Renal function outcomes in patients receiving TDF-containing antiretroviral therapy : a retrospective pilot study in Namibia

Introduction and aims: Combination antiretroviral therapy (cART) has improved morbidity and mortality in patients with HIV across countries including countries in sub-Sahara Africa. However, cART is associated with renal impairment. The lack of pre-cART data in a recently published study limited the discussion on renal-based treatment outcomes with cART, which could have important clinical implications. Consequently, the aim of this paper is to correct this. Methods: Longitudinal retrospective study, with renal function assessed pre-cART and at various time points on cART using the Cockcroft-Gault method. The data source was the patients’ care booklets. Results: 71 patients were included. The majority were adults and female. Before cART initiation, 70.4% and 29.6% had abnormal and normal CrCl, respectively. CrCl was normalised in 24% of patients, while abnormal in the remainder. The mean (median) time to normalisation was 47.4(33.7) months, observed more in paediatric than adult patients (p =0.014). However, in paediatric patients, normalisation took longer than in adult patients. The reduction in CrCl, was observed at variable time points. 9/16 patients experienced a decline during first-line cART and 7 of these were receiving TDF. 7/16 experienced this during second-line cART and 6 were receiving TDF. Conclusion: HIV is typically the cause of renal impairment prior to cART, with TDF likely to be the cause of renal impairment during cART. Consequently, co-administration of TDF with other nephrotoxic drugs should be undertaken with caution if unavoidable. Overall, improvement in renal impairment was faster in adults

Larvicidal, antimicrobial and brine shrimp activities of extracts from Cissampelos mucronata and Tephrosia villosa from coast region, Tanzania

<p>Abstract</p> <p>Background</p> <p>The leaves and roots of <it>Cissampelos mucronata </it>A. Rich (Menispermaceae) are widely used in the tropics and subtropics to manage various ailments such as gastro-intestinal complaints, menstrual problems, venereal diseases and malaria. In the Coast region, Tanzania, roots are used to treat wounds due to extraction of jigger. Leaves of <it>Tephrosia villosa </it>(L) Pers (Leguminosae) are reported to be used in the treatment of diabetes mellitus in India. In this study, extracts from the roots and aerial parts of <it>C. mucronata </it>and extracts from leaves, fruits, twigs and roots of <it>T. villosa </it>were evaluated for larvicidal activity, brine shrimps toxicity and antimicrobial activity.</p> <p>Methods</p> <p>Powdered materials from <it>C. mucronata </it>were extracted sequentially by dichloromethane followed by ethanol while materials from <it>T.villosa </it>were extracted by ethanol only. The extracts obtained were evaluated for larvicidal activity using <it>Culex quinquefasciatus </it>Say larvae, cytotoxicity using brine shrimp larvae and antimicrobial activity using bacteria and fungi.</p> <p>Results</p> <p>Extracts from aerial parts of <it>C. Mucronata </it>exhibited antibacterial activity against <it>Staphylococcus aureus</it>, <it>Escherichia coli</it>, <it>Pseudomonas aeruginosa</it>, <it>Salmonella typhi</it>, <it>Vibrio cholera</it>, <it>Bacillus anthracis</it>, <it>Streptococcus faecalis </it>and antifungal activity against <it>Candida albicans </it>and <it>Cryptococcus neoformans</it>. They exhibited very low toxicity to brine shrimps and had no larvicidal activity. The root extracts exhibited good larvicidal activity but weak antimicrobial activity. The root dichloromethane extracts from <it>C. mucronata </it>was found to be more toxic with an LC₅₀value of 59.608 μg/mL while ethanolic extracts from root were not toxic with LC₅₀>100 μg/mL). Ethanol extracts from fruits and roots of <it>T. villosa </it>were found to be very toxic with LC₅₀values of 9.690 μg/mL and 4.511 μg/mL, respectively, while, ethanol extracts from leaves and twigs of <it>T. villosa </it>were found to be non toxic (LC₅₀>100 μg/mL).</p> <p>Conclusion</p> <p>These results support the use of <it>C. mucronata </it>in traditional medicine for treatment of wounds. Extracts of <it>C. mucronata </it>have potential to yield active antimicrobial and larvicidal compounds. The high brine shrimp toxicity of <it>T. villosa </it>corroborates with literature reports that the plant is toxic to both livestock and fish. The results further suggest that <it>T. villosa </it>extracts have potential to yield larvicidal and possibly cytotoxic compounds. Further studies to investigate the bioactive compounds responsible for the observed biological effects are suggested.</p

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research