Surgery versus epilation for the treatment of minor trichiasis in Ethiopia: a randomised controlled noninferiority trial

Background

Trachomatous trichiasis can cause corneal damage and visual impairment. WHO recommends surgery for all cases. However, in many regions surgical provision is inadequate and patients frequently decline. Self-epilation is common and was associated with comparable outcomes to surgery in nonrandomised studies for minor trichiasis (Methods and Findings1,300 individuals with minor trichiasis from Amhara Regional State, Ethiopia were recruited and randomly assigned (1∶1) to receive trichiasis surgery or epilation. The epilation group were given new forceps and epilation training. The surgical group received trichiasis surgery. Participants were examined every 6 months for 2 years by clinicians masked to allocation, with 93.5% follow-up at 24 months. The primary outcome measure (“failure”) was ≥five lashes touching the eye or receiving trichiasis surgery during 24 months of follow-up, and was assessed for noninferiority with a 10% prespecified noninferiority margin. Secondary outcomes included number of lashes touching, time to failure, and changes in visual acuity and corneal opacity.Cumulative risk of failure over 24 months was 13.2% in the epilation group and 2.2% in the surgical group (risk difference = 11%). The 95% confidence interval (8.1%–13.9%) includes the 10% noninferiority margin. Mean number of lashes touching the eye was greater in the epilation group than the surgery group (at 24 months 0.95 versus 0.09, respectively; p<0.001); there was no difference in change in visual acuity or corneal opacity between the two groups.

Conclusions

This trial was inconclusive regarding inferiority of epilation to surgery for the treatment of minor trichiasis, relative to the prespecified margin. Epilation had a comparable effect to surgery on visual acuity and corneal outcomes. We suggest that surgery be performed whenever possible but epilation be used for treatment of minor trichiasis patients without access to or declining surgery.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00522912","term_id":"NCT00522912"}}NCT00522912 Please see later in the article for the Editors'' Summary     

Absorbable versus silk sutures for surgical treatment of trachomatous trichiasis in Ethiopia: a randomised controlled trial

Background

Trachoma causes blindness through an anatomical abnormality called trichiasis (lashes touching the eye). Trichiasis can recur after corrective surgery. We tested the hypothesis that using absorbable sutures instead of silk sutures might reduce the risk of recurrent disease among patients with major trichiasis in a randomised trial.

Methods and Findings

1,300 individuals with major trichiasis from rural villages in the Amhara Region of Ethiopia were recruited and assigned (1∶1) by computer-generated randomisation sequence to receive trichiasis surgery using either an absorbable suture (polyglactin-910) or silk sutures (removed at 7–10 days) in an otherwise identical surgical technique. Participants were examined every 6 months for 2 years by clinicians masked to allocation. The primary outcome measure was recurrent trichiasis (≥one lash touching the eye) at 1 year. There was no difference in prevalence of recurrent trichiasis at 1 year (114 [18.2%] in the absorbable suture group versus 120 [19.7%] in the silk suture group; odds ratio = 0.90, 95% CI 0.68–1.20). The two groups also did not differ in terms of corneal opacification, visual acuity, conjunctival inflammation, and surgical complications.

Conclusions

There was no evidence that use of absorbable polyglactin-910 sutures was associated with a lower prevalence of trichiasis recurrence at 1 year postsurgery than silk sutures. However, from a programmatic perspective, polyglactin-910 offers the major advantage that patients do not have to be seen soon after surgery for suture removal. The postoperative review after surgery using absorbable polyglactin-910 sutures can be delayed for 3–6 months, which might allow us to better determine whether a patient needs additional surgery.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT00522860","term_id":"NCT00522860"}}NCT00522860 Please see later in the article for the Editors'' Summary     

CD4 Cell Levels during Treatment for Tuberculosis (TB) in Ethiopian Adults and Clinical Markers Associated with CD4 Lymphocytopenia

Background

The clinical correlations and significance of subnormal CD4 levels in HIV-negative patients with TB are unclear. We have determined CD4 cell levels longitudinally during anti-tuberculosis treatment (ATT) in patients, with and without HIV co-infection, and their associations with clinical variables.

