Relationship between depression and sex steroid hormone among women with epilepsy

Introduction

Sex steroid hormones are emerging significant biomarkers of depression among Women with Epilepsy (WWE) with promising prognostic potential and therapeutic end point. Therefore, the study is aimed at exploring the association between sex steroids hormones, Anti-seizure Medication (ASM) and depression among WWE.

Methodology

A baseline questionnaire was used to obtain socio-demographics and clinical characteristic from one hundred and twelve (112) WWE and 50 age matched healthy control. The diagnosis of epilepsy and Electroencephalography (EEG) description was based on 2017 International League Against Epilepsy (ILAE) criteria. Blood samples were collected from cases and control during Luteal Phase (LP) and Follicular Phase (FP). The Zung Self-Rating Depression Scale (ZSRDS) was used to assess depression.

Result

The prevalence of depression among WWE is 18.8%, with a significant difference between the level of formal education (p0.000), age (p0.000), and mean ZSRDS (p0.000) among cases and control. There is a statistical difference in hormonal levels between cases and control with regards to higher testosterone [3.28 ± 9.99 vs. 0.31 ± 0.30; p0.037], lower FP prolactin [16.37 ± 20.14 vs. 17.20 ± 7.44; p0.778], and lower LP prolactin [15.74 ± 18.22 vs. 17.67 ± 7.27; p0.473]. Testosterone (p0.024), FP Follicle Stimulating Hormone (FSH) (p0.009), FP Estradiol (p0.006), LP FSH (p0.031), LP Progesterone (p0.023), and LP Prolactin (p0.000) were associated with depression. However, only prolactin (p0.042) and testosterone (p0.000) predicts depression among WWE.

Conclusion

There was higher mean depression score, lower prolactin and higher testosterone level among cases compared to control. Furthermore, there was lower prolactin and higher testosterone level in Carbamazepine (CBZ) group compared to Levetiracetam (LEV) groups.

Predictors and associated factors with adverse drug reaction in people with epilepsy

OBJECTIVES

There is a need for early identification and intervention of Adverse Drug Reaction (ADR) to alleviate the unacceptably growing burden, morbidity, and mortality associated with People With Epilepsy (PWE). This study is aimed at identifying associated factors and predictors of ADR among PWE.

METHODS

It is an interviewer-administered questionnaire-based study consisting of 940 consenting participants aged 16 years and above attending epilepsy clinics for 5 years with diagnosis confirmed by International League against Epilepsy (ILAE) criteria and supported by Electroencephalography (EEG). Twenty-one-item Liverpool Adverse Effect Profile (LAEP) and 8-item Morinsky Medication Adherence Scale (MMAS) were used to assess ADR and adherence respectively.

RESULTS

The highest reported ADR in PWE were nervousness (34.3%), aggression (33.6%), and weight gain (32.3%). Specifically, 20.1% of the participants complained of memory problems. On the other hand, ADR associated with skin, mouth/gum and hair loss was 9.3%, 8.9%, and 7.2% respectively, and these were the lowest reported ADRs. Using the MMAS, 545(90.2%), 28(4.6%), and 31(5.1%) of PWE in this study were classified as having high, medium, and low adherence, respectively. Duration of Anti-Seizure Medication (ASM) use and duration of epilepsy were the major determinants of ADR in PWE on the regression model.

CONCLUSION

Duration of ASM use and duration of epilepsy are the major determinants of ADR in PWE. Effective strategies to identify and reduce ADR should be incorporated into the management of PWE by Health Care Providers (HCPs) to improve their quality of life.

Can Advanced Radiotherapy Clinical Trials be Conducted in Resources Limited Countries?

PURPOSE/OBJECTIVE(S)

The Lancet Oncology Commission on Cancer in Sub-Saharan Africa (SSA) highlighted the region's increasing cancer incidence and mortality, and recommended a series of actions to address this growing crisis. One such approach recommended by the Commission to increase access to curative treatment is the use of hypofractionated radiotherapy (HFRT). Here we highlight the barriers and facilitators to launching HFRT in SSA, as identified through the HypoAfrica clinical trial.

