NRU :: Browsing by Author "Mugerwa, Roy D."

Browsing by Author "Mugerwa, Roy D."

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Drug Tolerance in Mycobacterium tuberculosis
(Antimicrobial agents and chemotherapy, 1999) Wallis, Robert S.; Patil, Shripad; Cheon, Seon-Hee; Edmonds, Kay; Phillips, Manijeh; Perkins, Mark D.; Joloba, Moses; Namale, Alice; Johnson, John L.; Teixeira, Lucileia; Dietze, Reynaldo; Siddiqi, Salman; Mugerwa, Roy D.; Eisenach, Kathleen; Ellner, Jerrold J.
Although Mycobacterium tuberculosis is eradicated rapidly during therapy in some patients with pulmonary tuberculosis, it can persist for many months in others. This study examined the relationship between mycobacterial drug tolerance (delayed killing in vitro), persistence, and relapse. It was performed with 39 fully drug-susceptible isolates from a prospective trial of standard short-course antituberculous therapy with sputum smear-positive, human immunodeficiency virus-uninfected subjects with pulmonary tuberculosis in Brazil and Uganda. The rate of killing in vitro was determined by monitoring the growth index (GI) in BACTEC 12B medium after addition of drug to established cultures and was measured as the number of days required for 99% sterilization. Drugs differed significantly in bactericidal activity, in the following order from greatest to least, rifampin > isoniazid-ethambutol > ethambutol (P < 0.001). Isolates from subjects who had relapses (n 5 2) or in whom persistence was prolonged (n 5 1) were significantly more tolerant of isoniazidethambutol and rifampin than isolates from other subjects (P < 0.01).
Effectiveness of the standard WHO recommended retreatment regimen (Category II) for tuberculosis in Kampala, Uganda
(PLoS medicine, 2011) Jones-López, Edward C.; Ayakaka, Irene; Levin, Jonathan; Reilly, Nancy; Mumbowa, Francis; Dryden-Peterson, Scott; Nyakoojo, Grace; Fennelly, Kevin; Temple, Beth; Nakubulwa, Susan; Joloba, Moses L.; Okwera, Alphonse; Eisenach, Kathleen D.; McNerney, Ruth; Elliott, Alison M.; Ellner, Jerrold J.; Smith, Peter G.; Mugerwa, Roy D.
Each year, 10%–20% of patients with tuberculosis (TB) in low- and middle-income countries present with previously treated TB and are empirically started on a World Health Organization (WHO)-recommended standardized retreatment regimen. The effectiveness of this retreatment regimen has not been systematically evaluated. Methods and Findings: From July 2003 to January 2007, we enrolled smear-positive, pulmonary TB patients into a prospective cohort to study treatment outcomes and mortality during and after treatment with the standardized retreatment regimen. Median time of follow-up was 21 months (interquartile range 12–33 months). A total of 29/148 (20%) HIV-uninfected and 37/140 (26%) HIV-infected patients had an unsuccessful treatment outcome. In a multiple logistic regression analysis to adjust for confounding, factors associated with an unsuccessful treatment outcome were poor adherence (adjusted odds ratio [aOR] associated with missing half or more of scheduled doses 2.39; 95% confidence interval (CI) 1.10–5.22), HIV infection (2.16; 1.01–4.61), age (aOR for 10-year increase 1.59; 1.13–2.25), and duration of TB symptoms (aOR for 1-month increase 1.12; 1.04–1.20). All patients with multidrug-resistant TB had an unsuccessful treatment outcome. HIV-infected individuals were more likely to die than HIV-uninfected individuals (p,0.0001). Multidrug-resistant TB at enrolment was the only common risk factor for death during follow-up for both HIV-infected (adjusted hazard ratio [aHR] 17.9; 6.0–53.4) and HIV-uninfected (14.7; 4.1–52.2) individuals. Other risk factors for death during follow-up among HIVinfected patients were CD4,50 cells/ml and no antiretroviral treatment (aHR 7.4, compared to patients with CD4$200; 3.0– 18.8) and Karnofsky score ,70 (2.1; 1.1–4.1); and among HIV-uninfected patients were poor adherence (missing half or more of doses) (3.5; 1.1–10.6) and duration of TB symptoms (aHR for a 1-month increase 1.9; 1.0–3.5). Conclusions: The recommended regimen for retreatment TB in Uganda yields an unacceptable proportion of unsuccessful outcomes. There is a need to evaluate new treatment strategies in these patients.
