Blood transfusion in the care of patients with visceral leishmaniasis: a review of practices in therapeutic efficacy studies

Blood transfusion remains an important aspect of patient management in visceral leishmaniasis (VL). However, transfusion triggers considered are poorly understood. This review summarises the transfusion practices adopted in VL efficacy studies using the Infectious Diseases Data Observatory VL clinical trials library. Of the 160 studies (1980-2021) indexed in the IDDO VL library, description of blood transfusion was presented in 16 (10.0%) (n=3459 patients) studies. Transfusion was initiated solely based on haemoglobin (Hb) measurement in nine studies, combining Hb measurement with an additional condition (epistaxis/poor health/clinical instability) in three studies and the criteria was not mentioned in four studies. The Hb threshold range for triggering transfusion was 3-8 g/dL. The number of patients receiving transfusion was explicitly reported in 10 studies (2421 patients enrolled, 217 underwent transfusion). The median proportion of patients who received transfusion in a study was 8.0% (Interquartile range: 4.7% to 47.2%; range: 0-100%; n=10 studies). Of the 217 patients requiring transfusion, 58 occurred before VL treatment initiation, 46 during the treatment/follow-up phase and the time was not mentioned in 113. This review describes the variation in clinical practice and is an important initial step in policy/guideline development, where both the patient's Hb concentration and clinical status must be considered.

Post-kala-azar dermal leishmaniasis (PKDL) drug efficacy study landscape: A systematic scoping review of clinical trials and observational studies to assess the feasibility of establishing an individual participant-level data (IPD) platform

BACKGROUND

Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis which can occur after successful treatment of visceral leishmaniasis (VL) and is a public health problem in VL endemic areas. We conducted a systematic scoping review to assess the characteristics of published PKDL clinical studies, understand the scope of research and explore the feasibility and value of developing a PKDL individual patient data (IPD) platform.

METHODS

A systematic review of published literature was conducted to identify PKDL clinical studies by searching the following databases: PubMed, Scopus, Ovid Embase, Web of Science Core Collection, WHO Global Index Medicus, PASCAL, Clinicaltrials.gov, Ovid Global Health, Cochrane Database and CENTRAL, and the WHO International Clinical Trials Registry Platform. Only prospective studies in humans with PKDL diagnosis, treatment, and follow-up measurements between January 1973 and March 2023 were included. Extracted data includes variables on patient characteristics, treatment regimens, diagnostic methods, geographical locations, efficacy endpoints, adverse events and statistical methodology.

RESULTS

A total of 3,418 records were screened, of which 56 unique studies (n = 2,486 patients) were included in this review. Out of the 56 studies, 36 (64.3%) were from India (1983-2022), 12 (21.4%) from Sudan (1992-2021), 6 (10.7%) were from Bangladesh (1991-2019), and 2 (3.6%) from Nepal (2001-2007). Five (8.9%) studies were published between 1981-1990 (n = 193 patients), 10 (17.9%) between 1991-2000 (n = 230 patients), 10 (17.9%) between 2001-2010 (n = 198 patients), and 31 (55.4%) from 2011 onwards (n = 1,865 patients). Eight (14.3%) were randomised clinical trials, and 48 (85.7%) were non-randomised studies. The median post-treatment follow-up duration was 365 days (range: 90-540 days) in 8 RCTs and 360 days (range: 28-2,373 days) in 48 non-randomised studies. Disease diagnosis was based on clinical criterion in 3 (5.4%) studies, a mixture of clinical and parasitological methods in 47 (83.9%) and was unclear in 6 (10.7%) studies. Major drugs used for treatment were miltefosine (n = 636 patients), liposomal amphotericin B (L-AmB) (n = 508 patients), and antinomy regimens (n = 454 patients). Ten other drug regimens were tested in 270 patients with less than 60 patients per regimen.

CONCLUSIONS

Our review identified studies with very limited sample size for the three major drugs (miltefosine, L-AmB, and pentavalent antimony), while the number of patients combined across studies suggest that the IPD platform would be valuable. With the support of relevant stakeholders, the global PKDL community and sufficient financing, a PKDL IPD platform can be realised. This will allow for exploration of different aspects of treatment safety and efficacy, which can potentially guide future healthcare decisions and clinical practices.

Haematological dynamics following treatment of visceral leishmaniasis: a protocol for systematic review and individual participant data (IPD) meta-analysis

INTRODUCTION

Visceral leishmaniasis (VL) is a parasitic disease with an estimated 30 000 new cases occurring annually. Despite anaemia being a common haematological manifestation of VL, the evolution of different haematological characteristics following treatment remains poorly understood. An individual participant data meta-analysis (IPD-MA) is planned to characterise the haematological dynamics in patients with VL.

