Good Quality of Life in Former Buruli Ulcer Patients with Small Lesions:Long-Term Follow-up of the BURULICO Trial

Buruli Ulcer is a tropical skin disease caused by Mycobacterium ulcerans, which, due to scarring and contractures can lead to stigma and functional limitations. However, recent advances in treatment, combined with increased public health efforts have the potential to significantly improve disease outcome.To study the Quality of Life (QoL) of former Buruli Ulcer patients who, in the context of a randomized controlled trial, reported early with small lesions (cross-sectional diameter <10 cm), and received a full course of antibiotic treatment.127 Participants of the BURULICO drug trial in Ghana were revisited. All former patients aged 16 or older completed the Dermatology Life Quality Index (DLQI) and the abbreviated World Health Organization Quality of Life scale (WHOQOL-BREF). The WHOQOL-BREF was also administered to 82 matched healthy controls. Those younger than 16 completed the Childrens' Dermatology Life Quality Index (CDLQI) only.The median (Inter Quartile Range) score on the DLQI was 0 (0-4), indicating good QoL. 85% of former patients indicated no effect, or only a small effect of the disease on their current life. Former patients also indicated good QoL on the physical and psychological domains of the WHOQOL-BREF, and scored significantly higher than healthy controls on these domains. There was a weak correlation between the DLQI and scar size (ρ = 0.32; p<0.001).BU patients who report early with small lesions and receive 8 weeks of antimicrobial therapy have a good QoL at long-term follow-up. These findings contrast with the debilitating sequelae often reported in BU, and highlight the importance of early case detection

Assessment and Treatment of Pain during Treatment of Buruli Ulcer

BACKGROUND:Buruli ulcer (BU) is described as a relatively painless condition; however clinical observations reveal that patients do experience pain during their treatment. Knowledge on current pain assessment and treatment in BU is necessary to develop and implement a future guideline on pain management in BU. METHODOLOGY:A mixed methods approach was used, consisting of information retrieved from medical records on prescribed pain medication from Ghana and Benin, and semi-structured interviews with health care personnel (HCP) from Ghana on pain perceptions, assessment and treatment. Medical records (n = 149) of patients treated between 2008 and 2012 were collected between November 2012 and August 2013. Interviews (n = 11) were audio-taped, transcribed verbatim and qualitatively analyzed. PRINCIPAL FINDINGS:In 113 (84%) of the 135 included records, pain medication, mostly simple analgesics, was prescribed. In 48% of the prescriptions, an indication was not documented. HCP reported that advanced BU could be painful, especially after wound care and after a skin graft. They reported not be trained in the assessment of mild pain. Pain recognition was perceived as difficult, as patients were said to suppress or to exaggerate pain, and to have different expectations regarding acceptable pain levels. HCP reported a fear of side effects of pain medication, shortage and irregularities in the supply of pain medication, and time constraints among medical doctors for pain management. CONCLUSIONS:Professionals perceived BU disease as potentially painful, and predominantly focused on severe pain. Our study suggests that pain in BU deserves attention and should be integrated in current treatment

Differential predictors for alcohol use in adolescents as a function of familial risk

Abstract: Traditional models of future alcohol use in adolescents have used variable-centered approaches, predicting alcohol use from a set of variables across entire samples or populations. Following the proposition that predictive factors may vary in adolescents as a function of family history, we used a two-pronged approach by first defining clusters of familial risk, followed by prediction analyses within each cluster. Thus, for the first time in adolescents, we tested whether adolescents with a family history of drug abuse exhibit a set of predictors different from adolescents without a family history. We apply this approach to a genetic risk score and individual differences in personality, cognition, behavior (risk-taking and discounting) substance use behavior at age 14, life events, and functional brain imaging, to predict scores on the alcohol use disorders identification test (AUDIT) at age 14 and 16 in a sample of adolescents (N = 1659 at baseline, N = 1327 at follow-up) from the IMAGEN cohort, a longitudinal community-based cohort of adolescents. In the absence of familial risk (n = 616), individual differences in baseline drinking, personality measures (extraversion, negative thinking), discounting behaviors, life events, and ventral striatal activation during reward anticipation were significantly associated with future AUDIT scores, while the overall model explained 22% of the variance in future AUDIT. In the presence of familial risk (n = 711), drinking behavior at age 14, personality measures (extraversion, impulsivity), behavioral risk-taking, and life events were significantly associated with future AUDIT scores, explaining 20.1% of the overall variance. Results suggest that individual differences in personality, cognition, life events, brain function, and drinking behavior contribute differentially to the prediction of future alcohol misuse. This approach may inform more individualized preventive interventions