MATERIALS/METHODS

HypoAfrica is a longitudinal multi-center clinical trial that was launched in late 2021 at three centers in Nigeria, Tanzania, and South Africa. The goal of HypoAfrica was to assess the feasibility of implementing HFRT for localized prostate cancer in SSA. To date, 155 of 182 subjects have been enrolled in this study. During the last year, a team of radiation oncology professionals from Africa, Europe, Australia, and USA met once every Saturday and reviewed the sites' data to identify the barriers to the implementation of HFRT and find solutions to overcome these challenges. With the intent to expand HFRT trials and practice to new SSA countries and radiotherapy centers, we also conducted an online survey to elucidate the readiness of radiotherapy centers across SSA to perform HFRT.

RESULTS

The major challenge identified by this team was securing high-quality data that will yield statistically significant results. Factors that contribute to quality data are: harmonization of machine and patient-specific quality assurance (QA) procedures across the centers, data quality harmonization, and challenges associated with machine maintenance. Immediate solutions implemented included introduction of low-cost QA tools for patient-specific QA measurements, ongoing training of the site's healthcare professionals, implementation of preventative maintenance for Linacs, and data centralization infrastructure. These actions have resulted in the production of a high-quality, standardized dataset. Planned longer-term solutions to HFRT challenges include implementation of ongoing training, telehealth for remote support and QA, and the creation of an Imaging and Radiation Oncology Core for Africa. The online survey indicated that 61% of respondents' institutions perform HFRT for palliative purposes, emphasizing the readiness of sites in SSA to utilize HFRT for curative purposes.

CONCLUSION

The study serves as a useful guide for increasing access to HFRT treatment in resource-limited settings and for conducting multicenter radiotherapy clinical trials.

Mesh fixation techniques for inguinal hernia repair: an overview of systematic reviews of randomised controlled trials

PURPOSE

Inguinal hernia repair using surgical mesh is a very common surgical operation. Currently, there is no consensus on the best technique for mesh fixation. We conducted an overview of existing systematic reviews (SRs) of randomised controlled trials to compare the risk of chronic pain and recurrence following open and laparoscopic inguinal hernia repairs using various mesh fixation techniques.

METHODS

We searched major electronic databases in April 2020 and assessed the methodological quality of identified reviews using the AMSTAR-2 tool.

RESULTS

We identified 20 SRs of variable quality assessing suture, self-gripping, glue, and mechanical fixation. Across reviews, the risk of chronic pain after open mesh repair was lower with glue fixation than with suture and comparable between self-gripping and suture. Incidence of chronic pain was lower with glue fixation than with mechanical fixation in laparoscopic repairs. There were no significant differences in recurrence rates between fixation techniques in open and laparoscopic mesh repairs, although fewer recurrences were reported with suture. Many reviews reported wide confidence intervals around summary estimates. Despite no clear evidence of differences among techniques, two network meta-analyses (one assessing open repairs and one laparoscopic repairs) ranked glue fixation as the best treatment for reducing pain and suture for reducing the risk of recurrence.

CONCLUSION

Glue fixation may be effective in reducing the incidence of chronic pain without increasing the risk of recurrence. Future research should consider both the effectiveness and cost-effectiveness of fixation techniques alongside the type of mesh and the size and location of the hernia defect.

Toxicological evaluation of hydroethanol leaf extract of Pupalia lappacea (Linn.) Juss. (Amaranthaceae) in rodents

OBJECTIVES

Several studies have established the ethnobotanical benefits of Pupalia lappacea (PL) in laboratory animals without extensive toxicological evaluation of its safety profiles. Thus, an extensive toxicological investigation of sub-chronic oral administration of the hydroethanol leaf extract of P. lappacea in rodents was carried out in this study.

METHODS

Different groups of rats were treated orally with the extract (10, 50 and 250 mg/kg) daily for 90 consecutive days. The control group received distilled water (10 mL/kg). After 90 days, some rats were left for additional 30 days without treatment for reversibility study. Blood and organs samples were collected for different evaluations at the end of study periods.