METHODS AND ANALYSIS

The Infectious Diseases Data Observatory (IDDO) VL data platform is a global repository of IPD from therapeutic studies identified through a systematic search of published literature (PROSPERO registration: CRD42021284622). The platform currently holds datasets from clinical trials standardised to a common data format. Corresponding authors and principal investigators of the studies indexed in the IDDO VL data platform meeting the eligibility criteria for inclusion were invited to be part of the collaborative IPD-MA. Mixed-effects multivariable regression models will be constructed to identify determinants of haematological parameters by taking clustering within study sites into account.

ETHICS AND DISSEMINATION

This IPD-MA meets the criteria for waiver of ethical review as defined by the Oxford Tropical Research Ethics Committee (OxTREC) granted to IDDO, as the research consists of secondary analysis of existing anonymised data (exempt granted on 29 March 2023, OxTREC REF: IDDO). Ethics approval was granted by the ICMR-Rajendra Memorial Research Institute of Medical Sciences ethics committee (letter no.: RMRI/EC/30/2022) on 4 July 2022. The results of this analysis will be disseminated at conferences, the IDDO website and peer-reviewed publications in open-access journals. The findings of this research will be critically important for control programmes at regional and global levels, policymakers and groups developing new VL treatments.

PROSPERO REGISTRATION NUMBER

CRD42021284622.

Characterization and Investigation of Novel Benzodioxol Derivatives as Antidiabetic Agents: An In Vitro and In Vivo Study in an Animal Model

In this study, we synthesized benzodioxol carboxamide derivatives and investigated their antidiabetic potential. The synthesized compounds (Ia-Ic and IIa-IId) underwent characterization via HRMS, 1H-, 13CAPT-NMR, and MicroED. Their efficacy against α-amylase was assessed in vitro, while MTS assays were employed to gauge cytotoxicity across cancer and normal cell lines. Additionally, the antidiabetic impact of compound IIc was evaluated in vivo using a streptozotocin-induced diabetic mice model. Notably, IIa and IIc displayed potent α-amylase inhibition (IC50 values of 0.85 and 0.68 µM, respectively) while exhibiting a negligible effect on the Hek293t normal cell line (IC50 > 150 µM), suggesting their safety. Compound IId demonstrated significant activity against four cancer cell lines (26-65 µM). In vivo experiments revealed that five doses of IIc substantially reduced mice blood glucose levels from 252.2 mg/dL to 173.8 mg/dL in contrast to the control group. The compelling in vitro anticancer efficacy of IIc and its safety for normal cells underscores the need for further in vivo assessment of this promising compound. This research highlights the potential of benzodioxol derivatives as candidates for the future development of synthetic antidiabetic drugs.

Implementing primary eye care in private practises in Malaysia: the challenges faced by optometrists

OBJECTIVE

In Malaysia, optometrists' role in the private sector is limited compared to their counterparts elsewhere. Primary eye care (PEC) is still not widely offered in private practises despite its demand to reduce the public's eye morbidity. This study aims to explore the challenges perceived by the private sector optometrists in implementing PEC in Malaysia.

MATERIALS AND METHODS

In-depth interview using semistructured open-ended questions were designed to explore the challenges of implementing PEC. Fifteen private optometrists across Malaysian were interviewed via purposive sampling until the data were saturated. The interviews were audio-recorded, transcribed and analysed.

RESULTS

Four major themes emerged: working environment, support and recognition, self-sufficiency and customer influence. The first major theme identified a lack of time and equipment in the workplace as a barrier to PEC implementation. The second major theme acknowledges the lack of support and recognition for PEC practise from financial bodies, the government, Malaysian Optical Council (MOC) and other eye professionals. Meanwhile, some practising optometrists faced significant challenges due to their lack of self-sufficiency regarding skills, knowledge and confidence. The final major theme, customer influence, reflects the customer's role in shaping eye care delivery through their perception and acceptance of PEC.

CONCLUSION

Each of the issues identified played a significant impact in impeding PEC implementation in Malaysia. This study is the first step toward developing tailored interventions to improve eye care delivery in Malaysia.

Changes of aortic hemodynamics after aortic valve replacement-A four dimensional flow cardiovascular magnetic resonance follow up study

Objectives

Non-invasive assessment of aortic hemodynamics using four dimensional (4D) flow magnetic resonance imaging (MRI) provides new information on blood flow patterns and wall shear stress (WSS). Aortic valve stenosis (AS) and/or bicuspid aortic valves (BAV) are associated with altered aortic flow patterns and elevated WSS. Aim of this study was to investigate changes in aortic hemodynamics over time in patients with AS and/or BAV with or without aortic valve replacement.

