Set-up of GoLBeT, a pragmatic clinical trial of podoconiosis management in a low-resource setting

 

Clinical trials are often perceived as being expensive, difficult and beyond the capacity of academic groups and healthcare workers in low-resource settings. However, in order to improve healthcare coverage, the WHO World Health Report 2013 stated that all countries need to become generators as well as recipients of data. This study is a methodological examination of the steps and processes involved in setting up the Gojjam Lymphoedema Best Practice Trial (GoLBeT; ISRCTN67805210), a highly pragmatic clinical trial conducted in northern Ethiopia. Challenges to the trial and strategies used to deal with them were explored, together with reasons for delays. A qualitative approach using the Global Health Research Process Map as a framework was used to analyse emails and reports from the period between trial inception and recruitment. This analysis was complemented by interviews with key informants from the operational team and a group discussion. This study showed that the key areas of difficulty in setting up and planning this trial were: the study design (definition and measurement of the study endpoint, and assuring statistical power); recruitment and appropriate training of staff; planning for data quality; and gaining regulatory approvals. Collaboration was essential to successfully setting up the trial. Other important aspects were a team and process perspective, staff training, community engagement, and data quality e.g., through data management. Lessons learnt from this trial might guide in planning pragmatic trials in settings where research is not common, allowing researchers to anticipate challenges and address them through trial design, planning and operational delivery. We also hope that this example might encourage similar pragmatic studies to be undertaken. Such studies are rarely undertaken or locally led, but are an accessible and efficient way to drive improved outcomes in public health.

Key messages

Pragmatic clinical trials are essential to drive improved outcomes in public health in low-resource settings, but are perceived as challenging to set up and initiate. Our analysis of the Gojjam Lymphoedema Best Practice Trial found that factors for a successful set-up were collaborations, a team perspective, staff training, community engagement and data management.

A comparative study of the target volume definition in radiotherapy with «Slow CT Scan» vs. 4D PET/CT Scan in early stages non-small cell lung cancer

OBJECTIVES

To evaluate the use of 4D PET/CT to quantify tumor respiratory motion compared to the «Slow»-CT (CTs) in the radiotherapy planning process.

MATERIAL AND METHODS

A total of 25 patients with inoperable early stage non small cell lung cancer (NSCLC) were included in the study. Each patient was imaged with a CTs (4s/slice) and 4D PET/CT. The adequacy of each technique for respiratory motion capture was evaluated using the volume definition for each of the following: Internal target volume (ITV) 4D and ITVslow in relation with the volume defined by the encompassing volume of 4D PET/CT and CTs (ITVtotal). The maximum distance between the edges of the volume defined by each technique to that of the total volume was measured in orthogonal beam's eye view.

RESULTS

The ITV4D showed less differences in relation with the ITVtotal in both the cranio-caudal and the antero-posterior axis compared to the ITVslow. The maximum differences were 0.36mm in 4D PET/CTand 0.57mm in CTs in the antero-posterior axis. 4D PET/CT resulted in the definition of more accurate (ITV4D/ITVtotal 0.78 vs. ITVs/ITVtotal 0.63), and larger ITVs (19.9 cc vs. 16.3 cc) than those obtained with CTs.

CONCLUSION

Planning with 4D PET/CT in comparison with CTs, allows incorporating tumor respiratory motion and improving planning radiotherapy of patients in early stages of lung cancer.

New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Quantification of concordance and discordance between apolipoprotein-B and the currently recommended non-HDL-cholesterol goals for cardiovascular risk assessment in patients with diabetes and hypertriglyceridemia

AIMS

In patients with diabetes and hypertriglyceridemia, LDL-cholesterol (LDL-C) provides an inaccurate reflection of LDL particle burden. The relative value of non-HDL-cholesterol (non-HDL-C) and apolipoprotein-B (Apo-B) in estimating cardiovascular risk is controversial. We assessed the discordance between non-HDL-C and Apo-B targets in patients with diabetes with TG 200-499 mg/dl.

METHODS

Data from 1430 determinations of LDL-C, non-HDL-C, and Apo-B in ambulatory patients with diabetes were analyzed. Rates of discordance were calculated, based on the currently recommended LDL-C, non-HDL-C, and Apo-B goals.

RESULTS

In patients with non-HDL-C goal of <130 mg/dl, there was a discordance with Apo-B level goal of <90 mg/dl, in 31% of samples. In patients with non-HDL-C goal of <100 mg/dl, 6% of samples had Apo-B ≥80 and 18% had Apo-B <80 mg/dl. Using the Apo-B goal of <70 mg/dl, these numbers were 37% and 3.5% respectively. There was also a significant gender difference, i.e. under-estimation of risk by suggested non-HDL-C cut-offs, in females, compared to males.

CONCLUSIONS

In patients with diabetes and hypertriglyceridemia, a considerable discordance exists between non-HDL-C and Apo-B. Our data suggest a need for prospective studies to compare the relative merits of non-HDL-C and Apo-B targets in the assessment of cardiovascular risk.

Impact of measles elimination activities on immunization services and health systems: findings from six countries

BACKGROUND

One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam.

METHODS

Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches.

RESULTS

This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia.

CONCLUSIONS

We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

Efficacy of topical 1% lidocaine in the symptomatic treatment of pain associated with oral mucosal trauma or minor oral aphthous ulcer: a randomized, double-blind, placebo-controlled, parallel-group, single-dose study

AIMS

To determine the efficacy in pain reduction of a topical 1% lidocaine compared to a placebo cream in patients with oral mucosal lesions due to trauma or minor oral aphthous ulcer.

METHODS

The design was a double-blind, randomized, placebo-controlled, six-center trial on 59 patients. Pain intensity and relief were measured using a 100-mm visual analog scale (VAS). One-tailed Student t test and ANOVA analyses were used for statistical analyses.