RESULTS

The extract decreased the bodyweights, feeding and water intakes in female rats. PL increased the weights of the liver and kidney in male rats. PL increased the red blood cell (RBC), packed cell volume (PCV), hemoglobin (Hb), triglycerides (TRIG), cholesterol and high density lipoprotein (HDL) contents in rats. PL (250 mg/kg) significantly reduced the sperm motility and serum testosterone level. Cyto-architectural distortions of the testes, liver and spleen were visible.

CONCLUSIONS

The findings showed that P. lappacea is relatively safe at lower doses but cautions should be taken at higher dose.

Toxicological evaluation of hydroethanol leaf extract of Pupalia lappacea (Linn.) Juss. (Amaranthaceae) in rodents

OBJECTIVES

Several studies have established the ethnobotanical benefits of Pupalia lappacea (PL) in laboratory animals without extensive toxicological evaluation of its safety profiles. Thus, an extensive toxicological investigation of sub-chronic oral administration of the hydroethanol leaf extract of P. lappacea in rodents was carried out in this study.

METHODS

Different groups of rats were treated orally with the extract (10, 50 and 250 mg/kg) daily for 90 consecutive days. The control group received distilled water (10 mL/kg). After 90 days, some rats were left for additional 30 days without treatment for reversibility study. Blood and organs samples were collected for different evaluations at the end of study periods.

RESULTS

The extract decreased the bodyweights, feeding and water intakes in female rats. PL increased the weights of the liver and kidney in male rats. PL increased the red blood cell (RBC), packed cell volume (PCV), hemoglobin (Hb), triglycerides (TRIG), cholesterol and high density lipoprotein (HDL) contents in rats. PL (250 mg/kg) significantly reduced the sperm motility and serum testosterone level. Cyto-architectural distortions of the testes, liver and spleen were visible.

CONCLUSIONS

The findings showed that P. lappacea is relatively safe at lower doses but cautions should be taken at higher dose.

Cognitive dysfunction in Nigerian women with epilepsy on carbamazepine and levetiracetam monotherapy

BACKGROUND

This study aims to identify the determinants of cognitive dysfunction and compare the effect of CPZ and LTC on cognition in WWE.

METHODS

An observational study involving 87 consenting adult WWE aged between 16 and 40 years on LTC or CZP monotherapy. At enrollment, an interviewer-based questionnaire was used to obtain demographic and clinical information from participants. The diagnosis of epilepsy was mainly clinical and supported by electroencephalographic (EEG) features and classified based on recommendation by the 2017 International League Against Epilepsy (ILAE). Zung Self-Reporting Depression Scale (ZSRDS) was used to assess the mood of participants. The Community Screening Interview for Dementia (CSID) was used to assess various cognition domains. The National Hospital Seizure Severity Scale (NHS-3) was used to assess disease severity.

RESULTS

There were statistical differences between the CZP and LTC groups in all domains of cognition assessed except for orientation. The total CSID scores of the LTC group were 59.2 (4.9) as opposed to CZP group, 57.2 (5.0); p: .005. Those with focal onset seizures had lower median total CSID score (58; IQR: 54-62) when compared to those with generalized onset seizures (62; IQR: 58-62), p: .012. There was a significant correlation between ZSRD score and NHS-3 score; rho: 0.30, p: .007. Bivariate analysis shows statistically significant correlation between total CSID score and ZSRDS (rho: -0.65), BMI (rho: 0.22), and NHSS-3 score (rho: -0.36), respectively. However, the effect of AED on CSID scores was lost after multivariate quantile regression with only ZSRDS retaining significance.

CONCLUSION

Depression, seizure severity, type and structural etiology were associated with cognitive impairment among WWE. However, on regression model, only depression was statistically significant. The presence of more risks for cognitive impairment in the CZP group limits possible conclusion of LTC superiority.