Methods

We rescheduled 20 patients for a second 4D flow MRI examination, whose first examination was at least 3 years prior. A total of 7 patients received an aortic valve replacement between baseline and follow up examination (=operated group = OP group). Aortic flow patterns (helicity/vorticity) were assessed using a semi-quantitative grading approach from 0 to 3, flow volumes were evaluated in 9 planes, WSS in 18 and peak velocity in 3 areas.

Results

While most patients had vortical and/or helical flow formations within the aorta, there was no significant change over time. Ascending aortic forward flow volumes were significantly lower in the OP group than in the NOP group at baseline (NOP 69.3 mL ± 14.2 mL vs. OP 55.3 mL ± 1.9 mL p = 0.029). WSS in the outer ascending aorta was significantly higher in the OP group than in the NOP group at baseline (NOP 0.6 ± 0.2 N/m² vs. OP 0.8 ± 0.2 N/m², p = 0.008). Peak velocity decreased from baseline to follow up in the aortic arch only in the OP group (1.6 ± 0.6 m/s vs. 1.2 ± 0.3 m/s, p = 0.018).

Conclusion

Aortic valve replacement influences aortic hemodynamics. The parameters improve after surgery.

The Burden of Unsafe Abortion Six Years before the COVID-19 Era in a Nigerian Tertiary Hospital: An Analytical Retrospective Study

BACKGROUND

Unsafe abortion remains a leading cause of maternal mortality and morbidity, especially in developing countries with restrictive abortion laws. Disease containment measures during the COVID-19 pandemic have reduced access to contraception and safe abortion care, potentially increasing rates of unintended pregnancies and unsafe abortion.

OBJECTIVE

To evaluate the morbidity and mortality burden of unsafe abortion before the COVID-19 pandemic.

METHODS

A six-year analytical retrospective study of unsafe abortion at the Federal Medical Centre, Lokoja, Nigeria. All case records of unsafe abortion managed within the study period were retrieved, and relevant data extracted using a purpose-designed proforma. Data obtained was analysed using the IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, N.Y., USA). Associations between categorical independent and outcome variables were assessed using the Chi square test at 95% confidence level. A p-value of <0.05 was considered statistically significant.

RESULTS

The prevalence of unsafe abortion was 8.6 per 1,000 deliveries. More than one-half (37, 52.9%) were medical abortions using misoprostol tablets. The mean age of the women was 23.15+ 3.96 years, and most of them were single (49, 70%), with primary/ secondary education (42, 60%), and of low socioeconomic status (67, 95.7%). Nearly one-half (33, 47.1%) had either never used any modern contraceptive (9, 12.9%) or only used emergency contraception (24, 34.3%). The predominant complications of unsafe abortion included retained product of conception (69, 98.6%), haemorrhagic shock (22,31.4%), and sepsis (19, 27.1%). There were two maternal deaths, giving a case fatality rate of 2.9%.

CONCLUSION

Unsafe abortion remains a significant cause of maternal mortality and morbidity in our setting. Improving access to effective modern contraceptives and liberalizing our abortion laws may reduce maternal morbidity and mortality from unsafe abortion.

SPLIT-DOSING OF COVID-19 VACCINES IS SAFE AND PROVIDES NON-INFERIOR ANTIBODY RESPONSIVENESS TO CONVENTIONAL VACCINE DOSING

Introduction

Vaccination has proven efficacy against COVID-19, yet allergic or adverse reactions have resulted in vaccine hesitancy nationwide. Graded or split dosing of vaccines is a relatively common allergy practice that is understudied for efficacy, particularly for COVID-19. We aimed to compare antibody responsiveness and safety of split versus conventional dosing of COVID-19 vaccines.

Methods

A total of 30 adult subjects received conventional/full (N=15) or 2-step split (N=15) dosing of a COVID-19 vaccine. Pre- and 6-week post-serum antibody levels were determined by multiplex, microsphere-based IgG quantitative assays for SARS-CoV-2 antigens including Receptor Binding Domain (RBD), Spike protein 1 (S1), and nucleocapsid (natural infection marker). The majority received Pfizer booster (73%). Any adverse reactions were recorded.