Method

Adults diagnosed with TB (maximum duration of ATT for 2 weeks, and with no history of antiretroviral therapy (ART) in HIV-positive subjects) were included consecutively in eight out-patient clinics in Ethiopia. Healthy individuals were recruited for comparison at one of the study health centers. Data on patient characteristics and physical findings were collected by trained nurses following a structured questionnaire at inclusion and on follow-up visits at 2 and 6 months. In parallel, peripheral blood CD4 cell levels were determined. The evolution of CD4 cell levels during ATT was assessed, and the association between clinical characteristics and low CD4 cell levels at baseline was investigated using regression analysis.

Results

In total, 1116 TB patients were included (307 HIV-infected). Among 809 HIV-negative patients, 200 (25%) had subnormal CD4 cell counts (<500 cells/mm³), with <350 cells/mm³ in 82 (10%) individuals. CD4 cell levels increased significantly during the course of ATT in both HIV+ and HIV- TB-patients, but did not reach the levels in healthy subjects (median 896 cells/mm³). Sputum smear status, signs of wasting (low mid upper arm circumference (MUAC)), and bedridden state were significantly associated with low CD4 cell counts.

Conclusion

A high proportion of Ethiopian TB patients have subnormal CD4 cell counts before starting treatment. Low CD4 cell levels are associated with smear positive disease and signs of wasting. The continuous increase of CD4 cell counts during the course of ATT suggest a reversible impact of active TB on CD4 cell homeostasis, which may be considered in interpretation of CD4 cell counts in HIV/TB co-infected subjects.     

Hybridization of nickel oxide nanoparticles with carbon dots and its application for antibacterial activities

A nickel oxide nanoparticle (NiO NP) composite with carbon dots (C-dots), (NiO NPs@C-dots) was synthesized, characterized, and then its antibacterial activity was evaluated. NiO NPs were prepared using Buddleja polystachya Fresen leaf extract and Ni(NO₃)₂.6H₂O as precursors. The C-dots were synthesized from benzene-1,4-diamine and citric acid. The cubic structure of the NiO NPs and NiO NPs@C-dots was in phase with their average particle size distributions of 21.47 ± 0.56 and 21.61 ± 0.34 nm, respectively. The surface morphology of the NiO NPs@C-dots was characterized using field emission scanning electron microscopy and also revealed a large surface area, which is advantageous for the specified application. The X-ray diffraction result indicated a cubic face wurtzite structure and the crystalline nature of the NiO NPs. Carbon-doped compounds had no influence on the crystal structure of the NiO compound and no new peaks were observed. The antibacterial activity of a composite made up of NiO NPs@C-dots was tested, as well as the antibacterial activities of compounds produced against human photogenic bacterial strains. Both NiO NPs and NiO NPs@C-dots were found to be powerful against all bacterial strains, based on the bioassay results. NiO NPs and NiO@C-dots appeared to display strong to inhibitory effects of 14–20 mm and 17–23 mm, respectively.     

Bovine Tuberculosis at the Wildlife-Livestock-Human Interface in Hamer Woreda,South Omo,Southern Ethiopia

