Browsing by Subject "Central nervous system"
Now showing 1 - 3 of 3
Results Per Page
Sort Options
- ItemOpen AccessCost effectiveness of cryptococcal antigen screening as a strategy to prevent HIV-associated cryptococcal meningitis in South Africa(Public Library of Science, 2013) Jarvis, Joseph N; Harrison, Thomas S; Lawn, Stephen D; Meintjes, Graeme; Wood, Robin; Cleary, SusanObjectives Cryptococcal meningitis (CM)-related mortality may be prevented by screening patients for sub-clinical cryptococcal antigenaemia (CRAG) at antiretroviral-therapy (ART) initiation and pre-emptively treating those testing positive. Prior to programmatic implementation in South Africa we performed a cost-effectiveness analysis of alternative preventive strategies for CM. Design Cost-effectiveness analysis. METHODS: Using South African data we modelled the cost-effectiveness of four strategies for patients with CD4 cell-counts <100 cells/µl starting ART 1) no screening or prophylaxis (standard of care), 2) universal primary fluconazole prophylaxis, 3) CRAG screening with fluconazole treatment if antigen-positive, 4) CRAG screening with lumbar puncture if antigen-positive and either amphotericin-B for those with CNS disease or fluconazole for those without. Analysis was limited to the first year of ART. RESULTS: The least costly strategy was CRAG screening followed by high-dose fluconazole treatment of all CRAG-positive individuals. This strategy dominated the standard of care at CRAG prevalence ≥0.6%. Although CRAG screening followed by lumbar puncture in all antigen-positive individuals was the most effective strategy clinically, the incremental benefit of LPs and amphotericin therapy for those with CNS disease was small and additional costs were large (US$158 versus US$51per person year; incremental cost effectiveness ratio(ICER) US$889,267 per life year gained). Both CRAG screening strategies are less costly and more clinically effective than current practice. Primary prophylaxis is more effective than current practice, but relatively cost-ineffective (ICER US$20,495). CONCLUSIONS: CRAG screening would be a cost-effective strategy to prevent CM-related mortality among patients initiating ART in South Africa. These findings provide further justification for programmatic implementation of CRAG screening.
- ItemOpen AccessEffects of long-term organophosphate exposures on neurological symptoms, vibration sense and tremor amongst South African farm workers(1998) London, Leslie; Nell, V; Thompson, M L; Myers, J EOBJECTIVES: This study assessed the relationship between long-term exposure to organophosphate insecticides and neurological symptoms, vibration sense, and motor tremor after control for the effect of past poisoning and acute exposure. METHODS: This cross-sectional study included 164 pesticide applicators and 83 nonspraying reference workers on deciduous fruit farms. The workers were tested on the Vibratron II, on tests of dynamic and static tremor, and for a set of neurological and "dummy" symptoms. Exposure was derived with the use of a job-exposure matrix for pesticides in agriculture. RESULTS: Compared with nonapplicators, current applicators reported significantly more dizziness, sleepiness, and headache and had a higher overall neurological symptom score. This association remained statistically significant after multiple logistic regression analyses controlling for a range of confounders and effect modifiers [odds ratio (OR) 2.25, for current applicators having high neurological score, 95% confidence interval (95% CI) 1.15-4.39]. The average lifetime intensity of organophosphate exposure was nonsignificantly associated with both neurological (OR 1.98, 95% CI 0.49-7.94) and "dummy" symptoms (OR 2.37, 95% CI 0.54-10.35). Previous pesticide poisoning was significantly associated with the neurological scores (OR 4.08, 95% CI 1.48-11.22) but not with the "dummy" symptoms. Vibration sense outcomes were associated with age and height, but not with the organophosphate exposure measures. In the multiple linear regression modeling for tremor intensity in the dominant hand, recent organophosphate exposure in the past 10 days was a significant predictor (partial correlation coefficient = 0.04), but none of the long-term organophosphate exposure measures were significant. CONCLUSIONS: Strong evidence was found for an association between symptom outcomes and past organophosphate poisoning and between symptom outcomes and current spray activity. In contrast to symptoms, there was no association between either past poisoning or current spray activity and vibration sense or tremor outcome. Long-term organophosphate exposure did not appear to predict symptoms, vibration sense, or tremor outcome.
- ItemOpen AccessSelf-reported side effects and adherence to antiretroviral therapy in HIV-infected pregnant women under option B+: a prospective study(Public Library of Science, 2016) Phillips, Tamsin; Cois, Annibale; Remien, Robert H; Mellins, Claude A; McIntyre, James A; Petro, Greg; Abrams, Elaine J; Myer, LandonBACKGROUND: Antiretroviral therapy (ART) regimens containing efavirenz (EFV) are recommended as part of universal ART for pregnant and breastfeeding women. EFV may have appreciable side effects (SE), and ART adherence in pregnancy is a major concern, but little is known about ART SE and associations with adherence in pregnancy. METHODS: We investigated the distribution of patient-reported SE (based on Division of AIDS categories) and the association of SE with missed ART doses in a cohort of 517 women starting EFV+3TC/FTC+TDF during pregnancy. In analysis, SE were considered in terms of their overall frequency, by systems category, and by latent classes. RESULTS: Overall 97% of women reported experiencing at least one SE after ART initiation, with 48% experiencing more than five SE. Gastrointestinal, central nervous system, systemic and skin SE were reported by 81%, 85%, 79% and 31% of women, respectively, with considerable overlap across groups. At least one missed dose was reported by 32% of women. In multivariable models, ART non-adherence was associated with systemic SE compared to other systems categories, and measures of the overall burden of SE experienced were most strongly associated with missed ART doses. CONCLUSION: These data demonstrate very high levels of SE in pregnant women initiating EFV-based ART and a strong association between SE burden and ART adherence. ART regimens with reduced SE profiles may enhance adherence, and as countries expand universal ART for all adult patients, counseling must include preparation for ART SE.