Results

Post-vaccine RBD and S1 (but not nucleocapsid) antibody expression as measured by mean fluorescent intensity increased in conventional (p=0.0006 and p=0.0054, respectively) and split (p<0.0001 and p=0.0002) dosed subjects. Findings persisted after removal of 3 subjects with evidence of new natural infection as determined by nucleocapsid antibody positive conversion. There was no difference in mean fold-change (post/pre) antibody expression for RBD (conventional: +5.3 vs. split: +26.7, p=0.22) and S1 (+11.7 vs. +27.3, p=0.26). Split dosing was overall well-tolerated with minimal adverse reactions.

Conclusion

Split dosing is safe and non-inferior in efficacy as evidenced by antibody responsiveness when compared to conventional dosing of the COVID-19 vaccines. This approach could be applied to persons with vaccine hesitancy of various reasons including allergic disease(s) to provide immunization against this pandemic and be modeled in future pandemic scenarios.

LEISH2b - A phase 2b study to assess the safety, efficacy, and immunogenicity of the Leishmania vaccine ChAd63-KH in post-kala azar dermal leishmaniasis

Background: The leishmaniases are neglected tropical diseases caused by various Leishmania parasite species transmitted by sand flies. They comprise a number of systemic and cutaneous syndromes including kala-azar (visceral leishmaniasis, VL), cutaneous leishmaniasis (CL), and post-kala-azar dermal leishmaniasis (PKDL). The leishmaniases cause significant mortality (estimated 20 - 50,000 deaths annually), morbidity, psychological sequelae, and healthcare and societal costs. Treatment modalities remain difficult. E.g., East African PKDL requires 20 days of intravenous therapy, and frequently relapsing VL is seen in the setting of HIV and immunodeficiency. We developed a new therapeutic vaccine, ChAd63-KH for VL / CL / PKDL and showed it to be safe and immunogenic in a phase 1 trial in the UK, and in a phase 2a trial in PKDL patients in Sudan.    Methods: This is a randomised double-blind placebo-controlled phase 2b trial to assess the therapeutic efficacy and safety of ChAd63-KH in patients with persistent PKDL in Sudan. 100 participants will be randomly assigned 1:1 to receive placebo or ChAd63-KH (7.5 x10 10vp i.m.) at a single time point. Follow up is for 120 days after dosing and we will compare the clinical evolution of PKDL, as well as the humoral and cellular immune responses between the two arms. Discussion: Successful development of a therapeutic vaccine for leishmaniasis would have wide-ranging direct and indirect healthcare benefits that could be realized rapidly. For PKDL patients, an effective therapeutic vaccination used alone   would have very significant clinical value, reducing the need for extensive hospitalization and chemotherapy. Combining vaccine with drug (immuno-chemotherapy) might significantly increase the effective life of new drugs, with lower dose / abbreviated regimens helping to limit the emergence of drug resistance. If therapeutic benefit of ChAd63-KH can be shown in PKDL further evaluation of the vaccine in other forms of leishmaniasis should be considered. Clinicaltrials.gov registration: NCT03969134.

Barriers and solutions to effective mentorship in health research and training institutions in Nigeria: Mentors, mentees, and organizational perspectives

Aims and Background

Mentoring relationships and programs have become a subject of global interest and their relevance is high in the ever-evolving health system. In Nigeria, informal system of mentoring is largely practiced. To be able to institutionalize mentoring program, there is need to explore the various challenges of mentoring process and suggest potential approaches for effective mentor-mentee relationship in health research institutions in Nigeria.

Subjects and Methods

The study was designed to explore the barriers and solutions to mentoring process from the perspectives of the mentor, mentee, and organization in health research and training institutions in Nigeria. A cross-sectional descriptive design was employed and the study was conducted among 21 health researchers drawn from 24 health research institutions across the 6 regions of Nigeria. The nominal group technique was adopted in the data collection process.

Results

The most frequently reported mentor challenges were "lack of understanding of mentorship process" (84.2%) and "lack of capacity for mentoring" (78.9%), while those of mentee were "mentor preference" (73.7%) and "lack of freedom of expression" (47.4%). "Culture of selfishness/individualism" (84.2%) and "lack of formal relationship" (63.2%) were the most mentioned systemic challenges. Training on mentoring process and relationship was mentioned as the most frequent approach to overcoming challenges for the three perspectives.

Conclusion

Significant mentorship challenges exist in the Nigerian health, academic and research institution. Systematic approaches to finding and implementing the appropriate solutions are needed to circumvent these bottlenecks.

Scoping review of evidence for managing postnatal hypoglycaemia

OBJECTIVES

To identify what is known empirically about the screening, treatment and harm of exposure to neonatal hypoglycaemia.

DESIGN

Scoping review that applied a preregistered protocol based on established frameworks.

