Methotrexate and prednisolone study in erythema nodosum leprosum (MaPs in ENL) protocol: a double-blind randomised clinical trial

INTRODUCTION

Erythema nodosum leprosum (ENL) is an immunological complication of leprosy. ENL results in morbidity and disability and if it is not treated can lead to death. The current treatment consists of thalidomide or high doses of oral corticosteroids for prolonged periods. Thalidomide is not available in many leprosy endemic countries. The use of corticosteroids is associated with morbidity and mortality. Identifying treatment regimens that reduce the use of corticosteroids in ENL is essential. Methotrexate (MTX) is used to treat many inflammatory diseases and has been used successfully to treat patients with ENL not controlled by other drugs, including prednisolone and thalidomide. We present the protocol of the 'MTX and prednisolone study in ENL' (MaPs in ENL) a randomised controlled trial (RCT) designed to test the efficacy of MTX in the management of ENL.

METHODS AND ANALYSIS

MaPs in ENL is an international multicentre RCT, which will be conducted in leprosy referral centres in Bangladesh, Brazil, Ethiopia, India, Indonesia and Nepal. Patients diagnosed with ENL who consent to participate will be randomly allocated to receive 48 weeks of weekly oral MTX plus 20 weeks of prednisolone or 48 weeks of placebo plus 20 weeks of prednisolone. Participants will be stratified by type of ENL into those with acute ENL and those with chronic and recurrent ENL. The primary objective is to determine whether MTX reduces the requirement for additional prednisolone. Patients' reported outcome measures will be used to assess the efficacy of MTX. Participants will be closely monitored for adverse events.

ETHICS AND DISSEMINATION

Results will be submitted for publication in peer-reviewed journals. Ethical approval was obtained from the Observational/Interventions Research Ethics Committee of the London School of Hygiene & Tropical Medicine (15762); The Leprosy Mission International Bangladesh Institutional Research Board (in process); AHRI-ALERT Ethical Review Committee, Ethiopia; Ethics Committee of the Managing Committee of the Bombay Leprosy Project; and The Leprosy Mission Trust India Ethics Committee; the Nepal Health and Research Council and Health Research Ethics Committee Dr. Soetomo, Indonesia. This study is registered at www.clinicaltrials.gov. This is the first RCT of MTX for ENL and will contribute to the evidence for the management of ENL.Trial registration numberNCT 03775460.

A leprosy clinical severity scale for erythema nodosum leprosum: An international, multicentre validation study of the ENLIST ENL Severity Scale

OBJECTIVES

We wished to validate our recently devised 16-item ENLIST ENL Severity Scale, a clinical tool for measuring the severity of the serious leprosy associated complication of erythema nodosum leprosum (ENL). We also wished to assess the responsiveness of the ENLIST ENL Severity Scale in detecting clinical change in patients with ENL.

METHODS

Participants, recruited from seven centres in six leprosy endemic countries, were assessed using the ENLIST ENL Severity Scale by two researchers, one of whom categorised the severity of ENL. At a subsequent visit a further assessment using the scale was made and both participant and physician rated the change in ENL using the subjective categories of "Much better", "somewhat better", "somewhat worse" and "much worse" compared with "No change" or "about the same".

RESULTS

447 participants were assessed with the ENLIST ENL Severity Scale. The Cronbach alpha of the scale and each item was calculated to determine the internal consistency of the scale. The ENLIST ENL Severity Scale had good internal consistency and this improved following removal of six items to give a Cronbach's alpha of 0.77. The cut off between mild ENL and more severe disease was 9 determined using ROC curves. The minimal important difference of the scale was determined to be 5 using both participant and physician ratings of change.

CONCLUSIONS

The 10-item ENLIST ENL Severity Scale is the first valid, reliable and responsive measure of ENL severity and improves our ability to assess and compare patients and their treatments in this severe and difficult to manage complication of leprosy. The ENLIST ENL Severity Scale will assist physicians in the monitoring and treatment of patients with ENL. The ENLIST ENL Severity Scale is easy to apply and will be useful as an outcome measure in treatment studies and enable the standardisation of other clinical and laboratory ENL research.

Corticosteroids for treating nerve damage in leprosy

BACKGROUND

Leprosy causes nerve damage that can result in nerve function impairment and disability. Corticosteroids are commonly used for treating nerve damage, although their long-term effect is uncertain. This is an update of a review first published in 2007, and previously updated in 2009 and 2011.

OBJECTIVES

To assess the effects of corticosteroids on nerve damage in leprosy.

SEARCH METHODS

On 16 June 2015, we searched the Cochrane Neuromuscular Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL Plus, and LILACS. We also checked clinical trials registers and contacted trial authors.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs of corticosteroids for nerve damage in leprosy. The comparators were no treatment, placebo treatment, or a different corticosteroid regimen.

DATA COLLECTION AND ANALYSIS

The primary outcome was improvement in nerve function after one year. Secondary outcomes were change in nerve pain, limitations in activities of daily living, limitations in participation, and adverse events. Two review authors independently extracted data and assessed trial quality. When data were lacking, we contacted trial authors for additional information.

MAIN RESULTS

We included five RCTs involving 576 people. The trials were largely at low risk of bias, but we considered the quality of the evidence from these trials as moderate to low, largely due to imprecision from small sample sizes. Two out of the five trials reported on improvement in nerve function at one year. These two trials compared prednisolone with placebo. One trial, with 84 participants, treated mild sensory impairment of less than six months' duration, and the other, with 95 participants, treated nerve function impairment of 6 to 24 months' duration. There was no significant difference in nerve function improvement after 12 months between people treated with prednisolone and those treated with placebo. Adverse events were not reported significantly more often with corticosteroids than with placebo. The other three trials did not report on the primary outcome measure. One (334 participants) compared three corticosteroid regimens for severe type 1 reactions. No serious side effects of steroids were reported in any participant during the follow-up period. Another trial (21 participants) compared low-dose prednisone with high-dose prednisone for ulnar neuropathy. Two participants on the higher dose of prednisone reported adverse effects. The last (42 participants) compared intravenous methylprednisolone and oral prednisolone with intravenous normal saline and oral prednisolone. The trial found no significant differences between the groups in the occurrence of adverse events.

AUTHORS' CONCLUSIONS

Corticosteroids are used for treating acute nerve damage in leprosy, but moderate-quality evidence from two RCTs treating either longstanding or mild nerve function impairment did not show corticosteroids to have a superior effect to placebo on nerve function improvement. A third trial showed significant benefit from a five-month steroid regimen over a three-month regimen in terms of response to treatment (need for additional corticosteroids). Further RCTs are needed to establish optimal corticosteroid regimens and to examine the efficacy and safety of adjuvant or new therapies for treating nerve damage in leprosy. Future trials should address non-clinical aspects, such as costs and impact on quality of life, which are highly relevant indicators for both policymakers and participants.

Comparison of Efficacy and Safety of Ciclosporin to Prednisolone in the Treatment of Erythema Nodosum Leprosum: Two Randomised, Double Blind, Controlled Pilot Studies in Ethiopia

BACKGROUND

Erythema Nodosum Leprosum (ENL) is a serious complication of leprosy. It is normally treated with high dose steroids, but its recurrent nature leads to prolonged steroid usage and associated side effects. There is little evidence on the efficacy of alternative treatments for ENL, especially for patients who have become steroid resistant or have steroid side effects. These two pilot studies compare the efficacy and side effect profile of ciclosporin plus prednisolone against prednisolone alone in the treatment of patients with either new ENL or chronic and recurrent ENL.