RESULTS

Independent of the pain origin (oral mucosal trauma or minor oral aphthous ulcer), the application of the 1% lidocaine cream led to a mean reduction in VAS pain intensity of 29.4 mm ± 17.0, which was significantly greater than the decrease obtained with the placebo cream. Analysis showed a statistically significant efficacy of the 1% lidocaine cream (P = .0003). Its efficacy was not related to the type of lesion, and no adverse drug reaction, either local or systemic, was reported by any of the patients.

CONCLUSION

A significant reduction in pain intensity occurred after application of 1% lidocaine cream and was significantly greater than that with the placebo cream. Taking into account the study's limitations, this product seems safe to use.

Enamel protein regulation and dental and periodontal physiopathology in MSX2 mutant mice

Signaling pathways that underlie postnatal dental and periodontal physiopathology are less studied than those of early tooth development. Members of the muscle segment homeobox gene (Msx) family encode homeoproteins that show functional redundancy during development and are known to be involved in epithelial-mesenchymal interactions that lead to crown morphogenesis and ameloblast cell differentiation. This study analyzed the MSX2 protein during mouse postnatal growth as well as in the adult. The analysis focused on enamel and periodontal defects and enamel proteins in Msx2-null mutant mice. In the epithelial lifecycle, the levels of MSX2 expression and enamel protein secretion were inversely related. Msx2+/- mice showed increased amelogenin expression, enamel thickness, and rod size. Msx2-/- mice displayed compound phenotypic characteristics of enamel defects, related to both enamel-specific gene mutations (amelogenin and enamelin) in isolated amelogenesis imperfecta, and cell-cell junction elements (laminin 5 and cytokeratin 5) in other syndromes. These effects were also related to ameloblast disappearance, which differed between incisors and molars. In Msx2-/- roots, Malassez cells formed giant islands that overexpressed amelogenin and ameloblastin that grew over months. Aberrant expression of enamel proteins is proposed to underlie the regional osteopetrosis and hyperproduction of cellular cementum. These enamel and periodontal phenotypes of Msx2 mutants constitute the first case report of structural and signaling defects associated with enamel protein overexpression in a postnatal context.

Msx2 -/- transgenic mice develop compound amelogenesis imperfecta, dentinogenesis imperfecta and periodental osteopetrosis

The physiological function of the transcription factor Msx2 in tooth and alveolar bone was analysed using a knock-in transgenic mouse line. In this mouse line, the beta-galactosidase gene was used to disrupt Msx2: thus, beta-galactosidase expression was driven by the Msx2 promoter, but Msx2 was not produced. This allowed to monitor Msx2 expression using a beta-galactosidase assay. Msx2 transgenic mice ubiquitously and continuously expressed the mutated Msx2-nlacZ gene in cells of the complex formed by tooth and alveolar bone. Msx2 -/- homozygous mice displayed a wide spectrum of alterations in tooth eruption and morphology as well as dental and periodontal defects from the first post-natal weeks up to 6 months. These defects culminated with the formation of an odontogenic tumour at the mandibular third molar site. This study suggests that bone resorption is a functional target of Msx2 in the alveolar compartment, since Msx2 was expressed in osteoclasts, with the highest expression levels found in the active sites of bone modelling associated with tooth eruption and root elongation. The RANK osteoclast differentiation pathway was affected in microdissected Msx2 -/- mouse alveolar bone (as inferred by RANK ligand mRNA levels) compared to basal bone and wild-type controls. Decreased alveolar osteoclast activity was observed in Msx2 -/- mice, similar to that seen in osteopetrosis, another condition in which osteoclast activity is impaired and odontogenic tumours form. These data suggest a pleiotropic role for Msx2 in oral bone growth from birth until adult homeostasis. RANK pathway appeared to be modulated by Msx2, in addition to the previously reported modulations of BMP4 and laminin5alpha3 in early tooth development. Non-overlapping Msx1 and Msx2 expression patterns suggested that these two homeogenes play non-redundant roles in skeletal growth, with Msx1 targeting basal bone and Msx2 targeting alveolar bone. This study provides a detailed analysis of the phenotype resulting from the Msx2 null mutation and identifies the impact of Msx1 and Msx2 on post-natal oral bone growth.

Applicability of the theory of planned behavior to intended and self-reported condom use in a rural Ethiopian population

This study aimed to assess the applicability of the Theory of Planned Behavior (TPB) in predicting intended and self-reported condom use and to examine the effect of previous condom use (PCE) among young adults in rural Ethiopia. A TPB interview was completed by 802 adults (mean age 20.7 years, 74.7% women) and 743 adults (mean age 20.7 years, 76.4% women) reported use of condom at three-months follow-up. The TPB and PCE explained 36% and 2.2% of the variance in intended condom use. Subjective norms discriminated strongly between individuals with and without PCE. The TPB and PCE accounted for 5.3% and 8.5% of the variance in reported condom use. This study concludes that the TPB provided a fairly accurate description of the process underlying intention but was less sufficient to account for self-reported condom use. Ethiopian youth decided on condom use if they anticipated predominantly positive consequences associated with performance and social support, whereas perceived barriers seemed to have less impact. Once they had started to use condoms, they were more likely to continue to do so in the future.

Bilateral facial microsomia associated with separation of the posterior portions of the maxilla. A case report

A case of bilateral facial microsomia associated with separations of the posterior portion of the maxilla is presented. The X-ray findings revealed hypoplasia of the condyles, absence of the coronoid processes of the mandible, and displacement of the pterygoid processes. Cephalometric analysis revealed a characteristic feature of the facial skeleton a rotation clockwise to the anterior cranial base.