DATA SOURCES

Medline and Embase, up to 12 May 2020.

STUDY SELECTION

Comparative and case-series studies, as well as guidelines, published in English or French, on the topic of immediate inpatient postnatal glucose screening in newborns.

DATA GATHERING

Article selection and characterisation were performed in duplicate using predefined data extraction forms specific to primary studies and guidelines.

RESULTS

12 guidelines and 74 primary studies were included. A neurodevelopmental outcome was primary in 32 studies: 30 observational studies followed up posthypoglycaemic, and the 2 intervention studies included 1 randomised controlled trial (RCT) about treatment thresholds. Three other RCTs assessed dextrose gel (two) and oral sucrose (one). 12 of 30 studies that evaluated non-neurodevelopmental primary outcomes were intervention studies. Only one cohort study compared outcomes in screened vs unscreened newborns. The guidelines did not arrive at a consensus definition of postnatal hypoglycaemic, and addressed potential harms of screening more often than primary studies.

CONCLUSIONS

The primary literature that informs hypoglycaemia screening is a series of studies that relate neurodevelopmental outcomes to postnatal hypoglycaemia. Further research is needed to better define an optimal threshold for hypoglycaemia that warrants intervention, based on long-term neurodevelopmental outcomes and a better delineation of potential screening harms.

1619 Evaluation of Referrals to The Maxillofacial on Call Service Over A Seven-Year Period in A Busy Tertiary Trauma Centre and Teaching Hospital

Aim

University Hospitals Plymouth is the only designated adult major trauma centre for the south west of England, also serving secondary care to a catchment of 450,000 patients. The on call maxillofacial service receives numerous referrals daily, which began to be recorded in a trauma database populated on a daily basis. Our study aims to evaluate these referrals with a view to classifying them and identifying service provision needs; improve support and training of the junior team; and understand patient demographics.

Method

There were 3717 referrals recorded between 7th January 2014 and 7th January 2021. All referrals were taken into account; from the emergency department; from primary care providers; from other hospital departments; and directly from patients themselves. Both adult and paediatric cases were included.

Results

Of these 3717 referrals, 2122 (57%) were pertaining to male patients. Adult patients accounted for 85% of the referrals and 1200 (32%) of all patients were referred for soft tissue injury. Around 20% of patients attended with facial swellings. 1090 (29%) patients were able to have treatment under a local anaesthetic, whilst 959 (26%) required admission. Most common fractures were nasal (8%), followed by orbital wall (6%) and mandibular fractures (4%).

Conclusions

Evaluation of the database shows a slight prevalence of male attenders, particularly in cases involving trauma. Management of soft tissue injuries under local anaesthetic is an important topic during the induction of new junior trainees to the department, in accordance with the expected service provision. Furthermore, the large sample has allowed for epidemiologic analysis and interventions.

Characterizing the non-linear pharmacokinetics of miltefosine in paediatric visceral leishmaniasis patients from Eastern Africa

Background

Conventional miltefosine dosing (2.5 mg/kg/day) for treatment of visceral leishmaniasis (VL) is less effective in children than in adults. A higher allometric dose (median 3.2 mg/kg/day) was therefore investigated in paediatric VL patients in Eastern Africa. Results of this trial showed an unforeseen, lower than dose-proportional increase in exposure_. Therefore, we performed a pooled model-based analysis of the paediatric data available from both dosing regimens to characterize observed non-linearities in miltefosine pharmacokinetics (PK).

Methods

Fifty-one children with VL were included in this analysis, treated with either a conventional (n = 21) or allometric (n = 30) miltefosine dosing regimen. PK data were analysed using non-linear mixed-effects modelling.

Results

A two-compartment model following first-order absorption and linear elimination, with two separate effects on relative oral bioavailability, was found to fit these data best. A 69% lower bioavailability at treatment start was estimated, presumably due to initial malnourishment and malabsorption. Stagnation in miltefosine accumulation in plasma, hampering increased drug exposure, was related to the increase in cumulative dose (mg/kg/day). However, the allometric regimen increased exposure 1.7-fold in the first treatment week and reduced the time to reach the PK target by 17.4%.

Conclusions

Miltefosine PK in children suffering from VL are characterized by dose-dependent non-linearities that obstruct the initially expected exposure levels. Bioavailability appeared to be affected by the cumulative dose, possibly as a consequence of impaired absorption. Despite this, allometric dosing led to a faster target achievement and increased exposure compared with conventional dosing.