Ethnomedicinal herbs in African traditional medicine with potential activity for the prevention, treatment, and management of coronavirus disease 2019

BACKGROUND

Ethnomedicine, a study of traditional medicine, is significant in drug discovery and development. African traditional medicine has been in existence for several thousands of years, and several drugs have been discovered and developed from it.

MAIN TEXT

The deadly coronavirus disease 2019 (COVID-19) caused by a novel coronavirus known as SARS-CoV-2 has widely spread globally with high mortality and morbidity. Its prevention, treatment and management still pose a serious challenge. A drug for the cure of this disease is yet to be developed. The clinical management at present is based on symptomatic treatment as presented by individuals infected and this is by combination of more than two drugs such as antioxidants, anti-inflammatory, anti-pyretic, and anti-microbials. Literature search was performed through electronic searches of PubMed, Google Scholar, and several research reports including WHO technical documents and monographs.

CONCLUSION

Drug discovery from herbs is essential and should be exploited for the discovery of drugs for the management of COVID-19. This review is aimed at identifying ethnomedicinal herbs available in Africa that could be used for the discovery and development of a drug for the prevention, treatment, and management of the novel coronavirus disease 2019.

Polycystic ovarian syndrome in Nigerian women with epilepsy on carbamazepine/levetiracetam monotherapy

OBJECTIVE

The study is aimed at comparing effects of older drugs like carbamazepine (CBZ) and newer agent like levetiracetam (LEV) on polycystic ovarian syndrome (PCOS) in women with epilepsy (WWE).

METHODS

An interviewer-based questionnaire was used to obtain relevant clinical information from 50 WWE on CBZ and LEV monotherapy, respectively, and 50 age-matched controls. The diagnosis of epilepsy was clinical with electroencephalographic features taken into consideration and the seizures classified using the 2017 International League Against Epilepsy classification. The diagnosis of PCOS was based on the European Society for Human Reproduction and Embryology/American Society for Reproductive Medicine.

RESULTS

The frequency of PCOS and its subcomponent were higher among WWE compare to controls. PCOS was present in 22 (44%) of LEV group compare to 8 (16%) CBZ group. The frequency of its subcomponent was higher among those on LEV except for comparable effect with regard to oligomenorrhea. The levels of the sex steroid hormone were comparable in both groups of WWE except luteal phase luteinizing hormone, which was lower among the LEV group (P .001). The follicular phase estradiol level was lower (P .021), and follicle-stimulating hormone level was about 2-fold higher (P .03) among WWE compare to controls. The mean value testosterone was significantly lower among controls compared to WWE.

CONCLUSIONS

The increased frequency of PCOS and its subcomponent and the unsatisfactory effect of LEV compared to CBZ on reproductive endocrine function underscore the need for routine reproductive endocrine evaluation to improve overall quality of life.

Implementation of multidrug-resistant tuberculosis (MDR-TB) treatment in Gabon: lessons learnt from the field

PURPOSE

Since May 2016, WHO recommended a 9-12 month short-treatment regimen for multidrug-resistant tuberculosis (MDR-TB) treatment known as the 'Bangladesh Regimen'. However, limited data exist on the appropriateness thereof, and its implementation in low- and middle-income countries (LMIC). We report here on the pilot phase of the evaluation of the Bangladesh regimen in Gabon, prior to its endorsement by the WHO.

METHODS

This ongoing observational study started in September 2015. Intensive training of hospital health workers as well as community information and education were conducted. GeneXpert-confirmed MDR-TB patients received the second-line anti-tuberculosis drugs (4KmMfxPtoHCfzEZ/5MfxCfzEZ). Sputum smears and cultures were done monthly. Adverse events were monitored daily.

RESULTS

Eleven patients have been treated for MDR-TB piloting the short regimen. All were HIV-negative and presented in poor health with extensive pulmonary lesions. The overall sputum culture conversion rate was 64% after 4 months of treatment. Three patients developed marked hearing loss; one a transient cutaneous rash. Of 11 patients in our continuous care, 7 (63.6%) significantly improved clinically and bacteriologically. One (9.1%) patient experienced a treatment failure, two (18.2%) died, and one (9.1%) was lost to follow up.

