A randomized controlled trial to evaluate the effect of a new skincare regimen on skin barrier function in those with podoconiosis in Ethiopia

Tropical leg lymphedema caused by podoconiosis is associated with increased colonisation by anaerobic bacteria

The non-filarial and non-communicable disease podoconiosis affects around 4 million people and is characterized by severe leg lymphedema accompanied with painful intermittent acute inflammatory episodes, called acute dermatolymphangioadenitis (ADLA) attacks. Risk factors have been associated with the disease but the mechanisms of pathophysiology remain uncertain. Lymphedema can lead to skin lesions, which can serve as entry points for bacteria that may cause ADLA attacks leading to progression of the lymphedema. However, the microbiome of the skin of affected legs from podoconiosis individuals remains unclear. Thus, we analysed the skin microbiome of podoconiosis legs using next generation sequencing. We revealed a positive correlation between increasing lymphedema severity and non-commensal anaerobic bacteria, especially Anaerococcus provencensis, as well as a negative correlation with the presence of Corynebacterium, a constituent of normal skin flora. Disease symptoms were generally linked to higher microbial diversity and richness, which deviated from the normal composition of the skin. These findings show an association of distinct bacterial taxa with lymphedema stages, highlighting the important role of bacteria for the pathogenesis of podoconiosis and might enable a selection of better treatment regimens to manage ADLA attacks and disease progression.

Phenotypical characterization, and antibiotics susceptibility patterns of skin bacteria found in podoconiosis patients in the North West Region of Cameroon

BACKGROUND

Podoconiosis, a non-infectious disease originating from long-term exposure of bare feet to irritant red clay soil is a lifelong, disabling disease with no specific diagnostic tool, classified into 5 stages based on the severity of leg swelling (lymphoedema). Secondary bacterial infections have been suggested to cause acute dermatolymphangioadenitis (ADLA) attacks and drive disease progression. Although the North West Region of Cameroon has a proven history of podoconiosis endemicity, the bacterial composition of lymphoedema due to this condition has not been studied. Thus, this study investigated the leg bacterial diversity of patients who suffered from the lymphoedema and their susceptibility pattern to selected antibiotics.

METHODS

A cross-sectional study was carried out in which podoconiosis affected and non-lymphoedema individuals living in the same community were purposively selected. Samples were collected by swabbing the skin between the toes and around the anklebone, then cultured and sub-cultured on nutrient agar to obtain pure isolates. The cultured isolates were then morphologically and biochemically classified using microscopy and analytic profile index test kits, respectively. The disk diffusion technique was used to determine antibiotic susceptibility.

RESULTS

Thirty-three participants were recruited, and 249 bacterial isolates were characterized into 29 genera, 60 species; with 30 (50%) being gram positive rods, 19 (31.7%) gram positive cocci, and 11 (18.3%) gram negative rods. Thirteen gram positive rods, fifteen gram positive cocci, and eight gram negative rods of bacterial species were found only in podoconiosis individuals among which Cellulomonas spp / Microbacterium spp. (2.8%), Staphylococcus lentus (3.3%), and Burkholderia cepacia (4.0%) dominated. 90% (90%) of the bacterial isolates were sensitive to doxycycline, whereas ampicillin had a high level of intermediate resistance, and penicillin G had the greatest resistant profile.

CONCLUSION

Our findings show that 94 (37.8%) out of 249 described bacterial isolates were exclusively found in the legs of podoconiosis individuals, and their susceptibility pattern to antibiotics was similar to that of others.

Reflections on the Centenary of Sir William Osler: Science and Humanity are One, for Nursing and Medicine

Sir William Osler (1849-1991) was Regius Professor of Medicine at the University of Oxford in the UK and a founding professor at Johns Hopkins Hospital. The centenary of Osler’s death is a time for recognition in nursing, as well as medicine, of a pioneering and highly influential Oxford physician on both sides of the Atlantic, an influence that extended to nursing from the UK to the USA.

This letter captures reflections and discussion on contemporary nursing issues from an Osler Seminar Series, held at the University of Oxford in 2019 to mark the Centenary of Sir William Osler’s death, focusing on his thinking and influence related to nursing.

This extended letter illuminates issues on themes of science and humanity within a clinical and educational context, exploring a range of key contemporary nursing issues. These include the significance of interpersonal relations as they relate to care attitude and care technology; the therapeutic influence of the nurse; nursing education and clinical-academic development; the value of a life world perspective on nursing and wellbeing; and practice development within the context of person-centred workplace cultures. These issues are contextualised with examples from practice and include some from nursing developments and those illustrated in part by the clinical speciality of dermatological care.

The letter concludes by considering the significance of the nursing service to promoting access to quality health care in the twenty-first century and its relevance to recognising the nursing contribution to universal health care through the WHO International Year(s) of the Nurse and Midwife in 2020-21.

