Establishing Sickle Cell Disease Stroke Prevention Teams in Africa is Feasible: Program Evaluation Using the RE-AIM Framework

We used the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate a Stroke Prevention Team's readiness to prevent strokes in children with sickle cell anemia living in northern Nigeria. The NIH sponsored Stroke Prevention Trial in Nigeria included a goal of a sustainable stroke prevention program. The program's 1-year reach for transcranial Doppler screening was 14.7% (4710/32,000) of which 6.0% (281/4710) had abnormal velocities (≥200 cm/s). All participants with abnormal transcranial Doppler velocities were started on hydroxyurea (effectiveness). The leaders of all 5 hospitals agreed to adopt the program. After 1 year, program-implementation and maintenance rates were 100%, demonstrating the program's feasibility and short-term sustainability.

Comparative pharmacokinetics of metronidazole in healthy and Trichomonas gallinae infected pigeons (Columba livia, var. domestica)

1. This study investigated the pharmacokinetics of metronidazole after intravenous (i.v.) and oral administration to healthy and experimentally Trichomonas gallinae-infected pigeons, and determined the in vitro antiprotozoal activity of metronidazole against T. gallinae.2. Twelve pigeons which were experimentally infected to T. gallinae and twelve healthy pigeons received metronidazole at the dose of 25 mg/kg by oral or i.v. administration. Serial blood sampling was used for pharmacokinetic analysis. The metronidazole minimum lethal concentration (MLC) and the concentration killing 50% of the trophozoites (LC₅₀) in the culture media were determined.3. In vitro data showed that the 24 h LC₅₀ and MLC of metronidazole were 0.31 and 25 µg/ml, respectively. In vivo results showed no statistical differences between pharmacokinetics in infected and non-infected pigeons for both routes of administration. The area under the curve was statistically higher after the i.v. administration in both infected and healthy pigeons. The mean oral bioavailability was similar in the infected (83.8%) and the healthy (81.5%) birds.4. In conclusion, the pharmacokinetics of metronidazole in pigeons was not affected by experimentally-induced trichomoniasis. Despite in vitro susceptibility testing, which showed probable resistance of the isolated T. gallinae to metronidazole, five-day oral treatment of infected pigeons with 25 mg/kg metronidazole twice a day resulted in total eradication of trophozoites recovered in crop lavage of infected birds.

Primary prevention of stroke in children with sickle cell anemia in sub-Saharan Africa: rationale and design of phase III randomized clinical trial

Strokes in children with sickle cell anemia (SCA) are associated with significant morbidity and premature death. Primary stroke prevention in children with SCA involves screening for abnormal transcranial Doppler (TCD) velocity coupled with regular blood transfusion therapy for children with abnormal velocities, for at least one year. However, in Africa, where the majority of children with SCA live, regular blood transfusions are not feasible due to inadequate supply of safe blood, cost, and the reluctance of caregivers to accept transfusion therapy for their children. We describe the Primary Prevention of Stroke in Children with Sickle Cell Disease in Nigeria Trial [StrokePreventioninNigeria (SPRING) trial, NCT02560935], a three-center double-blinded randomized controlled Phase III clinical trial to 1) determine the efficacy of moderate fixed-dose (20 mg/kg/day) versus low fixed-dose (10 mg/kg/day) hydroxyurea therapy for primary stroke prevention; 2) determine the efficacy of moderate fixed-dose hydroxyurea for decreasing the incidence of all cause-hospitalization (pain, acute chest syndrome, infection, other) compared to low fixed-dose hydroxyurea. We will test the primary hypothesis that there will be a 66% relative risk reduction of strokes in children with SCA and abnormal TCD measurements, randomly allocated, for a minimum of three years to receive moderate fixed-dose versus low fixed-dose hydroxyurea (total n = 220). The results of this trial will advance the care of children with SCA in sub-Saharan Africa, while improving research capacity for future studies to prevent strokes in children with SCA.

Antixenosis and Antibiosis Resistance in Rice Cultivars against Chilo suppressalis (Walker) (Lepidoptera: Crambidae)

The striped stem borer, Chilo suppressalis (Walker) (Lepidoptera: Crambidae), is an important pest afflicting rice in most rice-growing countries in the world. Deliniating the categories of resistance in rice genotypes under field conditions could be helpful in managment of this pest. Two categories of resistance, antixenosis and antibiosis, were examined in ten popular and diverse rice genotypes of different origin that had been selected for their resistance to the striped stem borer in a previous study. Significant differences were found between genotypes for the number of egg masses, number of eggs, preference index, larval and pupal weight, larval development time, larval survival rate, larval mine length, and leaf trichome density. It was found that the rice genotypes Novator, A7801, and Nemat had the more pronounced antixenosis-type resistance, whereas AB1 and Shirodi had better antiobiosis-type resistance. Interestingly, the rice genotype AN-74 for which Nemat is the parental line showed both types of resistance and could be effectively used in an integrated pest management of the rice striped stem borer.

Primary stroke prevention in Nigerian children with sickle cell disease (SPIN): challenges of conducting a feasibility trial

BACKGROUND

The majority of children with sickle cell disease (SCD), approximately 75%, are born in sub-Saharan Africa. For children with elevated transcranial Doppler (TCD) velocity, regular blood transfusion therapy for primary stroke prevention is standard care in high income countries, but is not feasible in sub-Saharan Africa.

PROCEDURE

In the first U.S. National Institute of Health (NIH) sponsored SCD clinical trial in sub-Saharan Africa, we describe the protocol and challenges unique to starting a clinical trial in this region. We are conducting a single arm pilot trial of hydroxyurea therapy in children with TCD velocity ≥200 cm/sec in the middle cerebral arteries. Eligible children will be placed on hydroxyurea (n = 40) and followed for 3 years at Aminu Kano Teaching Hospital, Nigeria. Adherence will be measured via the Morisky Scale and adverse events will be determined based on hospitalization.

RESULTS

Originally, a randomized placebo trial was planned; however, placebo was not approved by the local Ethics Committee. Hence a single arm trial of hydroxyurea will be conducted and five controls per patient with normal TCD measurements will be followed to compare the rate of adverse events to those with abnormal TCD measurements taking hydroxyurea. Using non-NIH funding, over 9 months, multiple face-to-face investigator meetings were conducted to facilitate training.

CONCLUSION

A hydroxyurea trial (NCT01801423) for children with SCD is feasible in sub-Saharan Africa; however, extensive training and resources are needed to build a global patient oriented multi-disciplinary research team with a common purpose.