ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
Nkhoma ET, Poole C, Vannappagari V, Hall SA, Beutler E, 2009. The global prevalence of glucose-6-phosphate dehydrogenase deficiency: a systematic review and meta-analysis. Blood Cells Mol Dis 42: 267–278.
-
2.
Calvert AF, Trimble GE, 1980. Glucose-6-phosphate dehydrogenase in an Afro-American population. Hum Hered 30: 271–277.
-
3.
Bryc K, Velez C, Karafet T, Moreno-Estrada A, Reynolds A, Auton A, Hammer M, Bustamante CD, Ostrer H, 2010. Colloquium paper: genome-wide patterns of population structure and admixture among Hispanic/Latino populations. Proc Natl Acad Sci USA 107 (Suppl 2): 8954–8961.
-
4.
Cappellini MD, Fiorelli G, 2008. Glucose-6-phosphate dehydrogenase deficiency. Lancet 371: 64–74.
-
5.
Tungsiripat M, Drechsler H, Sarlone C, Amyot K, Laffey E, Aberg J, 2008. Prevalence and significance of G6PD deficiency in patients of an urban HIV clinic. J Int Assoc Physicians AIDS Care 7: 88–90.
-
6.
Serpa JA, Villarreal-Williams E, Giordano TP, 2010. Prevalence of G6PD deficiency in a large cohort of HIV-infected patients. J Infect 61: 399–402.
-
7.
Aukrust P, Muller F, Svardal AM, Ueland T, Berge RK, Froland SS, 2003. Disturbed glutathione metabolism and decreased antioxidant levels in human immunodeficiency virus-infected patients during highly active antiretroviral therapy–potential immunomodulatory effects of antioxidants. J Infect Dis 188: 232–238.
-
8.
Feily A, Namazi MR, 2011. Glucose-6-phosphate-dehydrogenase deficiency may impart susceptibility to the development of AIDS. Arch Med Res 42: 77.
-
9.
Herzenberg LA, De Rosa SC, Dubs JG, Roederer M, Anderson MT, Ela SW, Deresinski SC, 1997. Glutathione deficiency is associated with impaired survival in HIV disease. Proc Natl Acad Sci USA 94: 1967–1972.
-
10.
Pace GW, Leaf CD, 1995. The role of oxidative stress in HIV disease. Free Radic Biol Med 19: 523–528.
-
11.
Rapezzi D, Porqueddu EM, Fenu L, Racchi O, Ferraris AM, Gaetani GF, Aceti A, 1998. Survival of people who are HIV-1-positive and G6PD-deficient is unaffected by virus-induced oxidative stress. Lancet 351: 264–265.
-
12.
Staal FJ, Ela SW, Roederer M, Anderson MT, Herzenberg LA, Herzenberg LA, 1992. Glutathione deficiency and human immunodeficiency virus infection. Lancet 339: 909–912.
-
13.
Schulze Zur Wiesch J, Wichmann D, Hofer A, van Lunzen J, Burchard GD, Schmiedel S, 2008. Primary HIV infection presenting as haemolytic crisis in a patient with previously undiagnosed glucose 6-phosphate dehydrogenase deficiency. AIDS 22: 1886–1888.
-
14.
Belperio PS, Rhew DC, 2004. Prevalence and outcomes of anemia in individuals with human immunodeficiency virus: a systematic review of the literature. Am J Med 116 (Suppl 7A): 27S–43S.
-
15.
Obirikorang C, Yeboah FA, 2009. Blood haemoglobin measurement as a predictive indicator for the progression of HIV/AIDS in resource-limited setting. J Biomed Sci 16: 102.
-
16.
Sullivan PS, Hanson DL, Brooks JT, 2008. Impact on hemoglobin of starting combination antiretroviral therapy with or without zidovudine in anemic HIV-infected patients. J Acquir Immune Defic Syndr 48: 163–168.
-
17.