METHODS AND RESULTS

Thirteen patients with new ENL and twenty patients with chronic ENL were recruited into two double-blinded randomised controlled trials. Patients were randomised to receive ciclosporin and prednisolone or prednisolone treatment only. Patients with acute ENL had a delay of 16 weeks in the occurrence of ENL flare-up episode, with less severe flare-ups and decreased requirements for additional prednisolone. Patients with chronic ENL on ciclosporin had the first episode of ENL flare-up 4 weeks earlier than those on prednisolone, as well as more severe ENL flare-ups requiring 2.5 times more additional prednisolone. Adverse events attributable to prednisolone were more common that those attributable to ciclosporin.

CONCLUSIONS

This is the first clinical trial on ENL management set in the African context, and also the first trial in leprosy to use patients' assessment of outcomes. Patients on ciclosporin showed promising results in the management of acute ENL in this small pilot study. But ciclosporin, did not appear to have a significant steroid-sparing effects in patients with chronic ENL, which may have been due to the prolonged use of steroids in these patients in combination with a too rapid decrease of steroids in patients given ciclosporin. Further research is needed to determine whether the promising results of ciclosporin in acute ENL can be reproduced on a larger scale.

ENLIST 1: An International Multi-centre Cross-sectional Study of the Clinical Features of Erythema Nodosum Leprosum

Erythema nodosum leprosum (ENL) is a severe multisystem immune mediated complication of borderline lepromatous leprosy and lepromatous leprosy. ENL is associated with skin lesions, neuritis, arthritis, dactylitis, eye inflammation, osteitis, orchitis, lymphadenitis and nephritis. The treatment of ENL requires immunosuppression, which is often required for prolonged periods of time and may lead to serious adverse effects. ENL and its treatment is associated with increased mortality and economic hardship. Improved, evidence-based treatments for ENL are needed; however, defining the severity of ENL and outcome measures for treatment studies is difficult because of the multiple organ systems involved. A cross-sectional study was performed, by the members of the Erythema Nodosum Leprosum International STudy (ENLIST) Group, of patients with ENL attending seven leprosy referral centres in Brazil, Ethiopia, India, Nepal, the Philippines and the United Kingdom. We systematically documented the clinical features and type of ENL, its severity and the drugs used to treat it. Patients with chronic ENL were more likely to be assessed as having severe ENL. Pain, the most frequent symptom, assessed using a semi-quantitative scale was significantly worse in individuals with “severe” ENL. Our findings will determine the items to be included in a severity scale of ENL which we are developing and validating. The study also provides data on the clinical features of ENL, which can be incorporated into a definition of ENL and used for outcome measures in treatment studies.

Leprosy is caused by a bacterium and is curable with a combination of antibiotics known as multi-drug therapy, which patients take for six or 12 months. However, a significant proportion of leprosy patients experience severe inflammation in their skin, nerves and other organs known as erythema nodosum leprosum (ENL). ENL is a severe complication of leprosy which can occur before, during, or after completion of antibacterial treatment. ENL causes severe morbidity affecting not only the skin, but also bones, joints, eyes, nerves, testes and kidneys. ENL may be fatal and it has been shown that the adverse effects of corticosteroid treatment also contribute to mortality. An effective treatment for ENL is thalidomide but this is not available in many leprosy endemic countries or is severely constrained by availability, cost and justified concerns about teratogenicity. Thalidomide, despite its effectiveness, is rarely used as a first line agent. Other effective drugs need to be identified to reduce the burden of this condition. In order to establish which treatments will be effective in ENL it is necessary to have a clear picture of the clinical features of the disease and how these influence severity. This is the first systematic study of ENL to define these and will help in developing tools to facilitate treatment studies of this severe, debilitating complication of leprosy.

A comparison of the change in clinical severity scale score and a retrospective physician assessment of neurological outcome in individuals with leprosy associated nerve function impairment after treatment with corticosteroids

OBJECTIVES

To determine whether the measured change in score of a validated clinical severity scale reflected physician assessed improvement in individuals who had received corticosteroid therapy for leprosy associated nerve damage.

DESIGN

Patients with nerve function impairment who participated in a randomised controlled trial of corticosteroids were classified into two groups using a retrospectively determined physician assessment of improvement. One group consisted of patients who had recovered or improved the other of patients who were unchanged or had deteriorated. The change in the clinical severity scale scores of these two groups was compared.

RESULTS

The change in the clinical severity scale scores of the 34 eligible individuals in the two groups were significantly different (P = 0.003). Individuals in the group who recovered or improved had a greater change in severity score than those whose nerve function was unchanged or deteriorated.

CONCLUSION

The scale for measuring the severity of leprosy Type 1 reactions (T1Rs) and/or nerve function impairment reflects the clinical improvement of individuals with leprosy associated nerve damage.

Effectiveness of Mindfulness-Based Stress Reduction in Mood, Breast- and Endocrine-Related Quality of Life, and Well-Being in Stage 0 to III Breast Cancer: A Randomized, Controlled Trial

Purpose

To assess the effectiveness of mindfulness-based stress reduction (MBSR) for mood, breast- and endocrine-specific quality of life, and well-being after hospital treatment in women with stage 0 to III breast cancer.

Patients and Methods

A randomized, wait-listed, controlled trial was carried out in 229 women after surgery, chemotherapy, and radiotherapy for breast cancer. Patients were randomly assigned to the 8-week MBSR program or standard care. Profile of Mood States (POMS; primary outcome), Functional Assessment of Cancer Therapy–Breast (FACT-B), Functional Assessment of Cancer Therapy–Endocrine Symptoms (FACT-ES) scales and the WHO five-item well-being questionnaire (WHO-5) evaluated mood, quality of life, and well-being at weeks 0, 8, and 12. For each outcome measure, a repeated-measures analysis of variance model, which incorporated week 0 measurements as a covariate, was used to compare treatment groups at 8 and 12 weeks.

Results

There were statistically significant improvements in outcome in the experimental group compared with control group at both 8 and 12 weeks (except as indicated) for POMS total mood disturbance (and its subscales of anxiety, depression [8 weeks only], anger [12 weeks only], vigor, fatigue, and confusion [8 weeks only]), FACT-B, FACT-ES, (and Functional Assessment of Cancer Therapy subscales of physical, social [8 weeks only], emotional, and functional well-being), and WHO-5.

Conclusion

MSBR improved mood, breast- and endocrine-related quality of life, and well-being more effectively than standard care in women with stage 0 to III breast cancer, and these results persisted at three months. To our knowledge, this study provided novel evidence that MBSR can help alleviate long-term emotional and physical adverse effects of medical treatments, including endocrine treatments. MBSR is recommended to support survivors of breast cancer.

Features and outcomes of unplanned hospital admissions of older people due to ill-defined (R-coded) conditions: retrospective analysis of hospital admissions data in England

BACKGROUND

Rising rates of unplanned admissions among older people are placing unprecedented demand on health services internationally. Unplanned hospital admissions for ill-defined conditions (coded with an R prefix within Chapter XVIII of the International Classification of Diseases-10) have been targeted for admission avoidance strategies, but little is known about these admissions. The aim of this study was to determine the incidence and factors predicting ill-defined (R-coded) hospital admissions of older people and their association with health outcomes.

METHODS

Retrospective analysis of unplanned hospital admissions to general internal and geriatric medicine wards in one hospital over 12 months (2002) with follow-up for 36 months. The study was carried out in an acute teaching hospital in England. The participants were all people aged 65 and over with unplanned hospital admissions to general internal and geriatric medicine. Independent variables included time of admission, residence at admission, route of admission to hospital, age, gender, comorbidity measured by count of diagnoses. Main outcome measures were primary diagnosis (ill-defined versus other diagnostic code), death during the hospital stay, deaths to 36 months, readmissions within 36 months, discharge destination and length of hospital stay.

