Assessment of the magnitude and associated factors of immunological failure among adult and adolescent HIV-infected patients in St. Luke and Tulubolo Hospital, Oromia Region, Ethiopia

Introduction: The use of antiretroviral therapy (ART) has become a standard of care for the treatment of HIV infection. However, cost and resistance to ART are major obstacles for access to treatment especially in resource-limited settings. In this study, we aimed to assess the magnitude and associated factors of Immunological failure among adult and adolescent HIV infected Patients (with age '15yrs) on Highly Active Antiretroviral Therapy (HAART) in St. Luke and Tulu Bolo Hospitals, Oromia Region, Ethiopia. Methods: A retrospective follow-up study was conducted among HIV-infected patients initiated 1st line ART at St. Luke and Tulu Bolo Hospitals, South West Shoa Zone, Oromia, Ethiopia. Results: A total of 828 patient charts were reviewed. 477(57.6%) were female and the median age was 32 years. The median baseline CD4 count was 148cells/mm3. The most common prescribed ART was TDF based (36.7%). Out of 828 patients chart reviewed 6.8% (56) were developed immunological failure. Out of them only 20 (2.4%) were detected and put on second line regimen. The incidence of immunological failure was 1.8 cases per 100 person years of follow-up. Patients who had not disclosed their HIV status to any one had high risk of immunological failure compared with patients those who had disclosed their HIV status (AHR, 0.429; 95% CI 0.206 - 0.893; P-value=0.024). Conclusion: Non disclosures of HIV status and with ambulatory of baseline functional status were found to be predictors of immunological failure. Most of the immunological failure cases were not detected early and not switched to second line ARV regimen. So patients with the above risk factors should be considered for a timely switch to second line HAART

Maximising trichiasis surgery success (MTSS) trial: rationale and design of a randomised controlled trial to improve trachomatous trichiasis surgical outcomes

INTRODUCTION: Trachomatous trichiasis (TT) is a condition in which the eyelid turns inward and eyelashes abrade the front part of the eye. To prevent eventual blindness, surgery is recommended. Two surgical procedures are commonly used, bilamellar tarsal rotation (BLTR) and posterior lamellar tarsal rotation (PLTR). Evidence suggests that incision height and surgery type may affect the risk of postoperative TT (PTT) and other surgical outcomes. However, these studies have not prospectively compared the impact of incision height on surgical outcomes. METHODS AND ANALYSIS: Maximising trichiasis surgery Success (MTSS) is a three-arm, randomised clinical trial being conducted in Ethiopia. Participants will be randomly assigned on a 1:1:1 basis to BLTR with a 3 mm incision height, BLTR with a 5 mm incision height, or PLTR 3 mm incision height. Patients are eligible for the trial if they have previously unoperated upper eyelid TT. Follow-up visits will be conducted by trained eye examiners at 1 day, 2 weeks, 6 weeks and 12 months after surgery. The primary outcome is incident PTT within 1 year following surgery. Logistic regression will be used in an intention-to-treat analysis to assess outcome incidence by surgical approach. ETHICS AND DISSEMINATION: The University of North Carolina and Johns Hopkins School of Medicine institution review boards, Ethiopian National Research Ethics Review Committee and Ethiopian Food, Medicine, Healthcare and Administration and Control Authority provided ethics approval for the trial. On completion, trial results will be disseminated at local and international meetings and in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03100747

Nature-based solutions for hydro-meteorological hazards: revised concepts, classification schemes and databases

Hydro-meteorological hazards (HMHs) have had a strong impact on human societies and ecosystems. Their impact is projected to be exacerbated by future climate scenarios. HMHs cataloguing is an effective tool to evaluate their associated risks and plan appropriate remediation strategies. However, factors linked to HMHs origin and triggers remain uncertain, which poses a challenge for their cataloguing. Focusing on key HMHs (floods, storm surge, landslides, droughts, and heatwaves), the goal of this review paper is to analyse and present a classification scheme, key features, and elements for designing nature-based solutions (NBS) and mitigating the adverse impacts of HMHs in Europe. For this purpose, we systematically examined the literature on NBS classification and assessed the gaps that hinder the widespread uptake of NBS. Furthermore, we critically evaluated the existing literature to give a better understanding of the HMHs drivers and their interrelationship (causing multi-hazards). Further conceptualisation of classification scheme and categories of NBS shows that relatively few studies have been carried out on utilising the broader concepts of NBS in tackling HMHs and that the classification and effectiveness of each NBS are dependent on the location, architecture, typology, green species, environmental conditions as well as interrelated non-linear systems. NBS are often more cost-effective than hard engineering approaches used within the existing systems, especially when taking into consideration their potential co-benefits. We also evaluated the sources of available data for HMHs and NBS, highlighted gaps in data, and presented strategies to overcome the current shortcomings for the development of the NBS for HMHs. We highlighted specific gaps and barriers that need to be filled since the uptake and upscaling studies of NBS in HMHs reduction is rare. The fundamental concepts and the key technical features of past studies reviewed here could help practitioners to design and implement NBS in a real-world situation