Volberding PA, Levine AM, Dieterich D, Mildvan D, Mitsuyasu R, Saag M, 2004. Anemia in HIV infection: clinical impact and evidence-based management strategies. Clin Infect Dis 38: 1454–1463.
-
18.
Beutler E, 1966. A series of new screening procedures for pyruvate kinase deficiency, glucose-6-phosphate dehydrogenase deficiency, and glutathione reductase deficiency. Blood 28: 553–562.
-
19.
Kaplan M, Hammerman C, 2011. Neonatal screening for glucose-6-phosphate dehydrogenase deficiency: biochemical versus genetic technologies. Semin Perinatol 35: 155–161.
-
20.
Miao J, Chen Q, Bao L, Huang Y, Zhang J, Wan K, Yi J, Wang S, Zou L, Li T, 2013. Determination of optimal cutoff value to accurately identify glucose-6-phosphate dehydrogenase-deficient heterozygous female neonates. Clin Chim Acta 424: 131–135.
-
21.
Minucci A, Giardina B, Zuppi C, Capoluongo E, 2009. Glucose-6-phosphate dehydrogenase laboratory assay: how, when, and why? IUBMB Life 61: 27–34.
-
22.
Peters AL, Van Noorden CJ, 2009. Glucose-6-phosphate dehydrogenase deficiency and malaria: cytochemical detection of heterozygous G6PD deficiency in women. J Histochem Cytochem 57: 1003–1011.
-
23.
1989. Glucose-6-phosphate dehydrogenase deficiency. WHO Working Group. Bull World Health Organ 67: 601–611.
-
24.
Pamba A, Richardson ND, Carter N, Duparc S, Premji Z, Tiono AB, Luzzatto L, 2012. Clinical spectrum and severity of hemolytic anemia in glucose 6-phosphate dehydrogenase-deficient children receiving dapsone. Blood 120: 4123–4133.
-
25.
Sirdah M, Reading NS, Perkins SL, Shubair M, Aboud L, Prchal JT, 2012. Hemolysis and Mediterranean G6PD mutation (c.563 C > T) and c.1311 C > T polymorphism among Palestinians at Gaza Strip. Blood Cells Mol Dis 48: 203–208.
-
26.
Sirdah M, Reading NS, Vankayalapati H, Perkins SL, Shubair ME, Aboud L, Roper D, Prchal JT, 2012. Molecular heterogeneity of glucose-6-phosphate dehydrogenase deficiency in Gaza Strip Palestinians. Blood Cells Mol Dis 49: 152–158.
-
27.
Mocroft A, Kirk O, Barton SE, Dietrich M, Proenca R, Colebunders R, Pradier C, d'Arminio Monforte A, Ledergerber B, Lundgren JD, 1999. Anaemia is an independent predictive marker for clinical prognosis in HIV-infected patients from across Europe. EuroSIDA study group. AIDS 13: 943–950.
-
28.
Saunders MA, Hammer MF, Nachman MW, 2002. Nucleotide variability at G6pd and the signature of malarial selection in humans. Genetics 162: 1849–1861.
-
29.
Motulsky AG, Campbell-Kraut JM, 1961. Population genetics of glucose-6-phosphate dehydrogenase deficiency of the red cell. Blumberg BS, ed. Proceedings of the Conference on Genetic Polymorphisms and Geographic Variations in Disease New York, NY: Grune and Stratton, 159–180.
-
30.
Boyer SH, Porter IH, Weilbacher RG, 1962. Electrophoretic heterogeneity of glucose-6-phosphate dehydrogenase and its relationship to enzyme deficiency in man. Proc Natl Acad Sci USA 48: 1868–1876.
-
31.
Chan TK, McFadzean JS, 1974. Haemolytic effect of trimethoprim-sulphamethoxazole in G-6-PD deficiency. Trans R Soc Trop Med Hyg 68: 61–62.
-
32.