Differential predictors for alcohol use in adolescents as a function of familial risk

Abstract: Traditional models of future alcohol use in adolescents have used variable-centered approaches, predicting alcohol use from a set of variables across entire samples or populations. Following the proposition that predictive factors may vary in adolescents as a function of family history, we used a two-pronged approach by first defining clusters of familial risk, followed by prediction analyses within each cluster. Thus, for the first time in adolescents, we tested whether adolescents with a family history of drug abuse exhibit a set of predictors different from adolescents without a family history. We apply this approach to a genetic risk score and individual differences in personality, cognition, behavior (risk-taking and discounting) substance use behavior at age 14, life events, and functional brain imaging, to predict scores on the alcohol use disorders identification test (AUDIT) at age 14 and 16 in a sample of adolescents (N = 1659 at baseline, N = 1327 at follow-up) from the IMAGEN cohort, a longitudinal community-based cohort of adolescents. In the absence of familial risk (n = 616), individual differences in baseline drinking, personality measures (extraversion, negative thinking), discounting behaviors, life events, and ventral striatal activation during reward anticipation were significantly associated with future AUDIT scores, while the overall model explained 22% of the variance in future AUDIT. In the presence of familial risk (n = 711), drinking behavior at age 14, personality measures (extraversion, impulsivity), behavioral risk-taking, and life events were significantly associated with future AUDIT scores, explaining 20.1% of the overall variance. Results suggest that individual differences in personality, cognition, life events, brain function, and drinking behavior contribute differentially to the prediction of future alcohol misuse. This approach may inform more individualized preventive interventions

Buruli Ulcer treatment; more than wound healing alone?

Buruli Ulcer (BU) is an infectious, necrotizing, skin disease caused by Mycobacterium ulcerans. The prevalence of BU is highest in West-Africa. At the moment the standard treatment for BU is eight weeks of streptomycin and rifampicin, wound care, and, when necessary, surgery. Clinical observations suggest that during treatment patients are in pain, and that they experience problems like stigma, disabilities, and various side effects. For this reason the aim of this study was to provide a better view of three different aspects of the treatment; pain, Quality of Life and toxicity. The aspect of pain was assessed in three ways; by examining the current prescribing behaviour, by interviewing health workers, by pain measurements in BU patients. Current prescribing behaviour was determined by reviewing 40 patient files of patient with BU admitted to the Agogo Presbyterian Hospital in the period January 2008 - December 2012. For 32 patients ten different pain medications had been prescribed 169 times, of which diclofenac was prescribed most often (34.9%). In 39.6% of the cases that pain medication was prescribed the indication was missing. In cases that the indications were known, wound debridement or excision was noted most frequently (15.4%). Additionally, seven health workers who were actively involved in the treatment of BU participated in a semi-structured interview on BU treatment and pain experienced by the patients. All the health workers stated that pain medication was given depending on the severity of the pain, but that the main restrictions for prescribing pain medication according to the health workers are shortage of financial means and doubts about the safety of the drugs or their side-effects. Pain measurements with pain rating scales were done for three patients of ages five and seven years who received regular wound treatment for their BU infection at Agogo Presbyterian Hospital. One out of three patients reported severe pain. For the assessment of Quality of Life 70 former BU patients from the BURULICO trial, and 82 healthy controls were interviewed using the WHOQOL-BREF questionnaire. Former patients scored a higher Quality of Life than the healthy controls in all the domains, but this difference is only significant (p<0.01) in the domains of Physical health and Environment. To measure toxicity of the treatment 127 former BU patients older than four years, and who had participated in the BURULICO trial and had scars less than 10 cm, were included. Blood was taken and audiometry was done. In adults (≥16 years) the treatment arm of SR8 has a significant (p<0.05) higher serum creatinine concentration than the SR4/CR4 treatment arm after eight weeks of treatment. At follow-up there is still a difference but this is not significant any more. For children under 16 years old there is no significant difference in serum creatinine between the two groups at all measure moments. The hearing levels of adult patients from the SR8 treatment arm are significantly (p<-.05) lower for all measured frequencies compared to the SR4/CR4 treatment arm, especially the highest frequencies (6000 Hz and 8000 Hz with p<0.01). The outcomes of both treatment arms are within the speech area. For children no significant difference was found between the two treatment groups at any frequency, with the outcomes of the measurements of both treatment arms within the speech area. In conclusion pain is an important aspect during the treatment of BU, as is mentioned by patients and health workers and recorded in patient files. There is need for standardized protocols for pain assessment and prescription of pain medication during the treatment of BU. The Quality of Life for patients with small lesions (≤ 10cm) seems to be high at follow-up, which gives a good prospective for the future. Quality of Life should, however, still be assessed in patients with bigger lesions (> 10cm). Besides that long term effects of the treatment are lower when 4 weeks streptomycin and rifampicin followed by 4 weeks clarithromycin and rifampicin is used instead of the current standard of 8 weeks streptomycin and rifampicin. In other words there is a lot more to BU treatment than only the wound healing and there is room for improvement of the treatment of BU, but there is still need for more research on all the aspects of the treatment.

