Engaging stakeholders in research to address water-energy-food (WEF) nexus challenges

The water-energy-food (WEF) nexus has become a popular, and potentially powerful, frame through which to analyse interactions and interdependencies between these three systems. Though the case for transdisciplinary research in this space has been made, the extent of stakeholder engagement in research remains limited with stakeholders most commonly incorporated in research as end-users. Yet, stakeholders interact with nexus issues in a variety of ways, consequently there is much that collaboration might offer to develop nexus research and enhance its application. This paper outlines four aspects of nexus research and considers the value and potential challenges for transdisciplinary research in each. We focus on assessing and visualising nexus systems; understanding governance and capacity building; the importance of scale; and the implications of future change. The paper then proceeds to describe a novel mixed-method study that deeply integrates stakeholder knowledge with insights from multiple disciplines. We argue that mixed-method research designs-in this case orientated around a number of cases studies-are best suited to understanding and addressing real-world nexus challenges, with their inevitable complex, non-linear system characteristics. Moreover, integrating multiple forms of knowledge in the manner described in this paper enables research to assess the potential for, and processes of, scaling-up innovations in the nexus space, to contribute insights to policy and decision making.

Use of antiretrovirals in HIV-infected children in a tuberculosis prevention trial: IMPAACT P1041

SETTING

International Maternal Pediatric Adolescent AIDS Clinical Trials (IMPAACT) P1041, a tuberculosis (TB) prevention trial conducted among children enrolled from 2004 to 2008 during South Africa's roll-out of combination antiretroviral therapy (ART).

OBJECTIVE

To estimate TB incidence and mortality and the effect of ART.

DESIGN

Children were pre-screened to exclude TB disease and exposure, actively screened 3-monthly for TB exposure and symptoms, and provided post-exposure isoniazid prophylaxis therapy (IPT). TB diagnoses were definite, probable, or possible, and mortality all-cause. Testing was at the 5% significance level.

RESULTS

In 539 children (aged 3-4 months) followed up for a median of 74 weeks (interquartile range [IQR] 48-116), incidence/100 person-years (py) was 10.67 (95%CI 8.47-13.26) for any TB and 2.89 (95%CI 1.85-4.31) for definite/probable TB. Any TB incidence was respectively 9.39, 13.59, and 9.83/100 py before, <180 days after, and 180 days after ART initiation. Adjusted analysis showed a non-significant increase in any TB (HR 1.32, 95%CI 0.71-2.52, P = 0.38) and a significant reduction in mortality (HR 0.39, 95%CI 0.17-0.82, P = 0.017) following ART initiation.

CONCLUSIONS

ART reduced mortality but not TB incidence in human immunodeficiency virus (HIV) infected children in IMPAACT P1041, possibly attributable to active screening for TB exposure and symptoms with post-exposure IPT. Research into this as a strategy for TB prevention in high HIV-TB burden settings may be warranted.

Echogenicity of the carotid arterial wall in active smokers

This pilot study evaluated associations between carotid wall echogenicity, cardiovascular disease (CVD) risk factors, and three markers of smoking heaviness in a cohort of active smokers. Common carotid artery (CCA) grayscale median (GSM) values were measured from sonographic images. Univariable correlations and exploratory multivariable models were used to determine associations between CCA GSM, CVD risk factors, and measures of smoking heaviness. CCA GSM was measured in 162 smokers and was correlated inversely with cigarettes smoked/day (r=-0.16, p=0.048), pack-years (r=-0.204, p=0.009), CVD risk factors such as age, male sex, waist circumference, and low-density lipoprotein cholesterol (all p≤0.03) and positively with high-density lipoprotein cholesterol (p<0.001). Associations between CCA GSM and smoking heaviness markers were not statistically significant after adjustment for traditional risk factors. The results from this pilot study demonstrate the feasibility of measuring the GSM value of the CCA far wall and its association with measures of smoking heaviness and traditional CVD risk factors among current smokers.