Degowin RL, Eppes RB, Powell RD, Carson PE, 1966. The haemolytic effects of diaphenylsulfone (DDS) in normal subjects and in those with glucose-6-phosphate-dehydrogenase deficiency. Bull World Health Organ 35: 165–179.
-
33.
Fanello CI, Karema C, Avellino P, Bancone G, Uwimana A, Lee SJ, d'Alessandro U, Modiano D, 2008. High risk of severe anaemia after chlorproguanil-dapsone + artesunate antimalarial treatment in patients with G6PD (A−) deficiency. PLoS One 3: e4031.
-
34.
Youngster I, Arcavi L, Schechmaster R, Akayzen Y, Popliski H, Shimonov J, Beig S, Berkovitch M, 2010. Medications and glucose-6-phosphate dehydrogenase deficiency: an evidence-based review. Drug Saf 33: 713–726.
-
35.
Aberg JA, Kaplan JE, Libman H, Emmanuel P, Anderson JR, Stone VE, Oleske JM, Currier JS, Gallant JE, 2009. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 49: 651–681.
-
36.
Sellier PO, Mario N, Rami A, Andreoli A, Choho BM, Simoneau G, Magnier JD, Evans J, Chappuis P, Bergmann JF, 2011. Is testing for glucose-6-phosphate dehydrogenase deficiency before starting sulfa useful in HIV-infected male patients originating from sub-Saharan Africa? J Acquir Immune Defic Syndr 56: e60–e63.
| Past two years | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 1032 | 851 | 42 |
| Full Text Views | 421 | 5 | 1 |
| PDF Downloads | 186 | 8 | 3 |
G6PD Deficiency in an HIV Clinic Setting in the Dominican Republic
Julia Z. Xu
Julia Z. Xu
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Richard O. Francis
Richard O. Francis
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Leonel E. Lerebours Nadal
Leonel E. Lerebours Nadal
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Maryam Shirazi
Maryam Shirazi
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Vaidehi Jobanputra
Vaidehi Jobanputra
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Eldad A. Hod
Eldad A. Hod
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Jeffrey S. Jhang
Jeffrey S. Jhang
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Brie A. Stotler
Brie A. Stotler
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Steven L. Spitalnik
Steven L. Spitalnik
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Stephen W. Nicholas
Stephen W. Nicholas
Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York; Clínica de Familia La Romana, La Romana, Dominican Republic; IFAP Global Health Program, Columbia University Medical Center, New York, New York
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Because human immunodeficiency virus (HIV)-infected patients receive prophylaxis with oxidative drugs, those with glucose-6-phosphate dehydrogenase (G6PD) deficiency may experience hemolysis. However, G6PD deficiency has not been studied in the Dominican Republic, where many individuals have African ancestry. Our objective was to determine the prevalence of G6PD deficiency in Dominican HIV-infected patients and to attempt to develop a cost-effective algorithm for identifying such individuals. To this end, histories, chart reviews, and G6PD testing were performed for 238 consecutive HIV-infected adult clinic patients. The overall prevalence of G6PD deficiency (8.8%) was similar in males (9.3%) and females (8.5%), and higher in Haitians (18%) than Dominicans (6.4%; P = 0.01). By logistic regression, three clinical variables predicted G6PD status: maternal country of birth (P = 0.01) and a history of hemolysis (P = 0.01) or severe anemia (P = 0.03). Using these criteria, an algorithm was developed, in which a patient subset was identified that would benefit most from G6PD screening, yielding a sensitivity of 94.7% and a specificity of 97.2%, increasing the pretest probability (8.8–15.1%), and halving the number of patients needing testing. This algorithm may provide a cost-effective strategy for improving care in resource-limited settings.