RESULTS

Incidence of R-codes at discharge was 21.6%, but was higher in general internal than geriatric medicine (25.6% v 14.1% respectively). Age, gender and co-morbidity were not significant predictors of R-code diagnoses. Admission via the emergency department (ED), out of normal general practitioner (GP) hours, under the care of general medicine and from non-residential care settings increased the risk of receiving R-codes. R-coded patients had a significantly shorter length of stay (5.91 days difference, 95% CI 4.47, 7.35), were less likely to die (hazard ratio 0.71, 95%CI 0.59, 0.85) at any point, but were as likely to be readmitted as other patients (hazard ratio 0.96 (95% CI 0.88, 1.05).

CONCLUSIONS

R-coded diagnoses accounted for 1/5 of emergency admission episodes, higher than anticipated from total English hospital admissions, but comparable with rates reported in similar settings in other countries. Unexpectedly, age did not predict R-coded diagnosis at discharge. Lower mortality and length of stay support the view that these are avoidable admissions, but readmission rates particularly for further R-coded admissions indicate on-going health care needs. Patient characteristics did not predict R-coding, but organisational features, particularly admission via the ED, out of normal GP hours and via general internal medicine, were important and may offer opportunity for admission reduction strategies.

A phase two randomised controlled double blind trial of high dose intravenous methylprednisolone and oral prednisolone versus intravenous normal saline and oral prednisolone in individuals with leprosy type 1 reactions and/or nerve function impairment

BACKGROUND

Leprosy Type 1 reactions are a major cause of nerve damage and the preventable disability that results. Type 1 reactions are treated with oral corticosteroids and there are few data to support the optimal dose and duration of treatment. Type 1 reactions have a Th1 immune profile: cells in cutaneous and neural lesions expressing interferon-γ and interleukin-12. Methylprednisolone has been used in other Th1 mediated diseases such as rheumatoid arthritis in an attempt to switch off the immune response and so we investigated the efficacy of three days of high dose (1 g) intravenous methylprednisolone at the start of prednisolone therapy in leprosy Type 1 reactions and nerve function impairment.

RESULTS

Forty-two individuals were randomised to receive methylprednisolone followed by oral prednisolone (n = 20) or oral prednisolone alone (n = 22). There were no significant differences in the rate of adverse events or clinical improvement at the completion of the study. However individuals treated with methylprednisolone were less likely than those treated with prednisolone alone to experience deterioration in sensory function between day 29 and day 113 of the study. The study also demonstrated that 50% of individuals with Type 1 reactions and/or nerve function impairment required additional prednisolone despite treatment with 16 weeks of corticosteroids.

CONCLUSIONS

The study lends further support to the use of more prolonged courses of corticosteroid to treat Type 1 reactions and the investigation of risk factors for the recurrence of Type 1 reaction and nerve function impairment during and after a corticosteroid treatment.

TRIAL REGISTRATION

Controlled-Trials.com ISRCTN31894035.

Analysis of antibody and cytokine markers for leprosy nerve damage and reactions in the INFIR cohort in India

Background

The ILEP Nerve Function Impairment in Reaction (INFIR) is a cohort study designed to identify predictors of reactions and nerve function impairment (NFI) in leprosy.

Aim of the Study

Antibodies to mycobacteria, nerve components and serum cytokine were measured as potential markers for their possible association with reactions and NFI.

Patients and Methods

303 newly diagnosed leprosy patients from two centres in North India were enrolled. Antibodies to PGL-1, LAM (IgG1 and IgG3), ceramide, S100 and TNFα levels were measured using ELISA techniques.

Results

S-100, PGL IgG and IgM antibody levels were lowest in patients with BT leprosy and highest in patients with lepromatous leprosy. LAM IgG1 and LAM IgG3 antibody levels were highest in patients with BL leprosy. Ceramide antibody levels were not correlated with type of leprosy. Levels of all the antibodies tested and TNF α were lowest in patients with only skin reaction. PGL IgM antibody levels were elevated in patients with skin reactions and NFI. Old sensory NFI is associated with significant elevation of PGL IgG, LAM IgG and S100 antibody levels.

Conclusion

These results reveal that the antibody response to mycobacterial antigens, nerve antigens and cytokines are in a dynamic flux and could collectively contribute to NFI in leprosy. The association of multiple markers with old NFI may indicate the contribution of different pathological processes.

Leprosy is one of the oldest known diseases. In spite of the established fact that it is least infectious and a completely curable disease, the social stigma associated with it still lingers in many countries and remains a major obstacle to self reporting and early treatment. The nerve damage that occurs in leprosy is the most serious aspect of this disease as nerve damage leads to progressive impairment and disability. It is important to identify markers of nerve damage so that preventive measures can be taken. This prospective cohort study was designed to look at the potential association of some serological markers with reactions and nerve function impairment. Three hundred and three newly diagnosed patients from north India were recruited for this study. The study attempts to reflect a model of nerve damage initiated by mycobacterial antigens and maintained by ongoing inflammation through cytokines such as Tumour Necrosis Factor alpha and perhaps extended by antibodies against nerve components.

Predicting neuropathy and reactions in leprosy at diagnosis and before incident events-results from the INFIR cohort study

BACKGROUND

Leprosy is a disease of skin and peripheral nerves. The process of nerve injury occurs gradually through the course of the disease as well as acutely in association with reactions. The INFIR (ILEP Nerve Function Impairment and Reactions) Cohort was established to identify clinically relevant neurological and immunological predictors for nerve injury and reactions.

METHODOLOGY/PRINCIPAL FINDINGS

The study, in two centres in India, recruited 188 new, previously untreated patients with multi-bacillary leprosy who had no recent nerve damage. These patients underwent a series of novel blood tests and nerve function testing including motor and sensory nerve conduction, warm and cold detection thresholds, vibrometry, dynamometry, monofilament sensory testing and voluntary muscle testing at diagnosis and at monthly follow up for the first year and every second month for the second year. During the 2 year follow up a total of 74 incident events were detected. Sub-clinical changes to nerve function at diagnosis and during follow-up predicted these new nerve events. Serological assays at baseline and immediately before an event were not predictive; however, change in TNF alpha before an event was a statistically significant predictor of that event.

CONCLUSIONS/SIGNIFICANCE

These findings increase our understanding of the processes of nerve damage in leprosy showing that nerve function impairment is more widespread than previously appreciated. Any nerve involvement, including sub-clinical changes, is predictive of further nerve function impairment. These new factors could be used to identify patients at high risk of developing impairment and disability.

The Participation Scale: Measuring a key concept in public health

PURPOSE

To develop a scale to measure (social) participation for use in rehabilitation, stigma reduction and social integration programmes.

METHOD

A scale development study was carried out in Nepal, India and Brazil using standard methods. The instrument was to be based on the Participation domains of the International Classification of Functioning, Disability and Health (ICF), be cross-cultural in nature and assess client-perceived participation. Respondents rated their participation in comparison with a "peer", defined as "someone similar to the respondent in all respects except for the disease or disability".

RESULTS

An 18-item instrument was developed in seven languages. Crohnbach's alpha was 0.92, intra-tester stability 0.83 and inter-tester reliability 0.80. Discrimination between controls and clients was good at a Participation Score threshold of 12. Responsiveness after a "life change" was according to expectation.