Prospective evaluation of quality of life in children treated in UKALL 2003 for acute lymphoblastic leukaemia: A cohort study

BACKGROUND

Health-related quality of life (HRQoL) from diagnosis until end of treatment for children with acute lymphoblastic leukaemia was investigated, examining effects of age, gender, risk-stratified treatment regimen, and therapy intensity (one vs. two 'delayed intensifications' [DIs]).

METHOD

In a multi-centre prospective study, parents reported their child's generic and disease-specific HRQoL and their own care-giving burden at five time points. From 1,428 eligible patients, 874 parents completed questionnaires at least once during treatment.

RESULTS

At each time point, generic HRQoL was significantly lower than equivalent norm scores for healthy children. HRQoL decreased significantly at the start of treatment, before recovering gradually (but remained below pre-treatment levels). Parents reported that older children worried more about side effects and their appearance, but showed less procedural anxiety than younger children. Concern for appearance was greater among girls than boys. Compared to Regimen B (i.e. additional doxorubicin during induction and additional cyclophosphamide and cytarabine during consolidation chemotherapy), patients receiving Regimen A had fewer problems with pain and nausea. There were no statistically significant differences in HRQoL by number of DI blocks received.

INTERPRETATION

HRQoL is compromised at all stages of treatment, and is partly dependent on age. The findings increase understanding of the impact of therapy on children's HRQoL and parental care-giving burden, and will contribute to the design of future trials.

The Safety of Multiple Flexible Sigmoidoscopies with Mucosal Biopsies in Healthy Clinical Trial Participants

During Phase 1 pharmacokinetic/pharmacodynamics studies, participants may undergo multiple sigmoidoscopies, with a collection of 10-20 biopsies during each procedure. This article characterizes the safety of flexible sigmoidoscopies in clinical trial participants. We determined the number of flexible sigmoidoscopies and rectal biopsies that participants underwent and analyzed the frequency, duration, and severity of flexible sigmoidoscopy-related adverse events (AEs). During the study period, 278 participants underwent 1,004 flexible sigmoidoscopies with the collection of 15,930 rectal biopsies. The average number of procedures per participant was 3.6 (median 3; range 1-25), with an average time interval between procedures of 61.8 days (median 28 days; range 1-1,159). There were no serious AEs. Sixteen AEs were related to flexible sigmoidoscopy and occurred in 16 participants, leading to an overall 1.6% (16/1,004) AE rate per procedure and 0.1% (16/15,930) AE rate per biopsy. Of the 16 AEs, 8 (50%) involved abdominal pain, diarrhea, bleeding, flatulence, and bloating, with an average duration of 4.7 days (median 1 day; range 1-28). Most (14/16) AEs were categorized as Grade 1 (mild), whereas two of the AEs were Grade 2 (moderate). No participant withdrew due to procedure-related AEs. Overall, the number of AEs caused by flexible sigmoidoscopy with multiple biopsies was low and the severity was mild, suggesting that this procedure can be safely integrated into protocols requiring repeated intestinal mucosal sampling.

Abstract 598: Carotid Artery Ultrasound Texture, Cardiovascular Risk Factors, and Subclinical Arterial Disease: The Multi-Ethnic Study of Atherosclerosis (Mesa)

Background: Ultrasound texture “contrast” can be used to characterize the arterial wall non-invasively. Texture contrast provides information about the distribution and gray level differences of the pixels in the arterial wall and may describe early changes related to arterial injury. We determined if ultrasound texture contrast was associated with cardiovascular disease (CVD) risk factors and subclinical arterial disease.

Methods: We evaluated ultrasound images of the distal right common carotid artery from a convenience sample of 151 participants from the first examination of the Multi-Ethnic Study of Atherosclerosis, a population-based cohort of individuals without clinical CVD. Images were digitized, normalized, and standardized to a pixel density of 20/mm. Plaque texture analysis software (LifeQ Medical, Cyprus) used the gray level difference statistics method to determine the contrast of the far wall of the carotid intima-media complex. Multivariable linear regression models (adjusted for age, sex and race/ethnicity) were used to examine relationships between contrast, CVD risk factors (age, BMI, total cholesterol, high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol, triglycerides, hypertension, diabetes mellitus, smoking, glomerular filtration rate, C-reactive protein, interleukin-6, D-dimer, fibrinogen, alcohol consumption, education level, physical activity level, statin use), carotid intima-media thickness (IMT), coronary artery calcium (CAC), and CVD risk score.