Bovine tuberculosis (BTB) is endemic in cattle in the Ethiopian Highlands but no studies have been done so far in pastoralists in South Omo. This study assessed the prevalence of bovine tuberculosis (BTB) at an intensive interface of livestock, wildlife and pastoralists in Hamer Woreda (South Omo), Ethiopia. A cross-sectional survey including a comparative intradermal skin testing (CIDT) was conducted in 499 zebu cattle and 186 goats in 12 settlements. Sputum samples from 26 symptomatic livestock owners were cultured for TB. Fifty-one wildlife samples from 13 different species were also collected in the same area and tested with serological (lateral flow assay) and bacteriological (culture of lymph nodes) techniques. Individual BTB prevalence in cattle was 0.8% (CI: 0.3%–2%) with the >4 mm cut-off and 3.4% (CI: 2.1%–5.4%) with the >2 mm cut-off. Herd prevalence was 33.3% and 83% when using the >4 and the >2 mm cut-off respectively. There was no correlation between age, sex, body condition and positive reactors upon univariate analysis. None of the goats were reactors for BTB. Acid fast bacilli (AFB) were detected in 50% of the wildlife cultures, 79.2% of which were identified as Mycobacterium terrae complex. No M. bovis was detected. Twenty-seven percent of tested wildlife were sero-positive. Four sputum cultures (15.4%) yielded AFB positive colonies among which one was M. tuberculosis and 3 non-tuberculous mycobacteria (NTM). The prevalence of M. avium-complex (MAC) was 4.2% in wildlife, 2.5% in cattle and 0.5% in goats. In conclusion, individual BTB prevalence was low, but herd prevalence high in cattle and BTB was not detected in goats, wildlife and humans despite an intensive contact interface. On the contrary, NTMs were highly prevalent and some Mycobacterium spp were more prevalent in specific species. The role of NTMs in livestock and co-infection with BTB need further research.     

Access to Water Source,Latrine Facilities and Other Risk Factors of Active Trachoma in Ankober,Ethiopia

Objective

This study aims to determine the prevalence and correlates of active trachoma in Ankober, Ethiopia.

Methods

A cross-sectional community-based study was conducted during July 2007. A total of 507 children (ages 1–9 years), from 232 households were included in the study. All children were examined for trachoma by ophthalmic nurses using the WHO simplified clinical grading system. Interviews and observations were used to assess risk factors. Logistic regression procedures were used to determine associations between potential risk factors and signs of active trachoma.

Results

Overall, the prevalence of active trachoma was found to be 53.9% (95%CI 49.6%–58.2%). Presence of fly-eye (fly contact with the eyelid margin during eye examination) (Odds Ratio (OR) = 4.03 95% CI 1.40–11.59), absence of facial cleanliness (OR = 7.59; 95%CI 4.60–12.52), an illiterate mother (OR = 5.88; 95%CI 2.10–15.95), lack of access to piped water (OR = 2.19; 95%CI 1.14–6.08), and lack of access to latrine facilities (OR = 4.36; 95%CI 1.49–12.74) were statistically significantly associated with increased risk of active trachoma.

Conclusion

Active trachoma among children 1–9 years of age in Ankober is highly prevalent and significantly associated with a number of risk factors including access to water and latrine facilities. Trachoma prevention programs that include improved access to water and sanitation, active fly control, and hygiene education are recommended to lower the burden of trachoma in Ankober, Ethiopia.     

The Outcome of Trachomatous Trichiasis Surgery in Ethiopia: Risk Factors for Recurrence

Background

Over 1.2 million people are blind from trachomatous trichiasis (TT). Lid rotation surgery is the mainstay of treatment, but recurrence rates can be high. We investigated the outcomes (recurrence rates and other complications) of posterior lamellar tarsal rotation (PLTR) surgery, one of the two most widely practised TT procedures in endemic settings.

Methodology/Principal Findings

We conducted a two-year follow-up study of 1300 participants who had PLTR surgery, conducted by one of five TT nurse surgeons. None had previously undergone TT surgery. All participants received a detailed trachoma eye examination at baseline and 6, 12, 18 and 24 months post-operatively. The study investigated the recurrence rates, other complications and factors associated with recurrence. Recurrence occurred in 207/635 (32.6%) and 108/641 (16.9%) of participants with pre-operative major (>5 trichiatic lashes) and minor (<5 lashes) TT respectively. Of the 315 recurrences, 42/315 (3.3% overall) had >5 lashes (major recurrence). Recurrence was greatest in the first six months after surgery: 172 cases (55%) occurring in this period. Recurrence was associated with major TT pre-operatively (OR 2.39, 95% CI 1.83–3.11), pre-operative entropic lashes compared to misdirected/metaplastic lashes (OR 1.99, 95% CI 1.23–3.20), age over 40 years (OR 1.59, 95% CI 1.14–2.20) and specific surgeons (surgeon recurrence risk range: 18%–53%). Granuloma occurred in 69 (5.7%) and notching in 156 (13.0%).