Podoconiosis - From known to unknown: Obstacles to tackle

Podoconiosis is a non-filarial and non-communicable disease leading to lymphedema of the lower limbs. Worldwide, 4 million individuals live with podoconiosis, which is accompanied by disability and painful intermittent acute inflammatory episodes that attribute to significant disability adjusted life years (DALYs). Different risk factors like contact with volcanic red clay soil, high altitude (above 1000 m), high seasonal rainfall (above 1000 mm/year) and occupation (e.g., subsistence farmer) are associated with the risk of podoconiosis. Although podoconiosis was described to be endemic in 32 countries in Africa, parts of Latin America and South East Asia, knowledge about related genetics, pathophysiology, immunology and especially the causing molecule(s) in the soil remain uncertain. Thus, podoconiosis can be considered as one of the most neglected diseases. This review provides an overview about this non-filarial related geochemical disease and aim to present perspectives and future directions that might be important for better understanding of the disease, prospect for point-of-care diagnosis, achieving protection and developing novel treatment strategies.

Podoconiosis: key priorities for research and implementation

Podoconiosis is a non-infectious tropical lymphoedema causing swelling of the lower legs. Podoconiosis is associated with stigma, depression and reduced productivity, resulting in significant socio-economic impacts for affected individuals, families and communities. It is caused by barefoot exposure to soils and affects disadvantaged populations. Evidence from the past 5 y suggests that podoconiosis is amenable to public health interventions, e.g. footwear and hygiene-based morbidity management, which reduce acute clinical episodes. Although much has been learned in recent years, advances in care for these patients and worldwide control requires further reliable and relevant research. To develop a comprehensive global control strategy, the following key research priorities are important: better understanding of the global burden of podoconiosis through extended worldwide mapping, development of new point-of-care diagnostic methods and approaches to define the presence of the environmental characteristics that contribute to the development of the condition, improving treatment through an increased understanding of the pathogenesis of dermal changes over time, improved understanding of optimal ways of providing patient care at the national level, including research to optimize behavioural change strategies, determine the optimum package of care and integrate approaches to deliver robust surveillance, monitoring and evaluation of control programmes.

With Bare Feet in the Soil: Podoconiosis, a Neglected Cause of Tropical Lymphoedema

Podoconiosis is a form of lymphoedema that occurs in tropical highland areas in genetically susceptible individuals who are exposed to irritant volcanic soils. The disease is preventable through consistent use of footwear and attention to foot hygiene; however, in endemic areas there is a strong barefoot tradition, and many cannot afford shoes. Patients with podoconiosis face significant physical disability, psychological comorbidity, reduced quality of life and experience frequent episodes of systemic illness due to acute dermatolymphangioadenitis. This review provides an overview of this important and neglected tropical skin disease and summarizes the latest research findings.

The impact of acute adenolymphangitis in podoconiosis on caregivers: A case study in Wayu Tuka woreda, Oromia, Western Ethiopia. 'If she was healthy, I would be free.'

Background

Podoconiosis, also known as mossy foot or endemic non-filarial elephantiasis, is a preventable form of lower-leg lymphoedema caused by prolonged (typically barefoot) exposure to soil derived from volcanic rocks. Acute adenolymphangitis (also called ‘acute attack’) is a serious complication of podoconiosis resulting in significant symptoms and worsening disability. Despite the well-known morbidity associated with podoconiosis, to date there have been no studies looking at the impact, or burden, of podoconiosis on caregivers. This study explored the experiences and impact of acute attacks on the caregivers of those with podoconiosis in one endemic district of Ethiopia.

Methods/Principal findings

This qualitative study was based in Wayu Tuka woreda (district), Oromia, Western Ethiopia. 27 semi-structured interviews of those with podoconiosis and their caregivers were conducted in June 2018. Here we report the findings from the caregiver’s interviews. Data were analysed using NVivo 12. Directed content analysis, a qualitative approach related to thematic analysis, was used to analyse the results. This study highlights a previously unreported impact of acute attacks on the caregivers of those affected by podoconiosis. The findings demonstrate the significant social and financial pressures placed on podoconiosis-affected families which are exacerbated during acute attacks. This study also highlighted the emotional burden experienced by caregivers, the range of care activities placed on them and the limited support available.

Conclusions

This study found a significant impact on the caregivers of those with podoconiosis, especially during acute attacks, in Wayu Tuka woreda. It also highlighted the limited support available to caregivers. Further research is needed to understand whether this impact applies to podoconiosis caregivers across Ethiopia, and beyond, and to establish if there are wider implications of this important consequence of podoconiosis, for example on the economy and caregivers’ mental and physical health.

Podoconiosis is a foot condition, common in the highlands of Ethiopia, caused by exposure to volcanic soil. It can be prevented by wearing shoes and adhering to foot hygiene practices. Podoconiosis causes swelling of the lower legs and is a disabling and stigmatised condition. It is made worse by ‘acute attacks’, during which the leg becomes painful, swollen and red. Often the person affected cannot work and is bedbound during these episodes. This study identified a previously unreported burden on the caregivers of those with podoconiosis during acute attacks in one endemic district of rural Ethiopia. Specifically, we identified a significant social and financial pressure placed on podoconiosis-affected families in meeting healthcare costs, covering daily expenses such as children’s education costs and progressing within their communities. This study also highlighted the emotional burden experienced by caregivers, the range of care activities placed on caregivers and the limited support available. These findings warrant further research in other contexts but highlight an important wider social consequence of podoconiosis.