Results: The 151 participants were mean (standard deviation) 68.1 (9.2) years old (54% female; 31% Hispanic, 28% Black, 10% Chinese, and 31% White). In models that included age, sex, and race, contrast was associated independently with age (beta [standard error] -0.9 [0.4] per year; p=0.02), HDL-C (0.6 [0.2] per mg/dL; p=0.02), C-reactive protein (-2.3 [0.9] per mg/L; p=0.02), and carotid IMT (-1.3 [0.4] microns; p=0.001). Other CVD risk factors and CAC were not associated independently with contrast.

Conclusions: Lower contrast, an ultrasound texture feature, is associated with increasing age, lower HDL-C, higher CRP, and higher carotid IMT, supporting its potential use for evaluating arterial injury and CVD risk.

Abstract WP126: Transcranial Doppler and Microemboli Detection. Relationships to Symptomatic Status and Histopathology Findings

Introduction: Microemboli, as detected by transcranial Doppler (TCD), are hypothesized to be associated with carotid plaque instability and symptomatic subject status associated with motor, sensory, visual and speech deficits of stroke and transient ischemic attack (TIA). However, the current clinical exam does not assess sequeli of small emboli and probable differences between symptomatic and asymptomatic plaques. The purpose of this study was to determine the relationship between symptomatic status, microemboli presence and histopathology findings.

Methods: TCD examination was performed on 60 study subjects for an hour to assess the presence of microemboli, prior to undergoing clinically indicated carotid endarterectomy. Macroscopic scoring for cholesterol, thrombus, calcium and ulceration were performed with a dissecting microscope. Histopathological examination, with high power magnification on fixed plaque was scored for hemorrhage, hemosiderin, inflammation, percent cholesterol and calcium. Pearson’s chi-squared test was used to assess the frequency of microemboli between symptomatic and asymptomatic subjects. Logistic regression was used to analyze the relationship between operative and histopathology plaque findings and presence of microemboli.

Results: The frequency of microemboli signals, as detected with TCD, was not significantly different between symptomatic and asymptomatic subject groups (p=0.88) nor was there any difference observed in the macroscopic or histopathology scoring of these plaques (p-values all > 0.05). The presence of microemboli was associated with an ulceration score (regardless of symptomatic or asymptomatic status, p=0.034), with a one level increase in ulceration rating associated with an odds ratio of 5.86 (95% [CI] 1.55, 4.34).

Conclusion: These findings suggest that both symptomatic and asymptomatic subjects (with clinical indications for carotid endarterectomy) may have plaque with similar features of instability and ability to create emboli. Thus, identifying new ways to measure plaque instability may provide important information for optimizing treatment to prevent future stroke. It also suggests that present clinical exam does not detect the sequeli of small emboli.

Does clinical trial participation improve outcomes in patients with ovarian cancer?

INTRODUCTION

Treatment on a clinical trial is considered to be beneficial to oncology patients. However, supportive evidence for this is scarce. Trial effect describes the phenomenon of improved health outcomes in patients treated with standard of care (SOC) on trial compared to those receiving SOC outside of a clinical trial. We evaluated trial effect in patients with ovarian cancer treated at our tertiary cancer centre.

METHODS

We performed a retrospective cohort study of patients with ovarian cancer treated at The Christie National Health Service Foundation Trust. Patients treated on one of three first-line clinical trials: (SCOTROC-4, ICON-5, ICON-7) were matched (for age, International Federation of Gynaecology and Obstetrics stage, surgical status and performance status) with individuals receiving the same SOC off trial. Survival was calculated using Kaplan-Meier methodology.