CONCLUSIONS

The Participation Scale is reliable and valid to measure client-perceived participation in people affected by leprosy or disability. It is expected to be valid in other (stigmatised) conditions also, but this needs confirmation. The scale allows collection of participation data and impact assessment of interventions to improve social participation. Such data may be compared between clients, interventions and programmes. The scale is suitable for use in institutions, but also at the peripheral level.

Development and validation of a severity scale for leprosy type 1 reactions

Objectives

To develop a valid and reliable quantitative measure of leprosy Type 1 reactions.

Methods

A scale was developed from previous scales which had not been validated. The face and content validity were assessed following consultation with recognised experts in the field. The construct validity was determined by applying the scale to patients in Bangladesh and Brazil who had been diagnosed with leprosy Type 1 reaction. An expert categorized each patient's reaction as mild or moderate or severe. Another worker applied the scale. This was done independently. In a subsequent stage of the study the agreement between two observers was assessed.

Results

The scale had good internal consistency demonstrated by a Cronbach's alpha >0.8. Removal of three items from the original scale resulted in better discrimination between disease severity categories. Cut off points for Type 1 reaction severities were determined using Receiver Operating Characteristic curves. A mild Type 1 reaction is characterized using the final scale by a score of 4 or less. A moderate reaction is a score of between 4.5 and 8.5. A severe reaction is a score of 9 or more.

Conclusions

We have developed a valid and reliable tool for quantifying leprosy Type 1 reaction severity and believe this will be a useful tool in research of this condition, in observational and intervention studies, and in the comparison of clinical and laboratory parameters.

Leprosy is caused by a bacterium and is curable with a combination of antibiotics known as multi-drug therapy which patients take for six or 12 months. However, a significant proportion of leprosy patients experience inflammation in their skin and/or nerves which may occur even after successful completion of multi-drug therapy. These episodes of inflammation are called leprosy Type 1 reactions. Type 1 reactions are an important complication of leprosy because they may result in nerve damage which leads to disability and deformity. Type 1 reactions require treatment with immunosuppressive agents such as corticosteroids. The severity of Type 1 reactions varies with time, treatment and between individuals. We have developed a clinical severity scale to measure the severity of Type 1 reactions. The scale has three sections. The first measures the involvement of the skin using the number of affected skin lesions, the degree of inflammation of those lesions and the presence of swelling of the hands, feet or face. The second section is a measurement of the sensory function of the nerves supplying the eyes, hands and feet by assessing a patient's ability to feel graded nylon fibres. The third section uses a standard measure of muscle power to assess motor function of the nerves of the face, hands and feet. The clinical severity scale we have developed will facilitate the study of Type 1 reactions and enable direct comparison between different studies. This will improve the management of this disabling complication of leprosy.

Corticosteroids for treating nerve damage in leprosy. A Cochrane review

OBJECTIVE

Corticosteroids are commonly used for treating nerve damage in leprosy. We assessed the effectiveness of corticosteroids for treating nerve damage due to leprosy.

METHODS

A systematic search was undertaken to identify randomised controlled trials (RCTs) comparing corticosteroids with placebo or with no treatment. Two authors independently assessed quality and extracted data. Where it was not possible to perform a meta-analysis, the data for each trial was summarised.

RESULTS

Three RCTs involving 513 people were found. Two trials compared prednisolone with placebo. One trial treated mild sensory impairment of less than 6 months duration and the other trial treated nerve function impairment of 6 to 24 months duration. Both trials examined nerve function improvement 12 months from the start of treatment, but found no significant difference between the two groups. The third trial compared three corticosteroid regimens for severe type 1 reactions. After 12 months, a significantly higher proportion of individuals on a 3 month course required extra corticosteroids compared to the groups with a high-dose and low-dose regimen of 5 months duration. Diabetes and peptic or infected ulcers were not significantly more often reported in the corticosteroid compared to the placebo group.

CONCLUSIONS

Evidence from RCTs does not show a significant long-term effect for either long-standing nerve function impairment or mild sensory impairment. A 5 month corticosteroid regimen was significantly more beneficial than a 3 month corticosteroid regimen. Further RCTs are needed to establish the effectiveness and optimal regimens of corticosteroids and to examine new therapies.

Voluntary muscle testing and dynamometry in diagnosis of motor impairment in leprosy: a comparative study within the INFIR Cohort Study

AIM

To evaluate hand muscle weakness detected through dynamometry as an indicator for change in motor nerve function detected by Voluntary Muscle Testing (VMT) of ulnar and median nerves.

DESIGN

The research was carried out as part of the INFIR Cohort Study among 303 subjects newly diagnosed with MB leprosy in two centres in UP state, northern India.

METHODS

To assess grip strength, key pinch and pulp-to-pulp pinch we adapted the cuffs of adult and neonatal sphygmomanometers. The testing was carried out at diagnosis and at each visit during a 2-year follow-up.

RESULTS

303 subjects with newly diagnosed MB leprosy were included in the study. We found statistically significant differences in grip strength, key pinch and pulp-to-pulp pinch between groups defined by ulnar VMT grades at time of diagnosis. There was also a statistically significant difference in hand grip between groups defined by median VMT at diagnosis. In each case, strength tended to reduce with increasing motor involvement. We explored reduction in grip strength, key pinch or pulp-to-pulp pinch as indicators of change in ulnar VMT during follow-up. A 25% reduction over two visits was the most effective indicator. Changes were also associated with marginal changes in motor and sensory nerve function, most commonly associated with Type I reactions.

CONCLUSION

Dynamometry is recommended as an additional method that may be used to monitor changes in nerve function in leprosy, particularly in subjects with early motor impairment of the ulnar nerve.

Early diagnosis of neuropathy in leprosy--comparing diagnostic tests in a large prospective study (the INFIR cohort study)

Background

Leprosy is the most frequent treatable neuromuscular disease. Yet, every year, thousands of patients develop permanent peripheral nerve damage as a result of leprosy. Since early detection and treatment of neuropathy in leprosy has strong preventive potential, we conducted a cohort study to determine which test detects this neuropathy earliest.

Methods and Findings

One hundred and eighty-eight multibacillary (MB) leprosy patients were selected from a cohort of 303 and followed for 2 years after diagnosis. Nerve function was evaluated at each visit using nerve conduction (NC), quantitative thermal sensory testing and vibrometry, dynamometry, monofilament testing (MFT), and voluntary muscle testing (VMT). Study outcomes were sensory and motor impairment detected by MFT or VMT. Seventy-four of 188 patients (39%) had a reaction, neuritis, or new nerve function impairment (NFI) event during a 2-year follow-up. Sub-clinical neuropathy was extensive (20%–50%), even in patients who did not develop an outcome event. Sensory nerve action potential (SNAP) amplitudes, compound motor action potential (CMAP) velocities, and warm detection thresholds (WDT) were most frequently affected, with SNAP impairment frequencies ranging from 30% (median) to 69% (sural). Velocity was impaired in up to 43% of motor nerves. WDTs were more frequently affected than cold detection thresholds (29% versus 13%, ulnar nerve). Impairment of SNC and warm perception often preceded deterioration in MF or VMT scores by 12 weeks or more.

Conclusions

A large proportion of leprosy patients have subclinical neuropathy that was not evident when only MFT and VMT were used. SNC was the most frequently and earliest affected test, closely followed by WDT. They are promising tests for improving early detection of neuropathy, as they often became abnormal 12 weeks or more before an abnormal monofilament test. Changes in MFT and VMT score mirrored changes in neurophysiology, confirming their validity as screening tests.