Platelet Indices and Erythrocyte Parameters in Healthy Police Dogs in Khartoum State – Sudan

Normal levels of platelets and erythrocytes parameters and the effect of breed and sex on them in healthy police dogs were determined. Forty-six dogs were used; 20 Labrador Retriever and 26 German Shepherd dogs comprising 21 males and 25 females, 20-83 months old. Five ml blood samples were collected from the cephalic vein; and analyzed using BK6100 Auto Hematology Analyzer. German Shepherd dogs showed significantly (p≤0.05) higher values than Labrador Retriever dogs for Mean platelet volume (MPV) (10.43±0.71vs. 9.9±0.73 FL), Red blood cells count (RBCs) (6.75±0.26 vs. 6.51±0.27 x1012 /L), and Hemoglobin concentration (HGB) (180.81±9.53vs.172.4±11.98 g/L), respectively. Highly positive significant correlations (p≤0.01) were found between Platelet count (PLT) and Plateletcrit (PCT) in males, females, and all dogs, and between MPV and Platelets distribution width (PDW) in all dogs. A highly positive significant correlation (p≤0.01) was found between MPV and PCT in all dogs. A highly negative significant correlation (p≤0.01) was found between PDW and RBCs and Red cell blood distribution width- index (RDW-CV) in males and all dogs. Also, a highly positive significant (p≤0.01) correlation was found between PDW and Mean corpuscular volume (MCV) in all dogs. A highly significant negative correlation (p≤0.01) was found between MPV and RBCs in males. A highly negative significant correlation (p≤0.01) was found between MPV and RDW (CV) in males. However, highly positive significant correlations (p≤0.01) were found between MPV and Hematocrit (HCT) in females. The breed may influence platelets and erythrocyte parameters and this should be considered in clinical interpretations.

Methodology for Calculating Minor Radioactive Releases From VVER 1000 Using TRACE Code

After the Fukushima DAIICHI accident, new safety requirements were imposed in order to reduce risk of severe accident. One of the principles that have been adopted is the introduction of emergency action levels resulting from the expected consequences. They cover a wide range of component and system malfunctions resulting in emergency, incident, and/or accident conditions. To evaluate those emergency action levels, thermal hydraulic (TH) analyses simulating these malfunction/incident/accident conditions are required. This paper describes the simulation of a real operational incident scenario using a standard thermal hydraulic model of the power plant in the TRACE code that was originally intended for simulation of design basis accidents such as large break coolant accident or loss of flow accident. Special attention was given to the methodology, addressing a long duration of an incident with corrective actions of the operators, and to computational issues leading to model modifications caused by a long duration of the incident along with the necessary conservatisms in the estimated results of the simulated radioactivity release.

Risks and Challenges of Arboviral Diseases in Sudan: The Urgent Need for Actions

The risk of emergence and/or re-emergence of arthropod-borne viral (arboviral) infections is rapidly growing worldwide, particularly in Africa. The burden of arboviral infections and diseases is not well scrutinized because of the inefficient surveillance systems in endemic countries. Furthermore, the health systems are fully occupied by the burden of other co-existing febrile illnesses, especially malaria. In this review we summarize the epidemiology and risk factors associated with the major human arboviral diseases and highlight the gap in knowledge, research, and control in Sudan. Published data in English up to March 2019 were reviewed and are discussed to identify the risks and challenges for the control of arboviruses in the country. In addition, the lack of suitable diagnostic tools such as viral genome sequencing, and the urgent need for establishing a genomic database of the circulating viruses and potential sources of entry are discussed. Moreover, the research and healthcare gaps and global health threats are analyzed, and suggestions for developing strategic health policy for the prevention and control of arboviruses with focus on building the local diagnostic and research capacity and establishing an early warning surveillance system for the early detection and containment of arboviral epidemics are offered.

OC 8489 CLINICAL DEVELOPMENT OF A THERAPEUTIC VACCINE FOR PREVENTION OF POST KALA AZAR DERMAL LEISHMANIASIS

Background

The leishmaniases represent a complex of human diseases, with 350 million people at risk of infection worldwide. Although the potential benefits of vaccination have been well-recognised, no human vaccine is registered. Post-kala azar dermal leishmaniasis (PKDL) is a chronic skin disease often following treatment for visceral leishmaniasis (VL). In addition to affecting quality of life, evidence suggests that PKDL patients may also act as reservoirs for VL transmission. Hence, PKDL vaccines may have a significant impact on disease burden. We recently developed a third-generation adenoviral vaccine for leishmaniasis (ChAd63-KH) that has been evaluated for safety and immunogenicity in healthy volunteers (Osman et al,2017). ChAd63-KH is currently being evaluated for safety as a therapeutic in Sudanese PKDL patients, with a phase IIb RCT starting in late 2018. With EDCTP funding, we are initiating a new phase IIa/IIb study (PREV_PKDL) to’determine whether ChAd63-KH can prevent PKDL development.