Author Notes
Financial support: Julia Z. Xu received funding from the Columbia University Doris Duke Charitable Foundation Clinical Research Fellowship 2012–2013 and received funding from an award from the American Society of Hematology (HONORS Award), as well as the Department of Pathology and Cell Biology at Columbia University. Jeffrey S. Jhang received compensation in the past from Aaronson Rappaport Feinstein and Deutsch LLP for expert testimony. Steven L. Spitalnik is currently receiving a grant (R01 HL115557) from the National Institutes of Health and funding from the American Society of Hematology (HONORS Award), and has an unrelated pending patent application regarding iron chelation and RBC transfusions.
Disclosure: Some of these data were presented previously at the 2013 annual meeting of the Academy Clinical Laboratory Physicians and Scientists in Atlanta, GA, June 6–8, 2013, and the 2013 annual meeting of the American Society of Hematology in New Orleans, LA, December 7–10, 2013.
Authors' addresses: Julia Z. Xu, Department of Medicine, Duke University Medical Center, Durham, NC, E-mail: julia.xu@dm.duke.edu. Richard O. Francis, Maryam Shirazi, Vaidehi Jobanputra, Eldad A. Hod, Brie A. Stotler, and Steven L. Spitalnik, Department of Pathology and Cell Biology, Columbia University Medical Center, New York, NY, E-mails: rof3@cumc.columbia.edu, ms4105@cumc.columbia.edu, vj2004@cumc.columbia.edu, eh2217@cumc.columbia.edu, bs2277@cumc.columbia.edu, and ss2479@cumc.columbia.edu. Jeffrey S. Jhang, Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, E-mail: jeffrey.jhang@mountsinai.org. Leonel E. Lerebours Nadal, Clínica de Familia La Romana, República Dominicana, E-mail: leonel.lereboursnadal@gmail.com. Stephen W. Nicholas, IFAP Global Health Program, Columbia University Medical Center, New York, NY, E-mail: swn2@cumc.columbia.edu.
Reprint requests: Stephen W. Nicholas, IFAP Global Health Program, Columbia University Medical Center, 630 West 168th Street, Box 41, Room P and S 1-416, New York, NY 10032, E-mail: swn2@cumc.columbia.edu, Tel: 212-305-3595, Fax: 212-305-3601.
ProCite
RefWorks
Reference Manager
BibTeX
Zotero
EndNote
-
1.
Nkhoma ET, Poole C, Vannappagari V, Hall SA, Beutler E, 2009. The global prevalence of glucose-6-phosphate dehydrogenase deficiency: a systematic review and meta-analysis. Blood Cells Mol Dis 42: 267–278.
-
2.
Calvert AF, Trimble GE, 1980. Glucose-6-phosphate dehydrogenase in an Afro-American population. Hum Hered 30: 271–277.
-
3.
Bryc K, Velez C, Karafet T, Moreno-Estrada A, Reynolds A, Auton A, Hammer M, Bustamante CD, Ostrer H, 2010. Colloquium paper: genome-wide patterns of population structure and admixture among Hispanic/Latino populations. Proc Natl Acad Sci USA 107 (Suppl 2): 8954–8961.
-
4.
Cappellini MD, Fiorelli G, 2008. Glucose-6-phosphate dehydrogenase deficiency. Lancet 371: 64–74.
-
5.
Tungsiripat M, Drechsler H, Sarlone C, Amyot K, Laffey E, Aberg J, 2008. Prevalence and significance of G6PD deficiency in patients of an urban HIV clinic. J Int Assoc Physicians AIDS Care 7: 88–90.
-
6.
Serpa JA, Villarreal-Williams E, Giordano TP, 2010. Prevalence of G6PD deficiency in a large cohort of HIV-infected patients. J Infect 61: 399–402.
-
7.
Aukrust P, Muller F, Svardal AM, Ueland T, Berge RK, Froland SS, 2003. Disturbed glutathione metabolism and decreased antioxidant levels in human immunodeficiency virus-infected patients during highly active antiretroviral therapy–potential immunomodulatory effects of antioxidants. J Infect Dis 188: 232–238.
-
8.