Leprosy is the most frequent treatable disease of the peripheral nerves. Yet, every year, thousands of patients develop nerve damage as a result of leprosy. If this is detected and treated early, the prognosis is good. We conducted the largest prospective study on this topic to date to determine which test would detect nerve damage earliest. One hundred and eighty-eight leprosy patients were selected from centres in North India and followed for 2 years after diagnosis. Nerve function was tested at each visit using a battery of nerve function tests. A large proportion of the patients had or developed subclinical nerve damage that was not detected with the standard clinical tests (monofilaments and voluntary muscle testing). Sensory nerve conduction was the most frequently and earliest affected test, closely followed by the warm temperature perception test. They are promising tests for improving early detection of nerve damage, as they often became abnormal 12 weeks or more before the monofilament test became abnormal. Changes measured with the monofilament and voluntary muscle tests mirrored changes in more advanced electronic measures, confirming their validity as screening tests. These findings open the door to future improvement of the prognosis of nerve damage in leprosy.

Response to ciclosporin treatment in Ethiopian and Nepali patients with severe leprosy Type 1 reactions

Leprosy type 1 reactions (T1R) are immune-mediated events with inflammation of peripheral nerves and skin. We report the clinical outcomes of a closely monitored open prospective trial in which eight Nepali and 33 Ethiopian patients with T1Rs were treated with an Indian generic formulation of ciclosporin (Cn; 5-7.5 mg/kg/day) for 12 weeks and followed up for 24 weeks after starting treatment. Outcomes were measured using a clinical severity score. Among the Nepalis, 75-100% improved in all acute clinical parameters; 67-100% patients maintained improvement, except for those with acute sensory nerve impairment among whom 67% relapsed after stopping treatment. The skin lesions of all Ethiopians on 5 mg/kg/day of Cn improved and 50-60% had peripheral nerve function improvement. Most Ethiopians needed a higher dose of Cn to improve nerve impairment and neuritis, and 50-78% of them developed worse clinical severity scores when Cn was stopped. Four Ethiopians and two Nepalis developed elevated serum creatinine levels on 7.5 mg/kg/day Cn, and three (9%) Ethiopians developed treatable hypertension. This suggests that Cn monotherapy is an effective treatment for severe T1R with few adverse effects. A dose of 5 mg/kg/day seems efficacious in Nepalis, but a higher dose may be required in Ethiopian patients.

Ensuring inter-tester reliability of voluntary muscle and monofilament sensory testing in the INFIR Cohort Study

OBJECTIVE

To assess the reliability of monofilament (MF) and voluntary muscle strength (VMT) testing carried out by nine physiotherapy staff recruited for the ILEP Nerve Function Impairment & Reaction (INFIR) Cohort Study in India.

DESIGN

A multiple pair inter-tester reliability study was carried out in Uttar Pradesh, India. Newly trained testers were paired up with an experienced physiotherapist, whose assessment served as the gold standard. Each pair completed a series of assessments. All testers had undertaken a week of specific VMT and MF training, followed by a month of practice in the hospital setting. Reliability was assessed by calculating weighted Kappa (Kw) statistics, which may be interpreted as the chance-corrected proportion of agreement between testers.

RESULTS

Eight newly-trained physiotherapists and one physiotechnician took part in the study. In the early stages of the study some areas of weak agreement were identified and correct assessment technique was reviewed, particularly for the eye. Good to very good reliability (Kw 0.62 to 0.99) was found for all sensory tests and most muscle strength tests. The only lower Kw scores (0-48 to 0-59, suggesting only moderate reliability) were for the VMT of muscles supplied by the median nerve in one of the study's two field centres. Even in this case, testers never varied by more than one grade, but calculation of Kw was negatively influenced by a lack of variation among the subjects. In addition, testers never varied by more than one grade from the gold standard.

CONCLUSION

Even though all testers were professionally trained and received additional specific training and practice in MF and VMT testing, discrepancies in technique required an early review and correction. This fact highlights the need for careful training and formal reliability testing. This should extend to referral centres where staff are involved in assessing the symptoms of reaction and monitoring response to treatment. Reliability testing provides the opportunity to address important discrepancies in technique that may persist even in the presence of protocols and qualified and trained staff. It is therefore a valuable tool as part of a training procedure for situations, where patients may be assessed by different testers. Overall, our results were deemed good enough to proceed with the INFIR study, using VMT and MF testing as a baseline against which to compare more sophisticated methods of nerve function testing.

Corticosteroids for treating nerve damage in leprosy

BACKGROUND

Leprosy causes nerve damage which can result in nerve function impairment and disability. Corticosteroids are commonly used for treating nerve damage, although the long-term effect is uncertain.

OBJECTIVES

To assess the effects of corticosteroids on nerve damage in leprosy.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Register, the Cochrane Central Register of Controlled Trials (Issue 4), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1980), LILACS (from 1982) in January 2006. We checked reference lists of the studies identified, the Current Controlled Trials Register (www.controlled-trials.com), conference proceedings and contacted trial authors.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials of corticosteroids for nerve damage in leprosy.

DATA COLLECTION AND ANALYSIS

The primary outcome was improvement in sensory and motor nerve function after one year. Secondary outcomes were improvement in nerve function after two years, change in nerve pain and tenderness, and adverse events. Two authors independently extracted data and assessed trial quality. We contacted trial authors for additional information. We collected adverse effects and cost effectiveness information from the trials and non-randomised studies.

MAIN RESULTS

We included three randomised controlled trials involving 513 people. Two trials compared prednisolone with placebo. One trial treated mild sensory impairment of less than six months duration and the other trial treated nerve function impairment of 6 to 24 months duration. Both trials examined an effect twelve months from the start of treatment. There was no significant difference in nerve function improvement between people treated with prednisolone or with placebo. The third trial compared three corticosteroid regimens for severe type 1 reactions. This trial did not report the prespecified outcomes. However, after 12 months, a significantly higher proportion of individuals on a 3-month course of prednisolone required extra corticosteroids compared to the groups with a high-dose and low-dose regimen of five months duration. Diabetes and peptic or infected ulcer were sometimes reported as serious adverse events in the placebo-controlled trials, but not significantly more often in the corticosteroid than placebo groups.

AUTHORS' CONCLUSIONS

Corticosteroids are used for treating acute nerve damage in leprosy, but evidence from randomised controlled trials does not show a significant long-term effect. Randomised controlled trials are needed to establish their effectiveness, the optimal regimens and to examine new therapies.

Promoting early detection in leprosy--a literature review to identify proven and potential interventions addressing patient-related delay

OBJECTIVES

The objective of the literature review was to identify proven and potential interventions to promote early diagnosis and start of treatment in leprosy, specifically, forms of intervention addressing needs at the local or primary level.

DESIGN

Using a structured search procedure, we identified recent leprosy-related publications describing proven interventions. To identify potential interventions the search was extended to publications assessing knowledge and attitudes towards leprosy and extended again to identify publications relating to patient-related delay in the context of other infectious diseases.

RESULTS

The review identified just 19 publications reporting leprosy-related interventions that included a form of evaluation of which only 10 directly addressed patient-related delay. These included health education interventions focussed on people directly affected by leprosy, their family members and other key individuals or groups within the local community. We identified no reports of interventions focussed specifically on the needs of women.

CONCLUSIONS

Our conclusion is that the evidence base available to inform the choice of small-scale interventions to promote early detection at the primary level is extremely limited. There is an urgent need to develop and extend the range of proven interventions, specifically those that address the needs of women, those that explore and develop the health promotion potential of people previously affected by,leprosy and those that exploit the potential of individuals with leadership roles within the community. This will require careful attention to planning, implementation, evaluation and reporting of interventions.