RESULTS

60 patients were evaluated; 30 on trial and 30 on SOC off trial. The median progression-free survival (PFS) was 21.8 months (control group) and 25.9 months (trial group), median overall survival (OS) was 64.3 months (control group) and 68.9 months (trial group). There was no difference in PFS (log-rank test: HR 0.87 (95% CI 0.48 to 1.54), p=0.6) or OS (log-rank test: HR 0.87 (95% CI 0.46 to 1.64), p=0.7) between groups.

CONCLUSIONS

Patient survival was similar regardless if treated on trial or as SOC. Our findings do not support trial effect, at least in a tertiary cancer centre. Clinical trial participation in specialised cancer centres promotes best practice to the benefit of all patients. These findings may impact discussions round consent of patients to trials and organisation of oncology services.

Assessing an isiZulu questionnaire with educators in primary schools in Pietermaritzburg to establish a baseline of knowledge of Autism Spectrum Disorder

Background

Autism Spectrum Disorder (ASD) is a significant childhood disorder and has a growing prevalence rate across the world. It has been identified in children from a wide range of racial groups, ethnicities and socio-economic groups, making it a globally relevant disorder. However, a lack of research on ASD in Africa makes it difficult to determine the prevalence rate, presentation and level of knowledge regarding the disorder locally. Therefore, assessing knowledge of ASD amongst professionals is a useful starting point for research in countries where research on ASD is limited. Educators in particular are a vital resource due to the likelihood of their early identification of developmental delays in children of school going age. Awareness studies reveal that professionals have poor awareness of ASD and therefore what educators in South Africa know about ASD needs to be established.

Methods

This study translated the Knowledge about Childhood Autism among Health Workers (KCAHW) questionnaire that was originally designed by Bakare and colleagues (Clinical Practice and Epidemiology in Mental Health 4:17, 2008). The isiZulu KCAHW questionnaire was then used to investigate the level of knowledge of ASD amongst educators in Edendale, Pietermaritzburg, South Africa. Fifty (50) educators consented to complete the questionnaire and the data was analysed using the statistical programme SPSS.

Results

The results suggested that educators have an adequate baseline knowledge of ASD but their knowledge was found to be lacking in specific detail. The mean total score for the educator sample was 13.08 (out of a possible 19) which suggested that educators in Edendale, Pietermaritzburg knew 68% of the symptoms covered in the questionnaire.

Conclusions

The isiZulu KCAHW questionnaire appears to be a useful measure for use in the South African context. It provided significant information regarding educator knowledge of ASD in Edendale, Pietermaritzburg. However, the analysis also showed that whilst the educators had an adequate general knowledge of ASD, they lacked specific insight into the disorder, particularly with regards to etiology and age of onset. Furthermore, the results showed that there is an opportunity for further research and interventions to develop knowledge of ASD within the local context in South Africa.

Electronic supplementary material

The online version of this article (doi:10.1186/s12887-016-0721-8) contains supplementary material, which is available to authorized users.

Outcomes following femoral lengthening

Aims

Patients undergoing femoral lengthening by external fixation tolerate treatment less well when compared to tibial lengthening. Lengthening of the femur with an intramedullary device may have advantages.

Patients and Methods

We reviewed all cases of simple femoral lengthening performed at our unit from 2009 to 2014. Cases of nonunions, concurrent deformities, congenital limb deficiencies and lengthening with an unstable hip were excluded, leaving 33 cases (in 22 patients; 11 patients had bilateral procedures) for review. Healing index, implant tolerance and complications were compared.

Results

In 20 cases (15 patients) the Precice lengthening nail was used and in 13 cases (seven patients) the LRS external fixator system. The desired length was achieved in all cases in the Precice group and in 12 of 13 cases in the LRS group. The mean healing index was 31.3 days/cm in the Precice and 47.1 days/cm in the LRS group (p < 0.001). This was associated with an earlier ability to bear full weight without aids in the Precice group. There were more complications with LRS lengthening, including pin site infections and regenerate deformity. Implant tolerance and the patients’ perception of the cosmetic result were better with the Precice treatment.