[What's new in clinical dermatology?]

In this article, we performed a review of all new data of clinical relevance for the dermatologists that were published in the medical literature between September, 2017 and September, 2018. Besides advances that will be useful in day-to-day dermatological practice, we intended to give a more general perspective to this review by taking into account certain international health issues that might in final concern each of us in a globalized world. Focus were more particularly done on the following topics: infectious diseases (including sexually transmitted infections), neglected tropical diseases, adverse effects of drugs, bullous diseases, allergology, wound healing, dermatology on black skin, and public health dermatology.

Integrated Management of Skin NTDs-Lessons Learned from Existing Practice and Field Research

Integration of neglected tropical diseases (NTDs) into the public health agenda has been a priority in global health for the last decade. Because a number of these diseases share not only the geographical distribution, but also a common feature which is skin involvement, bringing together a sub-group of 'skin NTDs' is one way forward to promote further integration among NTDs. With these diseases, which include leprosy, Buruli ulcer, yaws, mycetoma, lymphatic filariasis, and leishmaniasis, patients may be left with life-long deformities and disabilities when diagnosis and treatment are delayed. Stigma is another serious consequence of skin NTDs as it places a large barrier on the economic activities and social life of a patient. As a result, this creates a vicious cycle and obstructs a key goal of society, the elimination of poverty. Enhancement in surveillance systems as well as the further development of diagnostic methods, improvement in treatment and management, and identification of preventative measures for skin NTDs are therefore urgently needed. This article summarizes the existing practices and field research on skin NTDs and identifies potential synergies that could be achieved by adopting this integrated approach.

Lymphoedema management to prevent acute dermatolymphangioadenitis in podoconiosis in northern Ethiopia (GoLBeT): a pragmatic randomised controlled trial

BACKGROUND

Podoconiosis (also known as endemic, non-filarial elephantiasis) affects about 4 million subsistence farmers in tropical Africa. Poor awareness of the condition and inadequate evidence for the efficacy of treatment mean that no government in an endemic country yet offers lymphoedema management for patients with podoconiosis. Among patients with filarial lymphoedema, trials suggest that limb care is effective in reducing the most disabling sequelae: episodes of acute dermatolymphangioadenitis. We aimed to test the hypothesis that a simple, inexpensive lymphoedema management package would reduce the incidence of acute dermatolymphangioadenitis in adult patients with podoconiosis in northern Ethiopia.

METHODS

We did a pragmatic randomised controlled trial at health posts and health centres in 18 sub-districts of Aneded woreda (district) in Amhara, northern Ethiopia. Participants were adults aged 18 years and older, had a diagnosis of at least stage 2 podoconiosis (persistent lymphoedema) and a negative antigen test for filariasis, and intended to remain within Aneded woreda for the duration of the trial. Patients were randomly assigned (1:1) to either receive a package containing instructions for foot hygiene, skin care, bandaging, exercises, and use of socks and shoes, with support by lay Community Podoconiosis Agents at monthly meetings (intervention group) or to receive no intervention (control group). Participants were aware of their group assignment, but researchers doing all analyses were masked to treatment group. The primary outcome was incidence of acute dermatolymphangioadenitis episodes in the total period of observation of each participant, measured by use of validated patient self-reported pictorial diaries. This trial was registered with the International Standard Randomised Controlled Trials Number Register, number ISRCTN67805210.

FINDINGS

Between Dec 1, 2014, and June 30, 2015, 1339 patients were screened, and 696 patients were enrolled and randomly allocated to treatment groups. We allocated 350 patients to the intervention group and 346 patients to the control group. 321 (92%) patients from the intervention group and 329 (95%) patients from the control group provided follow-up results at 12 months. During the 12 months of follow-up, 16 550 new episodes of acute dermatolymphangioadenitis occurred during 765·2 person-years. The incidence of acute dermatolymphangioadenitis was 19·4 episodes per person-year (95% CI 18·9-19·9) in the intervention group and 23·9 episodes per person-year (23·4-24·4) in the control group. The ratio of incidence rate in the intervention group to that of the control group was 0·81 (0·74 to 0·89; p<0·0001), with a rate difference of -4·5 (-5·1 to -3·8) episodes per person-year. No serious adverse events related to the intervention were reported.

INTERPRETATION

A simple, inexpensive package of lymphoedema self-care is effective in reducing the frequency and duration of acute dermatolymphangioadenitis. We recommend its implementation by the governments of endemic countries.

FUNDING

Joint Global Health Trials scheme (from the Wellcome Trust, the UK Medical Research Council, and UK Aid).