The INFIR Cohort Study: assessment of sensory and motor neuropathy in leprosy at baseline

AIM

To compare different method(s) to detect peripheral neuropathy in leprosy and to study the validity of the monofilament test (MF) and the voluntary muscle test (VMT) as standard tests of nerve function.

DESIGN

A multi-centre cohort study of 303 multibacillary (MB) leprosy patients.

METHODS

Newly registered MB patients requiring a full course of MDT were recruited in two leprosy outpatient clinics in North India. Controls were people without leprosy or neurological conditions, attending the dermatological outpatient departments of the same clinics. Nerve function was evaluated electrophysiologically using standard parameters for sensory and motor nerve conduction (NC) testing, warm and cold detection thresholds (W/CDT), vibration perception thresholds, dynamometry, MF and VMT. The latter two defined the outcomes of sensory and motor impairment.

RESULTS

115 patients had nerve damage or a reaction of recent onset at diagnosis. Sensory and motor amplitudes and WDTs were the most frequently abnormal. Among the nerves tested, the sural and posterior tibial were the most frequently impaired. In the ulnar nerve, sensory latencies were abnormal in 25% of subjects; amplitudes in 40%. Ulnar above-elbow motor conduction velocities were abnormal in 39% and amplitudes 32%. WDTs were much more frequently affected than CDTs in all nerves tested. The thresholds of all test parameters differed significantly between controls and patients, while only some differed between patients with and without reaction. Good concordance was observed between MF results and sensory latencies and velocities (direct concordance 80% for the ulnar). However, a proportion of nerves with abnormal MF results tested normal on one or more of the other tests or vice versa. Concordance between VMT and motor conduction velocities was good for the ulnar nerve, but for the median and peroneal nerves, the proportion impaired by VMT out of those with abnormal motor conduction was very low.

CONCLUSIONS

Concordance between monofilaments and other sensory function test results was good, supporting the validity of the monofilaments as standard screening test of sensory function. Concordance between VMT results and motor nerve conduction was good for the ulnar nerve, but very few median and peroneal nerves with abnormal conduction had an abnormal VMT. A more sensitive manual motor test may be needed for these nerves. Of the nerve assessment tests conducted, NC amplitudes and warm sensation were the most frequently affected. Therefore, nerve conduction studies and WDT measurements appear to be most promising tests for early detection of leprous neuropathy. The pattern of concordance between tactile and thermal sensory impairment failed to support the hypothesis that small fibre neuropathy always precedes large fibre damage. Warm sensation was more frequently affected than cold sensation. This could indicate that unmyelinated C fibres are more frequently affected than small myelinated Asigma fibres.

Risk factors for participation restriction in leprosy and development of a screening tool to identify individuals at risk

The World Health Organisation International Classification of Functioning, Disability and Health defines participation as involvement in a life situation. Participation restrictions are problems experienced in any life situation, for example, in relationships or in employment. Our research explored risk factors for participation restrictions experienced by people affected by leprosy. Our objective was to develop a screening tool to identify individuals at risk. An initial round of qualitative fieldwork in eight centres in Nepal, India and Brazil identified 35 potential risk factors for participation restriction. These were then further assessed through quantitative fieldwork in six centres in India and Brazil. In all, 264 individuals receiving leprosy treatment or rehabilitation services made a retrospective assessment of their status at time of diagnosis. Their level of participation restriction was assessed using the Participation Scale. Regression analysis identified risk factors for participation restriction including fear of abandonment by family members (odds ratio 2.63, 95% CI 1.35-5.13) and hospitalization at diagnosis (3.98, 1.0-7.32). We recommend four consolidated items as the basis for a simple screening tool to identify individuals at risk. These are the physical impact of leprosy, an emotional response to the diagnosis, female gender and having little or no education. Such a tool may form the basis for a screening and referral procedure to identify newly diagnosed individuals at risk of participation restrictions and in need of actions that may prevent such restrictions.

The INFIR Cohort Study: investigating prediction, detection and pathogenesis of neuropathy and reactions in leprosy. Methods and baseline results of a cohort of multibacillary leprosy patients in north India

The aim of this study was to find predictors of neuropathy and reactions, determine the most sensitive methods for detecting peripheral neuropathy, study the pathogenesis of neuropathy and reactions and create a bank of specimen, backed up by detailed clinical documentation. A multi-centre cohort study of 303 multibacillary leprosy patients in Northern India was followed for 2 years. All newly registered MB patients requiring a full course of MDT, who were smear positive and/or had six or more skin lesions and/or had two or more nerve trunks involved, were eligible. A detailed history was taken and physical and neurological examinations were performed. Nerve function was assessed at each visit with nerve conduction testing, warm and cold detection thresholds, vibrometry, dynamometry, monofilaments and voluntary muscle testing. Because the latter two are widely used in leprosy clinics, they were used as 'gold standard' for sensory and motor impairment. Other outcome events were type 1 and 2 reactions and neuritis. All subjects had a skin biopsy at registration, repeated at the time of an outcome event, along with a nerve biopsy. These were examined using a variety of immunohistological techniques. Blood sampling for serological testing was done at every 4-weekly clinic visit. At diagnosis, 115 patients had an outcome event of recent onset. Many people had skin lesions overlying a major nerve trunk, which were shown to be significantly associated with an increased of sensory or motor impairment. The most important adjusted odds ratios for motor impairment were, facial 4.5 (1.3-16) and ulnar 3.5 (1.0-8.5); for sensory impairment they were, ulnar 2.9 (1.3-6.5), median 3.6 (1.1-12) and posterior tibial 4.0 (1.8-8.7). Nerve enlargement was found in 94% of patients, while only 24% and 3% had paraesthesia and nerve tenderness on palpation, respectively. These increased the risk of reactions only marginally. Seven subjects had abnormal tendon reflexes and seven abnormal joint position sense. In all but one case, these impairments were accompanied by abnormalities in two or more other nerve function tests and thus seemed to indicate more severe neuropathy. At diagnosis, 38% of a cohort of newly diagnosed MB leprosy patients had recent or new reactions or nerve damage at the time of intake into the study. The main risk factor for neuropathy found in this baseline analysis was the presence of skin lesions overlying nerve trunks. They increased the risk of sensory or motor impairment in the concerned nerve by 3-4 times. For some nerves, reactional signs in the lesions further increased this risk to 6-8 times the risk of those without such lesions. Patients with skin lesions overlying peripheral nerve trunks should be carefully monitored for development of sensory or motor impairment.

Factors contributing to delay in diagnosis and start of treatment of leprosy: analysis of help-seeking narratives in northern Bangladesh and in West Bengal, India

The objective of our research was to identify factors contributing to delay in diagnosis and start of treatment in leprosy, focussing on patients' narratives of help-seeking behaviour. Our research took place in Purulia, West Bengal, India and in Nilphamari, northern Bangladesh. Between January and August 2000, we conducted semi-structured interviews with 104 patients that explored each individual's narrative of help-seeking behaviour and the context of beliefs and attitudes towards leprosy. Subsequently we surveyed 356 patients currently receiving treatment for leprosy and recorded specific aspects of each help-seeking action and their reports of local beliefs and attitudes towards leprosy. Delay was estimated from time of first symptoms through to start of effective treatment (mean 18 months, median 9 months in Purulia and mean 20 months, median 12 months in Nilphamari). The number of help-seeking actions ranged from 1 to 7. Time committed to first actions contributed 86% (Nilphamari) and 79% (Purulia) to total delay. The most important contributor to delay in the first action occurred when people simply monitored or ignored first symptoms, 80% in Nilphamari and 67% in Purulia. With delay longer than 12 months as outcome, logistic regression analyses identified age over 35 years, multiple visits to practitioners in traditional medicine and multiple visits to health service practitioners as predictive of delay. Attending a nearby clinic and exposure to health education materials were predictive of early presentation reduced delay.