CONCLUSIONS

Our pioneering data on systematic MDR-TB treatment in Gabon, with currently almost total absence of resistance against the second-line drugs, demonstrate that a 9-month regimen has the capacity to facilitate early culture negativity and sustained clinical improvement. Close adverse events monitoring and continuous care are vital to success.

An Assessment of Cancer Pain Control in an LMIC Oncology Clinic

Background: Cancer has become a leading cause of morbidity and mortality in adults globally. Pain is universally one of the most commonly encountered symptoms by health and supportive care providers involved in care of cancer patients. Inadequate pain control negatively impacts the patient´s quality of life, and may slow down the healing process. Health care providers often ignore pain control as a target of treatment as they focus on reducing the tumor burden. Pain management should be considered an important target and end point in the treatment of cancer patients. Aim: To assess the prevalence of pain, oncologists´ prescribing patterns; and efficacy of pain control in the Radiotherapy Department of the Lagos University Teaching Hospital. Methods: Adult cancer outpatients were assessed using a Universal Pain Assessment Tool and followed up for 2-6 weeks thereafter. Pain scores were assessed at first interview and at the follow-up appointment within 2 weeks minimum and 6 weeks maximum. Results: 347 adult clinic attendees were recruited, assessed, and followed up with interviewer-administered questionnaires over a close-out period of 6 weeks. There was an 85% (298 respondents) prevalence of pain in the study group; with over half of respondents characterizing their pain in the moderate to severe ranges. [Figure: see text] 9 out of 10 respondents stated the cancer was the primary source of their pain. Other sources of pain were medical tests; and treatment-related such as chemotherapy and radiation therapy. 86 patients (29% of study group) were not asked about pain by their attending physician, and all respondents stated their physician had not used any pain assessment tool to determine the nature or severity of their pain. [Figure: see text] Oral nonsteroidal analgesics were the most frequently prescribed form of pain control (237 patients), with radiotherapy coming in second (69 patients). The only available strong opioid analgesics at the oncology pharmacy were oral morphine and parenteral pentazocine. Oxycodone, fentanyl pethidine, and hydromorphone were unavailable. Interventional (e.g., cordotomy) and alternative (e.g., massage) forms of pain control were not prescribed in any patients. 43 respondents (15%) despite being in pain, did not receive any form of treatment or recommendation for pain control. At follow-up appointment 2-6 weeks after; 4 out of 10 respondents had not obtained pain relief from instituted measures. [Figure: see text] Conclusion: Undertreatment of cancer pain remains a major concern. The treatment process must begin with a proper and thorough evaluation of the patient's pain; a clear pain control goal and end point target; and regular reevaluation with application of guidelines when adequate control is not achieved. Inclusion of pain assessment and management guidelines in medical training would be of benefit to reduce the prevalence of inadequately controlled pain in patients living with cancer; ultimately improving their quality of life.

The Unmet Supportive Care Needs of Nigerian Patients With Cancer

Background: Cancer is an important cause of morbidity and mortality globally, and its incidence has been on the increase in Nigeria, and the rest of the world. The diagnosis and treatment of cancer is associated with significant psychological distress and patients face a broad range of challenges which create a huge vacuum of “unmet needs” that patients feel as a loss of personal control and frustration. This impacts negatively on their quality of life and other care outcomes. Aim: This study was aimed at determining the magnitude, distribution, and predictors of unmet needs in Nigerian cancer patients. Methods: Using a descriptive cross-sectional approach, 205 cancer patients attending oncology outpatient clinics at Lagos University Teaching Hospital (LUTH), Idi-Araba, were assessed for unmet needs. Eligible patients were given the self-administered Supportive Care Needs Survey - Short Form (SCNS-SF34) questionnaire with focus on five domains of need - psychological, health system and information, physical and daily living, patient care and support, and sexuality. Data analysis was carried out with SPSS version 20, and the level of significance was set at < 0.05. Results: The mean age of the 205 cancer patients was 47.4 ± 12.3 years, who are predominantly females (96.6%). The most common diagnosis was breast cancer (92.2%), and the mean duration since diagnosis was 20.9 ± 21.9 months for all the patients. The mean SCNS score was 83.9 ± 24.8, and at least 46% of the participants indicated unmet needs in 15 items of the SCNS. The most frequent unmet needs were related to the health information (53.4%), physical and daily living (49.4%), and psychological (48.5%) need domains. The most frequently met needs were in the sexuality, and patient care and support need domains. None of the factors considered (age, gender, marital status, family type, educational attainment, employment status, economic status, presence of financial support, social support, and cancer type) were significantly predictive of unmet needs in these patients ( P > 0.05). Conclusion: Nigerian cancer patients experience high levels of unmet needs, particularly in the areas of health information, physical and daily living, and psychological health. Hence, there is an urgent need to provide sustainable and long-term interventions and support for these patients to help them achieve increased care satisfaction, improved treatment outcomes, and a better quality of life.