Conclusions/Significance

Risk of recurrence is high despite high volume, highly trained surgeons. However, the vast majority are minor recurrences, which may not have significant corneal or visual consequences. Inter-surgeon variation in recurrence is concerning; surgical technique, training and immediate post-operative lid position require further investigation.     

Comparison of the Kato-Katz and FLOTAC techniques for the diagnosis of soil-transmitted helminth infections

Decisions on individual or community treatment and evaluation of chemotherapy based control programs depend on parasitological diagnostic techniques. The aim of this study was to compare the accuracy of a single Kato-Katz thick smear and a single FLOTAC for the determination of the prevalence and intensity of soil-transmitted helminth infections. A total of 271 faecal specimens were collected from schoolchildren in Ethiopia, and microscopically examined using the Kato-Katz method (41.7 mg stool per slide) and the FLOTAC technique. The combined results from the Kato-Katz and FLOTAC methods were used as diagnostic 'gold' standard for reference in the analysis. Agreement between the two methods showed kappa values of 0.74, 0.73 and 0.28 for Ascaris lumbricoides, Trichuris trichiura and hookworm, respectively. A single FLOTAC revealed significantly more infections than a single Kato-Katz for each of the three soil-transmitted helminths (p<0.01). The sensitivities of a single Kato-Katz for diagnosis of T. trichiura, A. lumbricoides and hookworm infections were 76.6%, 67.8% and 19.6%, respectively, while the sensitivity of FLOTAC was 100% for all the three soil-transmitted helminth species. A single Kato-Katz yielded considerably higher mean faecal egg counts (FECs) (729.1, 145.2 and 60.7 eggs per gram of stool (EPG) for A. lumbricoides, T. trichiura and hookworm, respectively) compared with a single FLOTAC (142.5, 54.5 and 14.6 EPG, respectively) (p<0.05). Our study confirms that a single FLOTAC is more sensitive than a single Kato-Katz for the diagnosis of soil-transmitted helminth infections, but results in lower FECs. Further standardization and validation are still required in different epidemiological settings with varying levels of intensity of infections before recommending FLOTAC for large-scale community diagnosis.     

Identification of Early Vigor QTLs and QTL by Environment Interactions in Wheat (<Emphasis Type="Italic">Triticum eastivum</Emphasis> L.)

Crop productivity is highly dependent on successful seed germination and seedling establishment. This study evaluated two mapping populations, Batavia/Ernie (double haploid) and Synthetic/Opata (recombinant inbred lines), for early vigor under water stress and normal growing conditions. Significant gene, environment (water), and gene by environment interaction effects were observed. Broad sense heritability was 29 and 40% for the Batavia/Ernie and Synthetic/Opata populations, respectively. Quantitative trait loci (QTL) were analyzed based on single and multienvironment models. The two mapping populations differed in the number and locations of QTLs except qNev.uwa.4AL was identified in both populations under the non-stress condition, while qSev.uwa.3BL was specifically expressed under the stress condition in the Synthetic/Opata population. QTL by environment interaction (QEI) enabled identification of nine QTLs, including those identified by the single environment approach. Phenotypic variation expression (PVE) of QEIs ranged from 4.8 to 14.9% across the populations. Larger proportion of PVE of QEIs was explained by the additive components. Favorable alleles for three of the QTLs identified in the Synthetic/Opata population were derived from Synthetic, while Batavia contributed favorable alleles to a QTL on the long arm of chromosome 1D in the Batavia/Ernie population. QTL detected under water stress (qSev.uwa.3BL) co-located with the DREB 1 gene, which was mapped between markers Xmwg818 and Xfbb117 (58.1–77.6 cM). QTLs with high proportion of additive components can be validated for marker assisted gene pyramiding and selection.