A New Surgical Technique for Postoperative Trachomatous Trichiasis

INTRODUCTION: The World Health Organization has identified management of postoperative trichiasis (PTT) as one of the key remaining areas of focus needed to eliminate blinding trachoma as a public health problem. We developed the Bevel-Rotation Advancement Procedure (B-RAP) to treat individuals who need repeat trichiasis surgery. METHODS: Scarring caused by trichiasis surgery can cause the eyelid to become thick and distorted, making repeat surgery more difficult. To minimize eyelid thickness following B-RAP, a beveled incision of the tarsus is made allowing a marginal rotation of the eyelash fragment. Dissection between the anterior and posterior lamellae above the beveled incision and removal of scar tissue allows the marginal rotation to be combined with a posterior lamellar advancement to treat severely scarred eyelids with PTT and eyelid contour abnormalities (ECAs). RESULTS: Two surgeons performed B-RAP on 44 eyelids of 30 patients with PTT. The number of prior trachomatous trichiasis (TT) surgeries ranged from 2 to more than 4. At the 3-6 months postoperative visit, 37 eyelids (84%) had no recurrence of PTT. Three eyelids had central lashes touching; the remaining eyelids with recurrent PTT had nasal and temporal lashes touching. Fifteen eyelids (34%) had ECAs, but only 1 was severe. CONCLUSIONS: B-RAP was developed considering the altered eyelid anatomy found in the postsurgical eyelid with TT. Thinning of the eyelash fragment and removal of postoperative scar tissue improves the ability to advance and stabilize the eyelash fragment after external rotation. B-RAP shows promise as a procedure for improving outcomes of repeat trichiasis surgery

Characteristics and perspectives of patients with postoperative trichiasis in Hadiya Zone, Ethiopia

Background: Postoperative trachomatous trichiasis (PTT) is a challenge for trichiasis surgery programs. Little is known about PTT patients' perceptions regarding outcomes and future disease management. This study aimed to understand the characteristics of PTT patients, how they managed trichiasis and their perceptions of prior surgeries and future surgery uptake. Methods: Patients with PTT were identified during an existing trichiasis screening program in Hadiya Zone, Ethiopia. A vision assessment and evaluation of the eyelids were conducted to determine distance vision, presence and severity of trichiasis and eyelid contour abnormalities. A questionnaire was administered to obtain information regarding patients' perceptions of surgery and PTT management approaches. Descriptive statistics were used to characterize PTT and determine associations between PTT severity and patient perceptions. Results: Among 404 participants, most were female (79.7%) and aged 40-60 y (62.6%). In total, 514 eyelids had PTT, and nearly half had severe PTT (46.9%). Although >50% of participants were currently epilating to manage their PTT, the majority (82.8%) indicated that they wanted repeat surgery. Most participants indicated that pain persisted despite epilation. The majority (75.1%) indicated satisfaction with their prior surgery and 59.6% indicated that they would recommend surgery to others. Conclusions: This study, which included a large proportion of severe PTT cases, indicated that individuals were generally satisfied with prior surgery and would prefer to have surgery again for PTT management

Podoconiosis and soil-transmitted helminths (STHs): double burden of neglected tropical diseases in Wolaita zone, rural southern Ethiopia

Background Both podoconiosis and soil-transmitted helminth (STH) infections occur among barefoot people in areas of extreme poverty; however, their co-morbidity has not previously been investigated. We explored the overlap of STH infection and podoconiosis in Southern Ethiopia and quantified their separate and combined effects on prevalent anemia and hemoglobin levels in podoconiosis patients and health controls from the same area. Methods and Principal Findings A two-part comparative cross-sectional study was conducted in Wolaita zone, southern Ethiopia. Data were collected from adult patients presenting with clinically confirmed podoconiosis, and unmatched adult neighborhood controls living in the same administrative area. Information on demographic and selected lifestyle factors was collected using interviewer-administered questionnaires. Stool samples were collected and examined qualitatively using the modified formalin-ether sedimentation method. Hemoglobin level was determined using two different methods: hemoglobinometer and automated hematology analyzer. A total of 913 study subjects (677 podoconiosis patients and 236 controls) participated. The prevalence of any STH infection was 47.6% among patients and 33.1% among controls (p<0.001). The prevalence of both hookworm and Trichuris trichiura infections was significantly higher in podoconiosis patients than in controls (AOR 1.74, 95% CI 1.25 to2.42, AOR 6.53, 95% CI 2.34 to 18.22, respectively). Not wearing shoes and being a farmer remained significant independent predictors of infection with any STH. There was a significant interaction between STH infection and podoconiosis on reduction of hemoglobin level (interaction p value = 0.002). Conclusions Prevalence of any STH and hookworm infection was higher among podoconiosis patients than among controls. A significant reduction in hemoglobin level was observed among podoconiosis patients co-infected with hookworm and ‘non-hookworm STH’. Promotion of consistent shoe-wearing practices may have double advantages in controlling both podoconiosis and hookworm infection in the study area