Anti-inflammatory effects and anti-oxidant capacity of Myrathius arboreus (Cecropiaceae) in experimental models

BACKGROUND

Inflammation is involved in various diseases; search for safe treatments is warranted. Anti-inflammatory effects of ethanol extract of Myrathius arboreus (EEMa) were studied in carrageenan-induced model, formaldehyde sub-acute-induced model, and in 48 h lipopolysaccharide-induced air pouch model of inflammation. EEMa membrane-stabilizing activities and anti-oxidant capacity were determined in vitro.

METHODS

In the carrageenan model EEMa (125, 250, or 500 mg/kg), indomethacin (5 mg/kg), or vehicle 3 mL/kg was administered orally in rats (n=5). After 1 h, 0.1 mL of 1% carrageenan was injected into the right hind paw of rats. Change in edema sizes was measured for 3 h with plethysmometer. One-tenth milliliter (0.1 mL) of 2.5% formaldehyde was injected into the rat paw on the first day and the third day to induce sub-acute inflammation; changes in the edema sizes were determined, and percentages of inhibitions were calculated. Anti-inflammatory effects of EEMa were further examined in lipopolysaccharide (LPS)-induced air-pouch based on leukocytes count, volume of exudates, levels of malondialdehyde, glutathione, superoxide dismutase, nitric oxides, and tumor necrosis factor released into the inflammatory fluids. EEMa-free radicals scavenging activities were studied in DPPH and reducing power tests. Membrane-stabilizing activities of EEMa were evaluated in the red blood cell lysis induced by thermal and hypotonic solution.

RESULTS

EEMa (250, 500 mg/kg) produced significant (p<0.001; p<0.05) inhibition of inflammation when compared with vehicle. Also, EEMa (250, 500, or 1000 μg/mL) significantly stabilized membrane and produced free radical scavenging activities.

CONCLUSIONS

M. arboreus possesses anti-inflammatory and the anti-oxidant properties that might benefit translational medicine.

Low incidence of the immune reconstitution inflammatory syndrome among HIV-infected patients starting antiretroviral therapy in Gabon: a prospective cohort study

There is a paucity of data on the immune reconstitution inflammatory syndrome (IRIS) in the Central African region. We followed ART-naive HIV-infected patients initiating antiretroviral therapy in an HIV clinic in Gabon, for 6 months. Among 101 patients, IRIS was diagnosed in five. All IRIS cases were mucocutaneous manifestations. There were no cases of tuberculosis (TB) IRIS, but active TB (n = 20) was associated with developing other forms of IRIS (p = 0.02). Six patients died. The incidence of IRIS is low in Gabon, with mild, mucocutaneous manifestations.

The role of laparoscopic surgery in the management of a malfunctioning peritoneal catheter

INTRODUCTION

Peritoneal catheter malfunction is a common complication of peritoneal dialysis (PD). It has a high failure rate with conservative management. Catheter replacement was historically the standard surgical treatment of choice. Nowadays, laparoscopy has been introduced as an alternative surgical modality to rescue the malfunctioning peritoneal catheter and also offers the possibility of replacement if indicated. The aim of this study was to compare the outcomes of these two surgical modalities.

