Goals, challenges, and next steps in transdisciplinary fisheries research: perspectives and experiences from early-career researchers

Fisheries are highly complex social-ecological systems that often face 'wicked' problems from unsustainable resource management to climate change. Addressing these challenges requires transdisciplinary approaches that integrate perspectives across scientific disciplines and knowledge systems. Despite widespread calls for transdisciplinary fisheries research (TFR), there are still limitations in personal and institutional capacity to conduct and support this work to the highest potential. The viewpoints of early career researchers (ECRs) in this field can illuminate challenges and promote systemic change within fisheries research. This paper presents the perspectives of ECRs from across the globe, gathered through a virtual workshop held during the 2021 World Fisheries Congress, on goals, challenges, and future potential for TFR. Big picture goals for TFR were guided by principles of co-production and included (i) integrating transdisciplinary thinking at all stages of the research process, (ii) ensuring that research is inclusive and equitable, (iii) co-creating knowledge that is credible, relevant, actionable, and impactful, and (iv) consistently communicating with partners. Institutional inertia, lack of recognition of the extra time and labour required for TFR, and lack of skill development opportunities were identified as three key barriers in conducting TFR. Several critical actions were identified to help ECRs, established researchers, and institutions reach these goals. We encourage ECRs to form peer-mentorship networks to guide each other along the way. We suggest that established researchers ensure consistent mentorship while also giving space to ECR voices. Actions for institutions include retooling education programs, developing and implementing new metrics of impact, and critically examining individualism and privilege in academia. We suggest that the opportunities and actions identified here, if widely embraced now, can enable research that addresses complex challenges facing fishery systems contributing to a healthier future for fish and humans alike.

"When the Wild Roses Bloom": Indigenous Knowledge and Environmental Change in Northwestern North America

Indigenous Peoples in Northwestern North America have always worked with predictable cycles of day and night, tides, moon phases, seasons, and species growth and reproduction, including such phenological indicators as the blooming of flowers and the songs of birds. Negotiating variability has been constant in people's lives. Long-term monitoring and detailed knowledge of other lifeforms and landscapes of people's home territories have assisted in responding and adapting to change. Aspects of cultural knowledge and practice that have helped Indigenous Peoples navigate nature's cycles at different scales of time and space include kin ties and social relationships, experiential learning, language, storytelling and timing of ceremonies such as "First Foods" celebrations. Working with ecological processes, Indigenous Peoples have been able to maintain optimal conditions for preferred species, reducing variability and uncertainty through taking care of productive habitats, leaving ecosystems intact, and allowing other species to change in their own cycles. Since the onset of colonization, however, Indigenous Peoples' lifeways have been changed drastically, culminating with the current impacts of global climate change and biodiversity loss. This paper, based on contributions of numerous Indigenous Knowledge holders from across Northwestern North America, outlines some of the key ways in which Indigenous Peoples have embraced predictability and change in their environments and lifeways, and addresses the particular threat of climate change: its recognition, ways of adapting to it, and, ultimately, how it might be reversed through developing more careful, respectful relationships with and responsibilities for the other-than-human world.

Learning from Indigenous knowledge holders on the state and future of wild Pacific salmon

In response to colonial research paradigms that have subjugated Indigenous Peoples, knowledges, lands, and waters, Indigenous research methodologies have emerged to center Indigenous visions and voices in research practice. Here, we employ such methodologies to improve collective understanding of the state and future of wild Pacific salmon ( Oncorhynchus spp.) and fish–people–place relationships across British Columbia’s three largest salmon-producing rivers: the Fraser, Skeena, and Nass. Through partnerships with 18 communities of “Salmon People” and semi-structured interviews with 48 knowledge holders (i.e., Elders), we learned that, on average, Elders spent more than half of a century actively engaged in salmon fishing and processing. Modern salmon catches are reported to be approximately one-sixth of what they were estimated to be five to seven decades ago, and the top five threats to salmon identified by Elders included ( i) aquaculture, ( ii) climate change, ( iii) contaminants, ( iv) industrial development, and ( v) infectious diseases. Threat priorities varied regionally, reflecting distinct lived experiences and regional variation in the prevalence and impact of different threats. Elders perceived threats to salmon equally as threats to aquatic health and human well-being, with evidence that the relationships between people and water, and salmon and people, are being profoundly transformed.