Conclusion

Femoral lengthening with the Precice femoral nail achieved excellent functional results with fewer complications and greater patient satisfaction when compared with the LRS system in our patients. Cite this article: Bone Joint J 2016;98-B:1382–8.

Understanding NIH clinical case definitions for pediatric intrathoracic TB by applying them to a clinical trial

SETTING

Standardized clinical case definitions represent the best option for pediatric tuberculosis (TB) disease diagnosis and classification.

OBJECTIVE

To apply published guidelines for intrathoracic TB classification for use in reporting diagnostic studies with passive case finding to presumed TB patients from International Maternal Pediatric Adolescent AIDS Clinical Trials P1041, a trial of isoniazid prophylaxis in healthy human immunodeficiency virus exposed, bacille Calmette-Guérin vaccinated infants which employed active surveillance to assess a novel application of these guidelines in this setting.

METHODS

P1041 presumed TB patients were retrospectively cross-classified by protocol-defined and National Institutes of Health (NIH) classifications, and agreement was assessed.

RESULTS

Of 219 TB suspects, 166 had signs/symptoms, with 158 considered TB (21 confirmed, 92 probable, 45 possible) and 8 not TB (6 TB unlikely, 2 alternative diagnoses). Weight loss and failure to thrive represented the majority of the observed signs/symptoms. Among those with signs/symptoms, agreement between definitions was poor. Furthermore, 53 TB presumptives were without signs/symptoms, including 33 classified by the P1041 protocol as TB.

CONCLUSION

Poor agreement between P1041 and NIH classifications reflects cases identified through active vs. passive surveillance, the latter reflecting the intended use of NIH definitions. Given the interest in standardized definitions for broader application, future efforts could focus on expanding TB disease classification to presumed TB patients identified through active surveillance.

A Duty To Warn Relatives in Clinical Genetics: Arguably 'Fair just and reasonable' in English Law?

The use of 'next-generation' genetic sequencing technology that allows the sequencing of large parts, or even the entirety, of a patient's genome is advancing rapidly in the UK and around the world. This is set to greatly increase the level of health information that will be of relevance to relatives and the latest medical guidance advises that there is a professional duty to consider warning a patient's relatives of a serious genetic risk in limited circumstances. However, the High Court in ABC v St George's Healthcare NHS Trust [2015] EWHC 1394 (QB), recently found that a legal duty on the part of doctors to warn a patient's daughter of a genetic risk of Huntington's Disease without the patient's consent, was not even 'reasonably arguable' and would not be 'fair, just and reasonable'. This article considers the courts' approach to a duty of care towards 'third parties' in this context and concludes that some form of a duty of care to genetic relatives in clinical genetics is at very least arguably 'fair, just and reasonable'.

Protection of Pea Aphids Associated with Coinfecting Bacterial Symbionts Persists During Superparasitism by a Braconid Wasp

Bacterial endosymbionts that associate facultatively with insect herbivores can influence insect fitness and trophic interactions. The pea aphid, Acyrthosiphon pisum, can be protected from parasitism by the braconid wasp Aphidius ervi when harbouring particular symbiotic bacteria, with specific endosymbiont coinfections providing almost complete protection. However, studies often quantify aphid mummification with no control over parasitoid oviposition per aphid; thus, if mummy production fails or is low, the causes are often unclear. Here, we show that the high level of protection associated with the coinfecting endosymbionts Hamiltonella defensa and X-type is maintained even when pea aphids are superparasitised. This contrasts strongly with the protection provided by H. defensa alone, which has been shown by others to be overcome by superparasitism. By dissecting aphids exposed to two parasitoid attacks, we reveal that A. ervi deposits eggs equally freely in endosymbiont-infected and uninfected nymphs, and lack of mummification in endosymbiont-protected nymphs arises from failure of the wasp eggs to hatch or emerging larvae to develop.