Methods

In PREV_PKDL, we will conduct an open-label phase IIa safety study, followed by a placebo blinded, phase IIb RCT. Safety and clinical response represent primary outcome measures, and immunogenicity is a secondary outcome measure. In addition, working across the four countries of Leishmaniasis East Africa Platform (LEAP), we will use deep phenotyping methods to study the immune status of patients before and after treatment for VL to understand why PKDL development is limited to specific geographic regions. This work, and other research in the region, will be supported by the creation of a new flow cytometry ‘centre of excellence’ within LEAP.

Results

An update on the progress of our current therapeutic trial in PKDL patients will be provided.

Conclusion

PREV_PKDL represents an important step in the clinical development of ChAd63-KH and will help develop capacity to support future vaccine and drug trials for leishmaniasis in the East Africa Region.

Typhoid ileal perforation in a semi-urban tertiary health institution in north-eastern Nigeria

Introduction: Typhoid ileal perforation is a very serious complication of typhoid fever and remains a significant surgical problem in developing countries like Nigeria, where it is associated with higher mortality and morbidity, due to lack of adequate clean drinking water, poor sanitation and lack of access to health facilities in remote areas and delays in hospital presentation.Materials and methods: This was a retrospective study; all patients treated for typhoid ileal perforation at the centre in the period from January to December 2016 were included.Results: There were 22 (59.5%) males and 15 (40.5%) females, with a male to female ratio of 1.5: 1. The ages ranged from 5 to 49 years with mean of 16.5± 9.2 years. The month of October recorded the highest cases of typhoid ileal perforation. Abdominal pain, anorexia, fever and abdominal swelling were the most common symptoms reported by the subjects. The number of ileal perforations was from 1 to 7 with mean of 2.0 ± 1.3; however, the majority had a single perforation. In addition, excision and simple closure was the most common surgery performed in these cases. Operation site infection was the most common complication in this study. Furthermore, the majority of cases were successfully discharged while eight deaths were recorded.Conclusion: Typhoid ileal perforation was most common among males; abdominal pain, swelling and fever were common findings; single site perforation was the most common intra-operative findings and excision and simple closure was the most common operative procedure. Therefore early presentation, adequate resuscitation and lower number of ileal perforations are associated with better prognosis.

Assessment of biochemical liver function tests in relation to age among steady state sickle cell anemia patients

BACKGROUND AND OBJECTIVE

Multiorgan failure including liver dysfunction is a common finding in sickle cell anemia (SCA) patients, the cause of which is multifactorial with advancing age said to be a major determinant. There is a paucity of data on liver function among SCA patients in relation to age in northern Nigerian hospitals, including Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. This study was to assess the biochemical liver function tests (LFTs) as they relate to age among SCA patients in steady state, with a view to improving the overall monitoring of these patients.

SUBJECTS AND METHODS

This study was carried out in ABUTH, Zaria, Northern Nigeria. LFTs were carried out in 100 SCA and 100 apparently healthy participants (controls). The SCA group was made up of fifty adults and fifty children diagnosed of SCA, whereas the control group was made up of fifty adults and fifty children who were apparently healthy and had hemoglobin AA. Paired two-tailed Student's t-test for matched samples and Pearson's linear correlation statistical methods were employed for the data analysis using Microsoft Office Excel 2007. A P ≤ 0.05 was considered as statistically significant.

RESULTS

The serum concentrations of total bilirubin (TB), alanine transaminase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and AST/ALT ratio were significantly higher in SCA patients compared to the controls (P = 0.001, P = 0.001, P = 0.05, P = 0.05 and P = 0.001, respectively). Serum total protein (TP) and ALB were significantly lower (P = 0.01 and P < 0.05, respectively) in SCA patients compared with the controls. The levels of TB, ALT, AST, ALP, and AST/ALT were significantly lower in SCA adults compared to SCA children, whereas TP and ALB were higher in SCA adults compared to the SCA children. There were significant negative correlations between age and each of TB, ALT, AST, ALP, and AST/ALT, and significant positive correlations between age and each of TP and ALB in SCA patients.

CONCLUSION

There are mild LFTs derangements in SCA patients even in steady state with the extent of the abnormalities decreasing with advancing age of the patients.