Measuring the Three-Dimensional Structure of Ultrathin Insulating Films at the Atomic Scale

The increasing technological importance of thin insulating layers calls for a thorough understanding of their structure. Here we apply scanning probe methods to investigate the structure of ultrathin magnesium oxide (MgO) which is the insulating material of choice in spintronic applications. A combination of force and current measurements gives high spatial resolution maps of the local three-dimensional insulator structure. When force measurements are not available, a lower spatial resolution can be obtained from tunneling images at different voltages. These broadly applicable techniques reveal a previously unknown complexity in the structure of MgO on Ag(001), such as steps in the insulator–metal interface

Measuring the Three-Dimensional Structure of Ultrathin Insulating Films at the Atomic Scale

The increasing technological importance of thin insulating layers calls for a thorough understanding of their structure. Here we apply scanning probe methods to investigate the structure of ultrathin magnesium oxide (MgO) which is the insulating material of choice in spintronic applications. A combination of force and current measurements gives high spatial resolution maps of the local three-dimensional insulator structure. When force measurements are not available, a lower spatial resolution can be obtained from tunneling images at different voltages. These broadly applicable techniques reveal a previously unknown complexity in the structure of MgO on Ag(001), such as steps in the insulator–metal interface

Pain Associated with Wound Care Treatment among Buruli Ulcer Patients from Ghana and Benin

Buruli ulcer (BU) is a necrotizing skin disease caused by Mycobacterium ulcerans. People living in remote areas in tropical Sub Saharan Africa are mostly affected. Wound care is an important component of BU management; this often needs to be extended for months after the initial antibiotic treatment. BU is reported in the literature as being painless, however clinical observations revealed that some patients experienced pain during wound care. This was the first study on pain intensity during and after wound care in BU patients and factors associated with pain. In Ghana and Benin, 52 BU patients above 5 years of age and their relatives were included between December 2012 and May 2014. Information on pain intensity during and after wound care was obtained during two consecutive weeks using theWong-Baker Pain Scale. Median pain intensity during wound care was in the lower range (Mdn = 2, CV = 1), but severe pain (score > 6) was reported in nearly 30% of the patients. Nevertheless, only one patient received pain medication. Pain declined over time to low scores 2 hours after treatment. Factors associated with higher self-reported pain scores were; male gender, fear prior to treatment, pain during the night prior to treatment, and pain caused by cleaning the wound. The general idea that BU is painless is incorrect for the wound care procedure. This procedural pain deserves attention and appropriate intervention