Single-dose liposomal amphotericin B (AmBisome®) for the treatment of Visceral Leishmaniasis in East Africa: study protocol for a randomized controlled trial

BACKGROUND: AmBisome® is an efficacious, safe anti-leishmanial treatment. There is growing interest in its use, either as a single dose or in combination treatments. In East Africa, the minimum optimal single-dosage has not been identified. METHODS/DESIGN: An open-label, 2-arm, non-inferiority, multi-centre randomised controlled trial is being conducted to determine the optimal single-dose treatment with AmBisome®.Patients in the single-dose arm will receive one infusion on day 1, at a dose depending on body weight. For the first group of patients entered to the trial, the dose will be 7.5 mg/kg, but if this dose is found to be ineffective then in subsequent patient series the dose will be escalated progressively to 10, 12.5 and 15 mg/kg. Patients in the reference arm will receive a multi-dose regimen of AmBisome® (3 mg/kg/day on days 1-5, 14 and 21: total dose 21 mg/kg). Patients will be hospitalised for approximately one month after the start of treatment and then followed up at three and six months. The primary endpoint is the status of patients six months after treatment. A secondary endpoint is assessment at day 30. Treatment success is determined as the absence of parasites on microscopy samples taken from bone marrow, lymph node or splenic aspirates. Interim analyses to assess the comparative efficacy of the single dose are planned after recruitment of 20 and 40 patients per arm. The final non-inferiority analysis will include 120 patients per arm, to determine if the single-dose efficacy 6 months after treatment is not more than 10% inferior to the multi-dose. DISCUSSION: An effective, safe single-dose treatment would reduce hospitalization and treatment costs. Results will inform the design of combination treatment studies. TRIAL REGISTRATION: ClinicalTrials.gov NCT00832208

An overview of monitoring methods for assessing the performance of nature-based solutions against natural hazards

To bring to fruition the capability of nature-based solutions (NBS) in mitigating hydro-meteorological risks (HMRs) and facilitate their widespread uptake require a consolidated knowledge-base related to their monitoring methods, efficiency, functioning and the ecosystem services they provide. We attempt to fill this knowledge gap by reviewing and compiling the existing scientific literature on methods, including ground-based measurements (e.g. gauging stations, wireless sensor network) and remote sensing observations (e.g. from topographic LiDAR, multispectral and radar sensors) that have been used and/or can be relevant to monitor the performance of NBS against five HMRs: floods, droughts, heatwaves, landslides, and storm surges and coastal erosion. These can allow the mapping of the risks and impacts of the specific hydro-meteorological events. We found that the selection and application of monitoring methods mostly rely on the particular NBS being monitored, resource availability (e.g. time, budget, space) and type of HMRs. No standalone method currently exists that can allow monitoring the performance of NBS in its broadest view. However, equipments, tools and technologies developed for other purposes, such as for ground-based measurements and atmospheric observations, can be applied to accurately monitor the performance of NBS to mitigate HMRs. We also focused on the capabilities of passive and active remote sensing, pointing out their associated opportunities and difficulties for NBS monitoring application. We conclude that the advancement in airborne and satellite-based remote sensing technology has signified a leap in the systematic monitoring of NBS performance, as well as provided a robust way for the spatial and temporal comparison of NBS intervention versus its absence. This improved performance measurement can support the evaluation of existing uncertainty and scepticism in selecting NBS over the artificially built concrete structures or grey approaches by addressing the questions of performance precariousness. Remote sensing technical developments, however, take time to shift toward a state of operational readiness for monitoring the progress of NBS in place (e.g. green NBS growth rate, their changes and effectiveness through time). More research is required to develop a holistic approach, which could routinely and continually monitor the performance of NBS over a large scale of intervention. This performance evaluation could increase the ecological and socio-economic benefits of NBS, and also create high levels of their acceptance and confidence by overcoming potential scepticism of NBS implementations

