieval of long-term memory (p less than 0.001). Nine weeks after treatment, there were no longer significant differences between the treated children and an uninfected Control group in these three tests of cognitive function. It is concluded that whipworm infection has an adverse effect on certain cognitive functions which is reversible by therapy.

The spectrum of acute renal failure in a developing country - abstract

Acute renal failure (ARF) has had an unchanged mortality of greater than 50 percent for the past 30 years, despite advances in critical care management. The aetiologies, complications, and prognosis have been well described in the literature from developed countries. A 30-month prospective survey of all cases of ARF seen at the Princess Margaret Hospital since January 1986 was undertaken. Of a total of 1,014 cases, 98 were analyzed; and the principal findings were the following. Sepsis was the leading cause identified in 47 patients (48 percent); Hypoperfusion-related states occurred in 41 patients (42 percent); Nephrotoxins were identified in 18 patients (18 percent); Vasculatic disease accounted for 15 patients, and Obstructive uropathy was the major factor in 11 patients. Nearly 50 percent of the patients had non-oliguric ARF. The mortality was 36.1 percent, and 67.3 percent in the non-oliguric and oliguric groups, respectively. Seven patients were classified as having died due to renal failure, and the overall combined mortality of all the patients was 51 percent. Of the 98 patients, 21 had complete recovery (21 percent); 23 patients had renal insufficiency (24 percent); and 47 patients (48 percent) were classified as non-renal deaths. A new entity of Cocaine-induced Rhabdomyolysis is described in 2 patients and the pathogenesis discussed. This survey indicates that the mortality of 55 percent in this developing country is comparable to figures reported from more advanced metropolitan countries (AU)

The PermCath for temporary vascular access - abstract

This paper is a report of one year's experience with the PermCath central venous access dialysis catheter in the Bahamas. The PermCath was employed for temporary access in patients requiring chronic haemo-dialysis while awaiting permanent access sites. PermCaths were inserted via internal or external jugular vein cut-down under local anaesthesia. Fifteen catheters were inserted in 13 patients. One patient had three PermCaths. The 15 PermCaths were in situ for a total of 1,224 patient days and 385 dialysis episodes. The catheters were in situ for a range of 3 to 155 days, an average of 81.5 days per patient. Six patients had a catheter in situ longer than four months. Three PermCaths were removed because of sepsis and one for occlusion. There were no exit site infections or clinical thrombosis. It is concluded that PermCaths can be used safely for long term vascular access, with minimal morbidity and their use is recommended if temporary access is required for longer than four weeks (AU)

Temporary vascular access for chronic haemodialysis: the Bahamian experience - abstract

We report our experience with the Shiley Double Lumen (SDL) and Permacath (PC) central venous access dialysis catheters during the period May 1986 to August 1988. The SDL Catheter study was confined to all patients selected for chronic dialysis and awaiting vascular access by a visiting access surgeon; patients receiving A-V shunts or peritoneal dialysis were excluded. PC was introduced in December, 1987 as an alternative to SDL. SDLs were inserted by standard percutaneous Seldinger technique in the dialysis unit, and PC via an internal jugular vein cutdown under local anaesthesia. Of the group of patients for chronic renal dialysis on temporary SDL access, the 21 patients who eventually had permanent vascular access were reviewed. No patients failing to achieve permanent vascular access died or were discontinued from dialysis due to complications of SDL cannulation. The 21 patients received 40 SDL cannulations (17 right subclavian vein, 21 left subclavian and 2 right femorals) for a total of 1,170 patient days and 393 haemodialysis episodes. SDLs were resited if there was sepsis, luminal thrombosis or clinical signs of subclavian vein thrombosis. One patient was carried for 215 days on SDL catheterizations. The longest site cannulated was 139 days. Seven patients received PC for a total of 720 patient days and 240 dialysis. Four catheters were removed after permanent access was established, 1 after sepsis and 2 remain in situ. We conclude that SDL and PC catheters can be safely used over an extended period for temporary dialysis on an outpatient basis without compromising future permanent access. This is particularly suited for geographical areas lacking a permanent vascular access surgeon (AU)

Actinomycosis: a report on five cases

Five cases of actinomycosis seen at the University Hospital of the West Indies have been described. Unlike other reports, more than half of the cases (3) were of the thoracic type. There was no case of the cervico-facial form. In all instances, the correct diagnosis was not considered until the disease was well advanced. Pencillin therapy was effective in all the patients (AU)