Clinical outcomes in a randomized controlled study comparing azathioprine and prednisolone versus prednisolone alone in the treatment of severe leprosy type 1 reactions in Nepal

The ILEP nerve function impairment and reaction research programme (INFIR 2) was a group of clinical trials conducted to identify second-line treatments for severe leprosy type 1 reactions (T1R). This paper presents the clinical results of one of these trials in which azathioprine was used in combination with short-course prednisolone to ascertain if the combination was effective in controlling the symptoms and signs of reaction. Forty patients were alternately assigned to a 12-week treatment with either AP (12 weeks azathioprine at 3mg/kg/d plus 8 week reducing course prednisolone starting at 40mg/d) or P (12-week reducing course prednisolone starting at 40mg/d). Evaluation included serial quantitative clinical assessments. The overall frequency of side effects was similar in both groups. Results show that there was no difference in clinical outcome in the AP and P groups and a similar number of patients in each group required extra prednisolone for worsening clinical features. We conclude that a 12-week course of azathioprine at 3mg/kg/day plus an 8 week reducing course of prednisolone starting at 40mg/d is as effective as a 12 week reducing course of prednisolone starting at 40mg/d and that the combination therapy is well-tolerated in severe leprosy T1R patients.

Incidence of acute nerve function impairment and reactions in leprosy: a prospective cohort analysis after 5 years of follow-up

BACKGROUND

Nerve function impairment (NFI) is the key outcome of the pathological processes of infection with Mycobacterium leprae, which can continue after completion of multidrug therapy (MDT) and lead to disability after leprosy patients are released from treatment. The objective of this study was to assess the need for and duration of surveillance of NFI.

METHODS

Prospective cohort study of 2664 new leprosy patients in Bangladesh, with an observation period of 36 months in paucibacillary (PB) patients, and 60 months in multibacillary (MB) patients. Incidence rates (IR) were calculated with the number of patients developing NFI, type 1 and type 2 reactions, and silent neuritis for the first time after registration as the numerator, and cumulative person-years at risk (PYAR) as the denominator. Survival curves to the first event of NFI were also calculated.

RESULTS

The IR of first event of NFI amongst MB patients was 16.1 per 100 PYAR, with 121/357 (34%) developing NFI during the observation period. Of the 121 with a first event of NFI, 77 (64%) had this within a year after registration, 35 (29%) in the second year, and the remaining 9 (7%) after 2 years. The IR of first event of NFI amongst PB patients was 0.9 per 100 PYAR, with 54/2153 (2.5%) developing NFI during the observation period. Of the 54 with a first event of NFI, 48 (89%) had this within a year after registration, 3 (5.5%) in the second year, and the remaining 3 (5.5%) cases after 2 years. The percentage of PB patients with no NFI at registration surviving without developing NFI during the observation period was 99% and for PB patients with NFI at registration 92%. In MB patients without NFI at registration, the percentage surviving with no NFI during the observation period was 84% and for MB patients with NFI at registration only 36%.

CONCLUSION

New episodes of NFI and reactions after registration are common, in particular in MB patients with long-standing NFI at registration. The study highlights the importance of continuing surveillance for NFI of this risk group after registration for 2 years. Active surveillance beyond 2 years is not indicated.

Steroid prophylaxis for prevention of nerve function impairment in leprosy: randomised placebo controlled trial (TRIPOD 1)

OBJECTIVE

To determine whether addition of low dose prednisolone to multidrug treatment can prevent reaction and nerve function impairment in leprosy.

DESIGN

Multicentre, double blind, randomised, placebo controlled, parallel group trial.

SETTING

Six centres in Bangladesh and Nepal.

PARTICIPANTS

636 people with newly diagnosed multibacillary leprosy.

INTERVENTION

Prednisolone 20 mg/day for three months, with tapering dose in month 4, plus multidrug treatment, compared with multidrug treatment alone.

MAIN OUTCOME MEASURES

Signs of reaction, impairment of sensory and motor nerve function, and nerve tenderness needing full dose prednisolone at four months and one year.

RESULTS

Prednisolone had a significant effect in the prevention of reaction and nerve function impairment at four months (relative risk 3.9, 95% confidence interval 2.1 to 7.3), but this was not maintained at one year (relative risk 1.3, 0.9 to 1.8). Fewer events occurred in the prednisolone group at all time points up to 12 months, but the difference at 12 months was small. Subgroup analysis showed a difference in response between people with and without impairment of nerve function at diagnosis.

CONCLUSIONS

The use of low dose prophylactic prednisolone during the first four months of multidrug treatment for leprosy reduces the incidence of new reactions and nerve function impairment in the short term, but the effect is not sustained at one year. The presence of nerve function impairment at diagnosis may influence the response to low dose prednisolone.

The prognostic importance of detecting mild sensory impairment in leprosy: a randomized controlled trial (TRIPOD 2)

This study was designed to investigate whether leprosy patients diagnosed with mild sensory impairment have a better prognosis when treated with steroids than similarly impaired patients treated with placebo. A multi-centre, randomized, double-blind, placebo-controlled trial was conducted in Nepal and Bangladesh. Patients were eligible if they had a confirmed leprosy diagnosis, were between 15 and 50 years old, had mild sensory impairment of the ulnar or posterior tibial nerve of less than 6 months duration and did not require steroids for other reasons. 'Mild impairment' was defined as 'impaired on the Semmes-Weinstein monofilament test, but testing normal on the ballpen sensory test'. Subjects were randomized to either prednisolone treatment starting at 40 mg per day, tapering over 4 months, or placebo. Nerve function was monitored monthly. Any patient who deteriorated was taken out of the trial and was put on full-dose steroid treatment. Outcome assessment was done at 4, 6, 9 and 12 months from the start of the treatment. Outcome measures were the proportion of patients needing full-dose prednisolone and the Semmes-Weinstein sum scores. Each patient contributed only one nerve to the analysis. Seventy-five patients had nerves eligible for analysis, of whom 41 (55%) and 34 (45%) were allocated to the prednisolone and placebo arms, respectively. At 4 months, three patients in the prednisolone arm (7%) and six in the placebo arm (18%) had an outcome event requiring full dose steroids. At 12 months, these proportions had almost reversed, 11 (27%) and 6 (18%) in the treatment and placebo arms, respectively. In the latter group, 75% had recovered spontaneously after 12 months. Prednisolone treatment of sensory impairment of the ulnar and posterior tibial nerves detectable with the monofilament test, but not with the ballpen test, did not improve the long-term outcome in terms of recovery of touch sensibility, not did it reduce the risk of leprosy reactions or nerve function impairment beyond the initial 4-month treatment phase. Two unexpected main findings were the strong tendency of mild sensory impairment to recover spontaneously and the fact that patients with mild sensory impairment without any other signs or symptoms of reaction or nerve function impairment are relatively rare.