Nature-based solutions efficiency evaluation against natural hazards: modelling methods, advantages and limitations

Nature-based solutions (NBS) for hydro-meteorological risks (HMRs) reduction and management are becoming increasingly popular, but challenges such as the lack of well-recognised standard methodologies to evaluate their performance and upscale their implementation remain. We systematically evaluate the current state-of-the art on the models and tools that are utilised for the optimum allocation, design and efficiency evaluation of NBS for five HMRs (flooding, droughts, heatwaves, landslides, and storm surges and coastal erosion). We found that methods to assess the complex issue of NBS efficiency and cost-benefits analysis are still in the development stage and they have only been implemented through the methodologies developed for other purposes such as fluid dynamics models in micro and catchment scale contexts. Of the reviewed numerical models and tools MIKE-SHE, SWMM (for floods), ParFlow-TREES, ACRU, SIMGRO (for droughts), WRF, ENVI-met (for heatwaves), FUNWAVE-TVD, BROOK90 (for landslides), TELEMAC and ADCIRC (for storm surges) are more flexible to evaluate the performance and effectiveness of specific NBS such as wetlands, ponds, trees, parks, grass, green roof/walls, tree roots, vegetations, coral reefs, mangroves, sea grasses, oyster reefs, sea salt marshes, sandy beaches and dunes. We conclude that the models and tools that are capable of assessing the multiple benefits, particularly the performance and cost-effectiveness of NBS for HMR reduction and management are not readily available. Thus, our synthesis of modelling methods can facilitate their selection that can maximise opportunities and refute the current political hesitation of NBS deployment compared with grey solutions for HMR management but also for the provision of a wide range of social and economic co-benefits. However, there is still a need for bespoke modelling tools that can holistically assess the various components of NBS from an HMR reduction and management perspective. Such tools can facilitate impact assessment modelling under different NBS scenarios to build a solid evidence base for upscaling and replicating the implementation of NBS

Global, regional, and national burden of chronic kidney disease, 1990–2017 : a systematic analysis for the Global Burden of Disease Study 2017

Background Health system planning requires careful assessment of chronic kidney disease (CKD) epidemiology, but data for morbidity and mortality of this disease are scarce or non-existent in many countries. We estimated the global, regional, and national burden of CKD, as well as the burden of cardiovascular disease and gout attributable to impaired kidney function, for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. We use the term CKD to refer to the morbidity and mortality that can be directly attributed to all stages of CKD, and we use the term impaired kidney function to refer to the additional risk of CKD from cardiovascular disease and gout. Methods The main data sources we used were published literature, vital registration systems, end-stage kidney disease registries, and household surveys. Estimates of CKD burden were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool, and included incidence, prevalence, years lived with disability, mortality, years of life lost, and disability-adjusted life-years (DALYs). A comparative risk assessment approach was used to estimate the proportion of cardiovascular diseases and gout burden attributable to impaired kidney function. Findings Globally, in 2017, 1·2 million (95% uncertainty interval [UI] 1·2 to 1·3) people died from CKD. The global all-age mortality rate from CKD increased 41·5% (95% UI 35·2 to 46·5) between 1990 and 2017, although there was no significant change in the age-standardised mortality rate (2·8%, −1·5 to 6·3). In 2017, 697·5 million (95% UI 649·2 to 752·0) cases of all-stage CKD were recorded, for a global prevalence of 9·1% (8·5 to 9·8). The global all-age prevalence of CKD increased 29·3% (95% UI 26·4 to 32·6) since 1990, whereas the age-standardised prevalence remained stable (1·2%, −1·1 to 3·5). CKD resulted in 35·8 million (95% UI 33·7 to 38·0) DALYs in 2017, with diabetic nephropathy accounting for almost a third of DALYs. Most of the burden of CKD was concentrated in the three lowest quintiles of Socio-demographic Index (SDI). In several regions, particularly Oceania, sub-Saharan Africa, and Latin America, the burden of CKD was much higher than expected for the level of development, whereas the disease burden in western, eastern, and central sub-Saharan Africa, east Asia, south Asia, central and eastern Europe, Australasia, and western Europe was lower than expected. 1·4 million (95% UI 1·2 to 1·6) cardiovascular disease-related deaths and 25·3 million (22·2 to 28·9) cardiovascular disease DALYs were attributable to impaired kidney function. Interpretation Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease. CKD is largely preventable and treatable and deserves greater attention in global health policy decision making, particularly in locations with low and middle SDI