METHODS

The medical records of consecutive patients who underwent surgical treatment for malfunctioning PD catheters (between January 2010 and April 2013) were analysed. The primary outcome included successful return to adequate PD. The secondary endpoint was length of catheter patency and the cause of catheter failure.

RESULTS

A total of 32 cases were identified, of which 8 had open catheter replacement and 24 had a laparoscopic intervention. The overall median follow-up duration was 12.5 months. The success rate for laparoscopic surgery in terms of functioning catheter at 12 months was 62.5% but only 37.5% for open surgery. The mean length of catheter patency after laparoscopic intervention was 31.6 months compared with only 13.6 months for the open surgery group. The most common cause of catheter failure diagnosed during laparoscopic intervention was catheter migration (33.0%), followed by omental wrap and catheter blockage by fibrin/blood plug (25.0% each). Open surgery did not have any diagnostic potential.

CONCLUSIONS

Laparoscopy is the treatment of choice for malfunctioning PD. Its proven benefit includes simultaneous identification of the aetiological cause of malfunction together with direct correction of this problem, thereby maximising outcome. It also allows for rapid recommencement of PD and avoidance of haemodialysis, saving cost and resources.

Literacy, education and adherence to antiretroviral therapy in The Gambia

We examined the relationship of patients' literacy and education to antiretroviral therapy (ART) adherence in an urban treatment centre in The Gambia. Information on education and literacy systematically collected before ART initiation was compared against selected adherence outcomes. Formally educated patients were significantly more likely to achieve virological suppression at both six and 12 months (87% vs. 67%, OR=3.13, P=0.03; 88% vs. 63%, OR=4.49, P=0.007, respectively). Literate patients had similar benefit at 12 months (OR=3.39 P=0.03), with improved virological outcomes associated with degree of literacy (P=0.003). A trend towards similar results was seen at 6 months for Koranically educated patients; however, this was no longer apparent at 12 months. No significant correlation was seen between socio-demographic characteristics and missed appointments. Our study suggests that literacy, formal education and possibly Koranic education may impact favourably on adherence to ART.

Transanal endoscopic microsurgery in early rectal cancer: time for a trial?

OBJECTIVE

The optimal aim of oncological surgery is to balance cancer outcomes with preservation of function and quality of life. Radical resection (RR) offers the best curative procedure in colorectal cancer but at significant morbidity. Transanal endoscopic microsurgery (TEM) offers an alternative with less morbidity and better function. Its role remains unclear and needs to be established in the light of new emerging trends in rectal cancer. This review aims to evaluate the use of TEM and its limitations.

METHOD

PubMed and MEDLINE search was performed.

RESULTS

Strongest level of evidence (Level II) favoured TEM over RR and laparoscopic resection in term of mortality and morbidity. There was no difference in recurrence at follow-up of 41 and 56 months but neither study was adequately powered to detect a difference in recurrence/survival. Three retrospective case comparisons (Level III) also favoured TEM over RR but were subject to selection bias. Twenty eight published case series (Level IV) reported varying results due to different cancer stages, study population, full excision, adjuvant therapy and treatment indication. The oncological outcomes in TEM are similar to RR in highly selected cases but with far less mortality (near 0%), morbidity, blood loss, hospital stay and genitourinary/gastrointestinal dysfunction. TEM alone (+/- adjuvant therapy) appears sufficient for 'favourable' T1 tumours. 'Unfavourable' T1 or T2 tumours require adjuvant treatment. TEM should only be used for palliation in T3+ cancers. Seven functional studies reported significant transient dysfunction following TEM with full clinical recovery within a year. TEM is cost-effective providing sufficient cases are performed.

CONCLUSION

Significant heterogeneity limits conclusions from current literature. A trial is required. Alternate end-points to local recurrence may be required in assessing the optimal surgical approach, which balances disease control with quality of life, and probability of noncancer related death.