First Trial Of The HIV1 Vaccine In Africa: Ugandan Experience
(Bmj, 2002) Mugerwa, Roy D.; Kaleebu, Pontiano; Mugyenyi, Peter; Mbidde, Edward Katongole; Hom, David L.; Byaruhanga, Rose; Salata, Robert A.; Ellner, Jerrold J.; HIV1 Vaccine Trial Group
Trials of the HIV1 vaccine have been conducted in Europe, North America, Brazil, China, and Thailand.1 The first trial of a candidate vaccine in Africa was recently completed in Uganda. It involved a randomised, placebo controlled trial of a vaccine in healthy volunteers at low risk of HIV infection.2 3 The vaccine, called “ALVACHIV,” uses a live recombinant canarypox vector to express envelope and core genes of HIV1. Many commentators predicted that it would be difficult to conduct trials of HIV vaccines in developing countries because of scientific, sociobehavioural, ethical, and logistical barriers.4–8 Before we started the trial in Uganda, we gathered data to help us overcome these potential barriers. We collected epidemiological9 and sociobehavioural10 data about people who had participated in studies that looked at preparing for trials of the HIV vaccine. These data showed the prevalence and incidence of HIV, behaviours placing people at risk of becoming infected with HIV, and the social acceptability of a vaccine against HIV.9–11 The people received detailed education and counselling about infection with HIV and about HIV vaccines, and we recruited some for our trial.11We organised three open workshops at the HIV candidate vaccine trial workshop in Kampala in 1996 to gain consensus from scientists, policy makers, community representatives, and the media about how to undertake research into HIV vaccines. Despite these initiatives to solve problems before the trial began, we still encountered many barriers. In this article, we discuss these barriers and the strategiesthat we developed to overcome them.
Genome Scan of M. tuberculosis Infection and Disease in Ugandans
(PLoS ONE, 2018) Stein, Catherine M.; Zalwango, Sarah; Malone, LaShaunda L.; Won1, Sungho; Mayanja- Kizza, Harriet; Mugerwa, Roy D.; Leontiev, Dmitry V.; Thompson, Cheryl L.; Cartier, Kevin C.; Elston, Robert C.; Iyengar, Sudha K.; Boom, Henry; Whalen, Christopher C.
Tuberculosis (TB), caused by Mycobacterium tuberculosis (Mtb), is an enduring public health problem globally, particularly in sub-Saharan Africa. Several studies have suggested a role for host genetic susceptibility in increased risk for TB but results across studies have been equivocal. As part of a household contact study of Mtb infection and disease in Kampala, Uganda, we have taken a unique approach to the study of genetic susceptibility to TB, by studying three phenotypes. First, we analyzed culture confirmed TB disease compared to latent Mtb infection (LTBI) or lack of Mtb infection. Second, we analyzed resistance to Mtb infection in the face of continuous exposure, defined by a persistently negative tuberculin skin test (PTST-); this outcome was contrasted to LTBI. Third, we analyzed an intermediate phenotype, tumor necrosis factor-alpha (TNFa) expression in response to soluble Mtb ligands enriched with molecules secreted from Mtb (culture filtrate). We conducted a full microsatellite genome scan, using genotypes generated by the Center for Medical Genetics at Marshfield. Multipoint model-free linkage analysis was conducted using an extension of the Haseman-Elston regression model that includes half sibling pairs, and HIV status was included as a covariate in the model. The analysis included 803 individuals from 193 pedigrees, comprising 258 full sibling pairs and 175 half sibling pairs. Suggestive linkage (p,1023) was observed on chromosomes 2q21-2q24 and 5p13-5q22 for PTST-, and on chromosome 7p22-7p21 for TB; these findings for PTST- are novel and the chromosome 7 region contains the IL6 gene. In addition, we replicated recent linkage findings on chromosome 20q13 for TB (p = 0.002). We also observed linkage at the nominal a = 0.05 threshold to a number of promising candidate genes, SLC11A1 (PTST- p = 0.02), IL-1 complex (TB p = 0.01), IL12BR2 (TNFa p = 0.006), IL12A (TB p = 0.02) and IFNGR2 (TNFa p = 0.002). These results confirm not only that genetic factors influence the interaction between humans and Mtb but more importantly that they differ according to the outcome of that interaction: exposure but no infection, infection without progression to disease, or progression of infection to disease. Many of the genetic factors for each of these stages are part of the innate immune system.