Feily A, Namazi MR, 2011. Glucose-6-phosphate-dehydrogenase deficiency may impart susceptibility to the development of AIDS. Arch Med Res 42: 77.
-
9.
Herzenberg LA, De Rosa SC, Dubs JG, Roederer M, Anderson MT, Ela SW, Deresinski SC, 1997. Glutathione deficiency is associated with impaired survival in HIV disease. Proc Natl Acad Sci USA 94: 1967–1972.
-
10.
Pace GW, Leaf CD, 1995. The role of oxidative stress in HIV disease. Free Radic Biol Med 19: 523–528.
-
11.
Rapezzi D, Porqueddu EM, Fenu L, Racchi O, Ferraris AM, Gaetani GF, Aceti A, 1998. Survival of people who are HIV-1-positive and G6PD-deficient is unaffected by virus-induced oxidative stress. Lancet 351: 264–265.
-
12.
Staal FJ, Ela SW, Roederer M, Anderson MT, Herzenberg LA, Herzenberg LA, 1992. Glutathione deficiency and human immunodeficiency virus infection. Lancet 339: 909–912.
-
13.
Schulze Zur Wiesch J, Wichmann D, Hofer A, van Lunzen J, Burchard GD, Schmiedel S, 2008. Primary HIV infection presenting as haemolytic crisis in a patient with previously undiagnosed glucose 6-phosphate dehydrogenase deficiency. AIDS 22: 1886–1888.
-
14.
Belperio PS, Rhew DC, 2004. Prevalence and outcomes of anemia in individuals with human immunodeficiency virus: a systematic review of the literature. Am J Med 116 (Suppl 7A): 27S–43S.
-
15.
Obirikorang C, Yeboah FA, 2009. Blood haemoglobin measurement as a predictive indicator for the progression of HIV/AIDS in resource-limited setting. J Biomed Sci 16: 102.
-
16.
Sullivan PS, Hanson DL, Brooks JT, 2008. Impact on hemoglobin of starting combination antiretroviral therapy with or without zidovudine in anemic HIV-infected patients. J Acquir Immune Defic Syndr 48: 163–168.
-
17.
Volberding PA, Levine AM, Dieterich D, Mildvan D, Mitsuyasu R, Saag M, 2004. Anemia in HIV infection: clinical impact and evidence-based management strategies. Clin Infect Dis 38: 1454–1463.
-
18.
Beutler E, 1966. A series of new screening procedures for pyruvate kinase deficiency, glucose-6-phosphate dehydrogenase deficiency, and glutathione reductase deficiency. Blood 28: 553–562.
-
19.
Kaplan M, Hammerman C, 2011. Neonatal screening for glucose-6-phosphate dehydrogenase deficiency: biochemical versus genetic technologies. Semin Perinatol 35: 155–161.
-
20.
Miao J, Chen Q, Bao L, Huang Y, Zhang J, Wan K, Yi J, Wang S, Zou L, Li T, 2013. Determination of optimal cutoff value to accurately identify glucose-6-phosphate dehydrogenase-deficient heterozygous female neonates. Clin Chim Acta 424: 131–135.
-
21.
Minucci A, Giardina B, Zuppi C, Capoluongo E, 2009. Glucose-6-phosphate dehydrogenase laboratory assay: how, when, and why? IUBMB Life 61: 27–34.
-
22.
Peters AL, Van Noorden CJ, 2009. Glucose-6-phosphate dehydrogenase deficiency and malaria: cytochemical detection of heterozygous G6PD deficiency in women. J Histochem Cytochem 57: 1003–1011.
-
23.
1989. Glucose-6-phosphate dehydrogenase deficiency. WHO Working Group. Bull World Health Organ 67: 601–611.
-
24.
Pamba A, Richardson ND, Carter N, Duparc S, Premji Z, Tiono AB, Luzzatto L, 2012. Clinical spectrum and severity of hemolytic anemia in glucose 6-phosphate dehydrogenase-deficient children receiving dapsone. Blood 120: 4123–4133.