The Leishmaniasis East Africa Platform (LEAP): strengthening clinical trial capacity in resource-limited countries to deliver new treatments for visceral leishmaniasis

Visceral leishmaniasis is a neglected tropical disease endemic in East Africa where improved patient-adapted treatments are needed. The Leishmaniasis East Africa Platform (LEAP) was created in 2003 to strengthen clinical research capacity, serve as a base for training, and evaluate and facilitate implementation of new treatments. Major infrastructure upgrades and personnel training have been carried out. A short course of Sodium Stibogluconate and Paramomycin (SSG&PM) was evaluated and is now first-line treatment in the region; alternative treatments have also been assessed. LEAP can serve as a successful model of collaboration between different partners and countries when conducting clinical research in endemic countries to international standards.

Sodium stibogluconate (SSG) & paromomycin combination compared to SSG for visceral leishmaniasis in East Africa: a randomised controlled trial

Background

Alternative treatments for visceral leishmaniasis (VL) are required in East Africa. Paromomycin sulphate (PM) has been shown to be efficacious for VL treatment in India.

Methods

A multi-centre randomized-controlled trial (RCT) to compare efficacy and safety of PM (20 mg/kg/day for 21 days) and PM plus sodium stibogluconate (SSG) combination (PM, 15 mg/kg/day and SSG, 20 mg/kg/day for 17 days) with SSG (20 mg/kg/day for 30 days) for treatment of VL in East Africa. Patients aged 4–60 years with parasitologically confirmed VL were enrolled, excluding patients with contraindications. Primary and secondary efficacy outcomes were parasite clearance at 6-months follow-up and end of treatment, respectively. Safety was assessed mainly using adverse event (AE) data.

Findings

The PM versus SSG comparison enrolled 205 patients per arm with primary efficacy data available for 198 and 200 patients respectively. The SSG & PM versus SSG comparison enrolled 381 and 386 patients per arm respectively, with primary efficacy data available for 359 patients per arm. In Intention-to-Treat complete-case analyses, the efficacy of PM was significantly lower than SSG (84.3% versus 94.1%, difference = 9.7%, 95% confidence interval, CI: 3.6 to 15.7%, p = 0.002). The efficacy of SSG & PM was comparable to SSG (91.4% versus 93.9%, difference = 2.5%, 95% CI: −1.3 to 6.3%, p = 0.198). End of treatment efficacy results were very similar. There were no apparent differences in the safety profile of the three treatment regimens.

Conclusion

The 17 day SSG & PM combination treatment had a good safety profile and was similar in efficacy to the standard 30 day SSG treatment, suggesting suitability for VL treatment in East Africa.

Clinical Trials Registration

www.clinicaltrials.govNCT00255567

Visceral leishmaniasis (VL) is a parasitic disease with about 500,000 new cases each year and is fatal if untreated. The current standard therapy involves long courses, has toxicity and there is evidence of increasing resistance. New and better treatment options are urgently needed. Recently, the antibiotic paromomycin (PM) was tested and registered in India to treat this disease, but the same dose of PM monotherapy evaluated and registered in India was not efficacious in Sudan. This article reports the results of a clinical trial to test the effectiveness of injectable PM either alone (in a higher dose) or in combination with sodium stibogluconate (SSG) against the standard SSG monotherapy treatment in four East African countries—Sudan, Kenya, Ethiopia and Uganda. The study showed that the combination of SSG &PM was as efficacious and safe as the standard SSG treatment, with the advantages of being cheaper and requiring only 17 days rather than 30 days of treatment. In March 2010, a WHO Expert Committee recommended the use of the SSG & PM combination as a first line treatment for VL in East Africa.

Spectrofluorimetric assay method for glutathione and glutathione transferase using monobromobimane

The primary role of glutathione transferase is to defend an organism from toxicities through catalyzing the reaction of glutathione (GSH) with potentially toxic compounds or metabolites to their chemically and biologically inert conjugates. The objective of the study was to develop a simple and sensitive spectrofluorimetric assay method for glutathione transferase using monobromobimane (MBB), a non fluorescent compound with electrophilic site. MBB slowly reacted with glutathione to form fluorescent glutathione conjugate and that the reaction was catalysed by glutathione transferase. Both non-enzymatic and enzymatic reaction products of MBB, in presence of GSH in phosphate buffer (pH 6.5), were measured by following increase of fluorescence at wavelength of 475nm. For validation of the assay method, the kinetic parameters such as the apparent Michaelis-Mente constants and maximum rates of conjugate formation as well as the specific activity of rat hepatic glutathione transferase were determined. The method was found to be sensitive, thus, applied to measure glutathione contents of crude preparation of rat hepatic cytosol fraction.

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.