Immunoadjuvant Prednisolone Therapy for HIV-Associated Tuberculosis: A Phase 2 Clinical Trial in Uganda
(The Journal of infectious diseases, 2005) Mayanja-Kizza, Harriet; Jones-Lopez, Edward; Okwera, Alphonse; Wallis, Robert S.; Mugerwa, Roy D.; Uganda–Case Western Research Collaboration
Human immunodeficiency virus (HIV)–infected patients with tuberculosis (TB) respond to effective antituberculous therapy, but their prognosis remains poor. Mounting evidence from clinical studies supports the concept of copathogenesis in which immune activation that is triggered by TB and mediated by cytokines stimulates viral replication and worsens HIV infection, especially when immune function is preserved. We performed a phase 2, randomized, double-blind, placebo-controlled clinical trial in Kampala, Uganda, to determine whether immunoadjuvant prednisolone therapy in HIV-infected patients with TB who have CD4+ T cell counts ⩾200 cells/μL is safe and effective at increasing CD4+ T cell countsShort-term prednisolone therapy reduced levels of immune activation and tended to produce higher CD4+ T cell counts. Although prednisolone therapy was associated with a more rapid clearance of Mycobacterium tuberculosis from the sputum, it was also associated with a transient increase in HIV RNA levels, which receded when prednisolone therapy was discontinued. The intervention worsened underlying hypertension and caused fluid retention and hyperglycemiaThe benefits of prednisolone therapy on immune activation and CD4+ T cell counts do not outweigh the risks of adverse events in HIV-infected patients with TB and preserved immune function
Incidence and Predictors of Mortality and the Effect of Tuberculosis Immune Reconstitution Inflammatory Syndrome in a Cohort of TB/HIV Patients Commencing Antiretroviral Therapy
(JAIDS Journal of Acquired Immune Deficiency Syndromes, 2011) Worodria, William; Massinga-Loembe, Marguerite; Mazakpwe, Doreen; Luzinda, Kenneth; Mayanja-Kizza, Harriet; Mugerwa, Roy D.; Reiss, Peter; Colebunders, Robert; For the TB-IRIS Study Group
Tuberculosis-HIV (TB-HIV) coinfection remains an important cause of mortality in antiretroviral therapy (ART) programs. In a cohort of TB-HIV-coinfected patients starting ART, we examined the incidence and predictors of early mortality.Consecutive TB-HIV-coinfected patients eligible for ART were enrolled in a cohort study at the Mulago National Tuberculosis and Leprosy Program clinic in Kampala, Uganda. Predictors of mortality were assessed using Cox proportional hazards analysis. Three hundred and two patients [median CD4 count 53 cells/μL (interquartile range, 20-134)] were enrolled. Fifty-three patients died, 36 (68%) of these died within the first 6 months of TB diagnosis. Male sex [hazard (HR): 2.19; 95% confidence interval (CI): 1.19 to 4.03; P = 0.011], anergy to tuberculin skin test [HR: 2.59 (1.10 to 6.12); P = 0.030], a positive serum cryptococcal antigen result at enrollment (HR: 4.27; 95% CI: 1.50 to 12.13; P = 0.006) and no ART use (HR: 4.63; 95% CI: 2. 37 to 9.03; P < 0.001) were independent predictors of mortality by multivariate analysis. Six (10%) patients with TB immune reconstitution inflammatory syndrome died, and in most, an alternative contributing cause of death was identified.Mortality among these TB-HIV-coinfected patients was high particularly when presenting with advanced HIV disease and not starting ART, reinforcing the need for timely and joint treatment for both infections. Screening for a concomitant cryptococcal infection and antifungal treatment for patients with cryptococcal antigenemia may further improve clinical outcome.
Induction of the Antigen 85 Complex of Mycobacterium tuberculosis in Sputum: A Determinant of Outcome in Pulmonary Tuberculosis Treatment
(The Journal of infectious diseases, 1998) Wallis, Robert S.; Perkins, Mark; Phillips, Manijeh; Joloba, Moses; Demchuk, Barbara; Namale, Alice; Johnson, John L.; Williams, Donna; Wolski, Kathy; Dietze, Reynaldo; Mugerwa, Roy D.; Eisenach, Kathleen; Ellner, Jerrold J.