-
25.
Sirdah M, Reading NS, Perkins SL, Shubair M, Aboud L, Prchal JT, 2012. Hemolysis and Mediterranean G6PD mutation (c.563 C > T) and c.1311 C > T polymorphism among Palestinians at Gaza Strip. Blood Cells Mol Dis 48: 203–208.
-
26.
Sirdah M, Reading NS, Vankayalapati H, Perkins SL, Shubair ME, Aboud L, Roper D, Prchal JT, 2012. Molecular heterogeneity of glucose-6-phosphate dehydrogenase deficiency in Gaza Strip Palestinians. Blood Cells Mol Dis 49: 152–158.
-
27.
Mocroft A, Kirk O, Barton SE, Dietrich M, Proenca R, Colebunders R, Pradier C, d'Arminio Monforte A, Ledergerber B, Lundgren JD, 1999. Anaemia is an independent predictive marker for clinical prognosis in HIV-infected patients from across Europe. EuroSIDA study group. AIDS 13: 943–950.
-
28.
Saunders MA, Hammer MF, Nachman MW, 2002. Nucleotide variability at G6pd and the signature of malarial selection in humans. Genetics 162: 1849–1861.
-
29.
Motulsky AG, Campbell-Kraut JM, 1961. Population genetics of glucose-6-phosphate dehydrogenase deficiency of the red cell. Blumberg BS, ed. Proceedings of the Conference on Genetic Polymorphisms and Geographic Variations in Disease New York, NY: Grune and Stratton, 159–180.
-
30.
Boyer SH, Porter IH, Weilbacher RG, 1962. Electrophoretic heterogeneity of glucose-6-phosphate dehydrogenase and its relationship to enzyme deficiency in man. Proc Natl Acad Sci USA 48: 1868–1876.
-
31.
Chan TK, McFadzean JS, 1974. Haemolytic effect of trimethoprim-sulphamethoxazole in G-6-PD deficiency. Trans R Soc Trop Med Hyg 68: 61–62.
-
32.
Degowin RL, Eppes RB, Powell RD, Carson PE, 1966. The haemolytic effects of diaphenylsulfone (DDS) in normal subjects and in those with glucose-6-phosphate-dehydrogenase deficiency. Bull World Health Organ 35: 165–179.
-
33.
Fanello CI, Karema C, Avellino P, Bancone G, Uwimana A, Lee SJ, d'Alessandro U, Modiano D, 2008. High risk of severe anaemia after chlorproguanil-dapsone + artesunate antimalarial treatment in patients with G6PD (A−) deficiency. PLoS One 3: e4031.
-
34.
Youngster I, Arcavi L, Schechmaster R, Akayzen Y, Popliski H, Shimonov J, Beig S, Berkovitch M, 2010. Medications and glucose-6-phosphate dehydrogenase deficiency: an evidence-based review. Drug Saf 33: 713–726.
-
35.
Aberg JA, Kaplan JE, Libman H, Emmanuel P, Anderson JR, Stone VE, Oleske JM, Currier JS, Gallant JE, 2009. Primary care guidelines for the management of persons infected with human immunodeficiency virus: 2009 update by the HIV medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 49: 651–681.
-
36.
Sellier PO, Mario N, Rami A, Andreoli A, Choho BM, Simoneau G, Magnier JD, Evans J, Chappuis P, Bergmann JF, 2011. Is testing for glucose-6-phosphate dehydrogenase deficiency before starting sulfa useful in HIV-infected male patients originating from sub-Saharan Africa? J Acquir Immune Defic Syndr 56: e60–e63.
| Past two years | Past Year | Past 30 Days | |
|---|---|---|---|
| Abstract Views | 1032 | 851 | 42 |
| Full Text Views | 421 | 5 | 1 |
| PDF Downloads | 186 | 8 | 3 |