Adverse events of standardized regimens of corticosteroids for prophylaxis and treatment of nerve function impairment in leprosy: results from the 'TRIPOD' trials

Reactions in leprosy causing nerve function impairment (NFI) are increasingly treated with standardized regimens of corticosteroids, often under field conditions. Safety concerns led to an assessment of adverse events of corticosteroids, based on data of three trials studying prevention of NFI (the TRIPOD study). A multicentre, randomized, double-blind placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Treatment was with prednisolone according to fixed schedules for 16 weeks, starting in one trial with 20 mg/day (prophylactic regimen: total dosage 1.96 g) and in the other two trials with 40 mg/day (therapeutic regimen: total dosage 2.52 g). Minor adverse events were defined as moon face, fungal infections, acne, and gastric pain requiring antacid. Major adverse events were defined as psychosis, peptic ulcer, glaucoma, cataract, diabetes and hypertension. Also, the occurrence of infected plantar, palmar, and corneal ulceration was monitored, together with occurrence of TB. Considering all three trials together, minor adverse events were observed in 130/815 patients (16%). Of these, 51/414 (12%) were in the placebo group and 79/401 (20%) in the prednisolone group. The relative risk for minor adverse events in the prednisolone group was 1.6 (P = 0.004). Adverse events with a significantly increased risk were acne, fungal infections and gastric pain. Major adverse events were observed in 15/815 patients (2%); 7/414 (2%) in the placebo group and 8/401 (2%) in the prednisolone group. No major adverse events had a significantly increased risk in the prednisolone arm of the trials. No cases of TB were observed in 300 patients who could be followed-up for 24 months. Standardized regimens of corticosteroids for both prophylaxis and treatment of reactions and NFI in leprosy under field conditions in developing countries are safe when a standard pre-treatment examination is performed, treatment for minor conditions can be carried out by field staff, referral for specialized medical care is possible, and sufficient follow-up is done during and after treatment.

Treatment with corticosteroids of long-standing nerve function impairment in leprosy: a randomized controlled trial (TRIPOD 3)

Some leprosy patients with long-standing nerve function impairment (NFI) appear to have responded favourably to treatment with corticosteroids. This study investigated whether patients with untreated NFI between 6 and 24 months duration and who are given standard regimen corticosteroid therapy, will have a better treatment outcome than a placebo group. A multicentre, randomized, double-blind placebo-controlled trial was conducted in Nepal and Bangladesh. Subjects were randomised to either prednisolone treatment starting at 40 mg/day, tapered by 5 mg every 2 weeks, and completed after 16 weeks, or placebo. Outcome assessments were at 4, 6, 9, and 12 months from the start of treatment. 92 MB patients on MDT were recruited, of whom 40 (45%) received prednisolone and 52 (55%) placebo treatment. No demonstrable additional improvement in nerve function, or in preventing further leprosy reaction events was seen in the prednisolone group. Overall, improvement of nerve function at 12 months was seen in about 50% of patients in both groups. Analysis of subgroups according to nerve (ulnar and posterior tibial), duration of NFI, and sensory and motor function, also did not reveal any differences between the treatment and placebo groups. There was however, indication of less deterioration of nerve function in the prednisolone group. Finally, there was no difference in the occurrence of adverse events between both groups. The trial confirms current practice not to treat long-standing NFI with prednisolone. Spontaneous recovery of nerve function appears to be a common phenomenon in leprosy. Leprosy reactions and new NFI occurred in a third of the study group, emphasizing the need to keep patients under regular surveillance during MDT, and, where possible, after completion of MDT.

Delay in presentation, an indicator for nerve function status at registration and for treatment outcome--the experience of the Bangladesh Acute Nerve Damage Study cohort

The objective of our research was to relate delay in presentation in the Bangladesh Acute Nerve Damage Study cohort to intake status and to treatment outcome. The Bangladesh Acute Nerve Damage Study (BANDS) is a prospective cohort study of 2664 consecutive newly registered patients at clinics run by the Danish-Bangladesh Mission Leprosy (DBLM) project in Nilphamari, northern Bangladesh. The 1-year intake began in April 1995. Three-year follow-up for PB cases and 5 years for MB cases was completed in 2001. Delay in presentation in the BANDS cohort is associated with increased signs of nerve function impairment at registration. Individuals presenting with no nerve impairment and maintaining nerve function to the end of follow-up had the shortest mean delays. Individuals presenting with impairment that did not improve during follow-up had the longest mean delays. Discussion focuses on the value of setting a threshold value defining early presentation. Since the WHO Grade 2 disability rate effectively sanctions lengthy delays where there is no impairment, an indicator relating directly to delay is preferred as an indicator for good practice in leprosy control.

A clinical prediction rule for nerve function impairment in leprosy patients-revisited after 5 years of follow-up

Nerve function impairment (NFI) commonly occurs during or after chemotherapy in leprosy. We previously described a clinical prediction rule to estimate the risk of NFI occurring within 2 years of diagnosis, based on 2510 patients who are followed up in the Bangladesh Acute Nerve Damage Study (BANDS). This prediction rule assigns new leprosy patients to one of three risk groups based on leprosy group and the presence or absence of NFI at registration. Updated data with up to 5 years of follow-up showed that 95% of all NFI occurred within 2 years. This study confirms the validity of the rule and supports the conclusion that there is little value for the detection of NFI in extending follow-up beyond 2 years.

Delay in Presentation in the Context of Local Knowledge and Attitude Towards Leprosy—The Results of Qualitative Fieldwork in Paraguay

OBJECTIVE

The primary objective of our research was to explore help-seeking behavior in the context of knowledge, attitude, and practice as factors contributing to delay in presentation in leprosy. The secondary objective was to demonstrate the value of basic qualitative research methods in this context.

METHODOLOGY

Fieldwork was based at the Hospital Mennonita Km 81, the referral center for leprosy services in Paraguay. We adopted exclusively qualitative methods for fieldwork, effectively carrying out a rapid assessment of factors contributing to delay. We relied on multiple sources of information and the use of multiple methods to ensure the validity of our findings.

RESULTS

Our findings linked delay in presentation to traditional beliefs, lack of awareness of the early symptoms of leprosy, stigma, seeking help from natural healers, and to interactions with the health services. Traditional beliefs diminish the importance of the early symptoms of leprosy. Stigma has an impact on decisions to seek help. Natural healers have maintained their traditional status in society; their preferred treatments for leprosy are ineffective. Only rarely do natural healers refer to the health services. Once presented to the health services, some individuals affected by leprosy experienced lengthy delays in diagnosis and start of treatment.

DISCUSSION

To address the traditional values of a society and provide effective public health initiatives is a clearly a major challenge for program organizers and for health education. Increased awareness of leprosy and sensitivity to its social consequences among health service practitioners is a further priority.

Avoiding misperceptions: classifying rehabilitation projects using letters rather than numbers

A classification system proposed earlier of the many different known rehabilitation approaches and activities used a quantitative scoring system, thus giving the impression that projects with a higher score were better, more correct or more important than projects with a lower score. We therefore propose an alternative classification based on letters, so that a given combination of letters characterizes a particular type of project. The letters are derived from four dimensions: desired outcome of the intervention, participation of the clients in the rehabilitation process, the target group served and the services offered. Some examples are presented. The classification serves to analyse rehabilitation projects, to define policy and as a starting point for evaluation.

Delay in presentation and start of treatment in leprosy: experience in an out-patient clinic in Nepal

Delayed presentation is a recognized risk factor for disability in leprosy but is the result of complex interactions between physical, social, economic and psychological factors. The present study is a response to the situation in an outpatient clinic in Nepal where the wide variation in delay in presentation was a cause for concern. A purpose-written questionnaire was used to collect information on 166 consecutive outpatient admissions. The data included demographics, the first symptom of leprosy, first actions, initial help-seeking behaviour, the reasons for finally seeking treatment and experience with professional health services. Initial analysis found a relationship between delay in presentation and age, rural environment, leprosy classification, walking time, housing not shared with another person affected by leprosy, and an inappropriate first action. The relationship with lack of education and total travel time just failed to reach significance. Further analysis identified that for the study population initial lack of awareness of leprosy and an inappropriate first action were the primary contributors to delay. Extensive and effective health education is needed to address this situation.