Sputum quantitative culture, acid-fast smear, days-to-positive by BACTEC, and Mycobacterium tuberculosis antigen 85 complex were monitored during therapy in 42 patients with pulmonary tuberculosis (TB). By BACTEC, 4 patients were persistently positive on days 90–180, and treatment ultimately failed in 2 of these. Antigen 85 expression increased in subjects in whom disease persisted (persisters) from days 0 to 14 when the difference between persisters and nonpersisters was statistically significant (P .002). Only antigen 85 complex values at day 14 suggested TB persistence at or after day 90. All subjects with day 14 antigen 85 complex values 60 pg/mL responded rapidly to treatment and were cured. Of those with values 60 pg/mL, in 33% TB persisted at or after day 90 and treatment failed in 17%. Biologic factors expressed early in therapy, not related to compliance or resistance, may exert a substantial influence on outcome. The antigen 85 complex is critical in cell wall biosynthesis and is induced by isoniazid in vitro. Its induction may represent an adaptive transition to a persistent state during therapy
Linkage and association analysis of candidate genes for TB and TNFa cytokine expression: evidence for association with IFNGR1, IL-10, and TNF receptor 1 genes
(Springer, 2007) Stein, Catherine M.; Zalwango, Sarah; Chiunda, Allan B.; Millard, Christopher; Leontiev, Dmitry V.; Horvath, Amanda L.; Cartier, Kevin C.; Chervenak, Keith; Boom, W. Henry; Elston, Robert C.; Mugerwa, Roy D.; Whalen, Christopher C.; Iyengar, Sudha K.
Tuberculosis (TB) is a growing public health threat globally and several studies suggest a role of host genetic susceptibility in increased TB risk. As part of a household contact study in Kampala, Uganda, we have taken a unique approach to the study of genetic susceptibility to TB by developing an intermediate phenotype model for TB susceptibility, analyzing levels of tumor necrosis factor-a (TNFa) in response to culture filtrate as the phenotype. In the present study, we analyzed candidate genes related to TNFa regulation and found that interleukin (IL)-10, interferon-gamma receptor 1 (IFNGR1), and TNFa receptor 1 (TNFR1) genes were linked and associated to both TB and TNFa. We also show that these associations are with progression to active disease and not susceptibility to latent infection. This is the first report of an association between TB and TNFR1 in a human population and our findings for IL-10 and IFNGR1 replicate previous findings. By observing pleiotropic effects on both phenotypes, we show construct validity of our intermediate phenotype model, which enables the characterization of the role of these genetic polymorphisms on TB pathogenesis. This study further illustrates the utility of such a model for disentangling complex traits.
Mycobacterium tuberculosis Microbiologic and Clinical Treatment Outcomes in a Randomized Trial of Immediate versus CD4+ -Initiated Antiretroviral Therapy in HIV-Infected Adults with a High CD4+ Cell Count
(Clinical infectious diseases, 2010) Chamie, Gabriel; Charlebois, Edwin D.; Walusimbi-Nanteza, Maria; Mugerwa, Roy D.; Mayanja, Harriet; Okwera, Alphonse; Whalen, Christopher C.; Havlir, Diane V.
In a prospective randomized, controlled trial in Uganda comparing the efficacy of antiretroviral therapy during tuberculosis therapy with the efficacy of tuberculosis therapy alone in HIV-infected patients with tuberculosis who have a CD4+ cell count >350 cells/µL, it was found that antiretroviral therapy did not accelerate microbiologic, radiographic, or clinical responses to tuberculosis therapy: 18% of participants had sputum smears positive for Mycobacterium tuberculosis after 5 months of tuberculosis therapy, despite having had negative culture results.
Rate and Amplification of Drug Resistance among Previously-Treated Patients with Tuberculosis in Kampala, Uganda
(Clinical infectious diseases, 2008) Temple, Beth; Ayakaka, Irene; Ogwang, Sam; Nabanjja, Helen; Kayes, Susan; Nakubulwa, Susan; Worodria, William; Levin, Jonathan; Joloba, Moses; Okwera, Alphonse; Eisenach, Kathleen D.; McNerney, Ruth; Elliott, Alison M.; Smith, Peter G.; Mugerwa, Roy D.; Ellner, Jerrold J.; Jones-Lopez, Edward C.
Drug-resistant Mycobacterium tuberculosis has emerged as a global threat. In resource-constrained settings, patients with a history of tuberculosis (TB) treatment may have drug-resistant disease and may experience poor outcomes. There is a need to measure the extent of and risk factors for drug resistance in such patients. Methods. From July 2003 through November 2006, we enrolled 410 previously treated patients with TB in Kampala, Uganda. We measured the prevalence of resistance to first- and second-line drugs and analyzed risk factors associated with baseline and acquired drug resistance. Results. The prevalence of multidrug-resistant TB was 12.7% (95% confidence interval [95% CI], 9.6%–16.3%). Resistance to second-line drugs was low. Factors associated with multidrug-resistant TB at enrollment included a history of treatment failure (odds ratio, 23.6; 95% CI, 7.7–72.4), multiple previous TB episodes (odds ratio, 15.6; 95% CI, 5.0–49.1), and cavities present on chest radiograph (odds ratio, 5.9; 95% CI, 1.2–29.5). Among a cohort of 250 patients, 5.2% (95% CI, 2.8%–8.7%) were infected with M. tuberculosis that developed additional drug resistance. Amplification of drug resistance was associated with existing drug resistance at baseline (P ! .01) and delayed sputum culture conversion (P ! .01). Conclusions. The burden of drug resistance in previously treated patients with TB in Uganda is sizeable, and the risk of generating additional drug resistance is significant. There is an urgent need to improve the treatment for such patients in low-income countries.
Treatment Outcomes of New Tuberculosis Patients Hospitalized in Kampala, Uganda: A Prospective Cohort Study
(PLoS ONE, 2014) Kirenga, Bruce J.; Levin, Jonathan; Ayakaka, Irene; Worodria, William; Reilly, Nancy; Mumbowa, Francis; Nabanjja, Helen; Nyakoojo, Grace; Fennelly, Kevin; Nakubulwa, Susan; Joloba, Moses; Okwera, Alphonse; Eisenach, Kathleen D.; McNerney, Ruth; Elliott, Alison M.; Mugerwa, Roy D.; Smith, Peter G.; Ellner, Jerrold J.; Jones-Lopez, Edward C.
In most resource limited settings, new tuberculosis (TB) patients are usually treated as outpatients. We sought to investigate the reasons for hospitalisation and the predictors of poor treatment outcomes and mortality in a cohort of hospitalized new TB patients in Kampala, Uganda Methods and findings: Ninety-six new TB patients hospitalised between 2003 and 2006 were enrolled and followed for two years. Thirty two were HIV-uninfected and 64 were HIV-infected. Among the HIV-uninfected, the commonest reasons for hospitalization were low Karnofsky score (47%) and need for diagnostic evaluation (25%). HIV-infected patients were commonly hospitalized due to low Karnofsky score (72%), concurrent illness (16%) and diagnostic evaluation (14%). Eleven HIV uninfected patients died (mortality rate 19.7 per 100 person-years) while 41 deaths occurred among the HIV-infected patients (mortality rate 46.9 per 100 person years). In all patients an unsuccessful treatment outcome (treatment failure, death during the treatment period or an unknown outcome) was associated with duration of TB symptoms, with the odds of an unsuccessful outcome decreasing with increasing duration. Among HIV-infected patients, an unsuccessful treatment outcome was also associated with male sex (P = 0.004) and age (P = 0.034). Low Karnofsky score (aHR = 8.93, 95% CI 1.88 – 42.40, P = 0.001) was the only factor significantly associated with mortality among the HIV-uninfected. Mortality among the HIV-infected was associated with the composite variable of CD4 and ART use, with patients with baseline CD4 below 200 cells/mL who were not on ART at a greater risk of death than those who were on ART, and low Karnofsky score (aHR = 2.02, 95% CI 1.02 – 4.01, P = 0.045). Conclusion: Poor health status is a common cause of hospitalisation for new TB patients. Mortality in this study was very high and associated with advanced HIV Disease and no use of ART.
Variability of Infectious Aerosols Produced during Coughing by Patients with Pulmonary Tuberculosis
(American journal of respiratory and critical care medicine, 2012) Fennelly, Kevin P.; Jones-Lopez, Edward C.; Ayakaka, Irene; Kim, Soyeon; Menyha, Harriet; Kirenga, Bruce; Muchwa, Christopher; Joloba, Moses; Dryden-Peterson, Scott; Reilly, Nancy; Okwera, Alphonse; Elliott, Alison M.; Smith, Peter G.; Mugerwa, Roy D.; Eisenach, Kathleen D.; Ellne, Jerrold J.
Mycobacterium tuberculosis is transmitted by infectious aerosols, but assessing infectiousness currently relies on sputum microscopy that does not accurately predict the variability in transmission. Objectives: To evaluate the feasibility of collecting cough aerosols and the risk factors for infectious aerosol production from patients with pulmonary tuberculosis (TB) in a resource-limited setting. Methods: We enrolled subjects with suspected TB in Kampala, Uganda and collected clinical, radiographic, and microbiological data in addition to cough aerosol cultures. A subset of 38 subjects was studied on 2 or 3 consecutive days to assess reproducibility. Measurements and Main Results: M. tuberculosis was cultured from cough aerosols of 28 of 101 (27.7%; 95% confidence interval [CI], 19.9–37.1%) subjects with culture-confirmed TB, with a median 16 aerosol cfu (range, 1–701) in 10 minutes of coughing. Nearly all (96.4%) cultivable particles were 0.65 to 4.7 mm in size. Positive aerosol cultures were associated with higher Karnofsky performance scores (P ¼ 0.016), higher sputum acid-fast bacilli smear microscopy grades (P ¼ 0.007), lower days to positive in liquid culture (P ¼ 0.004), stronger cough (P ¼ 0.016), and fewer days on TB treatment (P ¼ 0.047). In multivariable analyses, cough aerosol cultures were associated with a salivary/mucosalivary (compared with purulent/ mucopurulent) appearance of sputum (odds ratio, 4.42; 95% CI, 1.23–21.43) and low days to positive (per 1-d decrease; odds ratio, 1.17;95%CI, 1.07–1.33). The within-test (kappa, 0.81; 95%CI, 0.68– 0.94) and interday test (kappa, 0.62; 95% CI, 0.43–0.82) reproducibility were high. Conclusions: A minority of patients with TB (28%) produced culturable cough aerosols. Collection of cough aerosol cultures is feasible and reproducible in a resource-limited setting.
Whole Blood Interferon-Gamma Responses to Mycobacterium tuberculosis Antigens in Young Household Contacts of Persons with Tuberculosis in Uganda
(Plos one, 2008) Lewinsohn, Deborah A.; Zalwango, Sarah.; Stein, Catherine M.; Mayanja-Kizza, Harriet.; Okwera, Alphonse.; Boom, Henry W.; Mugerwa, Roy D.; Whalen, Christopher C.
Background: Due to immunologic immaturity, IFN-c-producing T cell responses may be decreased in young children compared to adults, thus we hypothesized that IFN-c responses to mycobacterial antigens in household contacts exposed to Mycobacterium tuberculosis (Mtb) would be impaired in young children relative to adults. The objective of this study was to compare whole blood IFN-c production in response to mycobacterial antigens between children and adults in Uganda. Methodology/Principal Findings: We studied household contacts of persons with culture-positive pulmonary tuberculosis (TB) enrolled in a cohort study conducted in Kampala, Uganda. Whole blood IFN-c production in response to Mtb culturefiltrate antigens was measured by ELISA and compared between infants (,2 years old, n = 80), young children (2 ,5 years old, n = 216), older children (5 ,15 years old, n = 443) and adults ($15 years old, n = 528). We evaluated the relationship between IFN-c responses and the tuberculin skin test (TST), and between IFN-c responses and epidemiologic factors that reflect exposure to Mtb, and the effect of prior BCG vaccination on IFN-c responses. Young household contacts demonstrated robust IFN-c responses comparable to those of adults that were associated with TST and known risk factors for infection. There was no effect of prior BCG immunization on the IFN-c response. Conclusions/Significance: Young children in a TB endemic setting can mount robust IFN-c responses generally comparable to those of adults, and as in adults, these responses correlated with the TST and known epidemiologic risk factors forMtb infection.

Browsing by Author "Mugerwa, Roy D."

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