Impact of traumatic perinatal events on burnout rates among midwives

BACKGROUND

Little is known about the prevalence of burnout among Irish midwives and how traumatic perinatal events in work contributes to this.

AIMS

To establish the prevalence of burnout among midwives in Ireland and whether exposure to traumatic perinatal events in work contributes to this.

METHODS

A cross-sectional study utilizing a designed questionnaire was carried out in a tertiary-referral maternity hospital involving all clinical midwives (n = 248). Demographic details and frequency of perinatal events deemed traumatic were recorded. The extent of distress was documented on two visual analogues read in combination to reflect the impact of the distressing events. Burnout severity was assessed using the Copenhagen Burnout Inventory.

RESULTS

The response rate was 55% (n = 137). Mean scores for personal, work-related and patient-related burnout were 56.0, 55.9 and 34.3, respectively. Over 90% of respondents experienced exposure to a traumatic event in work in the previous year, with 58% reporting a frequency of monthly or greater. No significant relationship was demonstrated between frequency of trauma and burnout; however, the extent of distress experienced was positively related to burnout in each domain (R2 = 0.18, 0.15 and 0.09, respectively, P < 0.01). A modest negative linear relationship exists between personal and work-related burnout and increasing age (ρ = -0.25 and -0.27, P < 0.01). A significant difference in work-related burnout score was evident between midwives with less experience and more experienced colleagues (P < 0.01).

CONCLUSIONS

Burnout is common among midwives. Exposure to discrete traumatic perinatal events experienced by women under their care contributes to this.

Indigenous Systems of Management for Culturally and Ecologically Resilient Pacific Salmon (Oncorhynchus spp.) Fisheries

Pacific salmon (Oncorhynchus spp.) are at the center of social–ecological systems that have supported Indigenous peoples around the North Pacific Rim since time immemorial. Through generations of interdependence with salmon, Indigenous Peoples developed sophisticated systems of management involving cultural and spiritual beliefs, and stewardship practices. Colonization radically altered these social–ecological systems, disrupting Indigenous management, consolidating authority within colonial governments, and moving most harvest into mixed-stock fisheries. We review Indigenous management of salmon, including selective fishing technologies, harvest practices, and governance grounded in multigenerational place-based knowledge. These systems and practices showcase pathways for sustained productivity and resilience in contemporary salmon fisheries. Contrasting Indigenous systems with contemporary management, we document vulnerabilities of colonial governance and harvest management that have contributed to declining salmon fisheries in many locations. We suggest that revitalizing traditional systems of salmon management can improve prospects for sustainable fisheries and healthy fishing communities and identify opportunities for their resurgence.

Teaching Post-Secondary Students in Ecology and Evolution: Strategies for Early-Career Researchers

Teaching can be a rewarding, yet challenging, experience for early career researchers (ECRs) in fields like ecology and evolution. Much of this challenge arises from the reality that ECRs in ecology and evolution typically receive little, if any, pedagogical training or advice on how to balance teaching, research (which can include extended field work), and other demands on their time. Here, we aim to provide accessible, pragmatic advice for ECRs in ecology and evolution who are given the opportunity to teach (as instructor of record). The advice is based on the authors’ collective experiences teaching in ecology and evolution as ECRs and is meant to help ECRs address two challenges: a) balancing the demands of teaching against one’s research, service, and personal life, and b) being effective in the classroom while doing so. The guidance we provide includes practical steps to take when teaching for the first time, including carefully refining the syllabus (course planning), adopting ‘non-traditional’ teaching methods, and taking advantage of free teaching resources. We also discuss a range of ‘soft skills’ to consider including guarding against imposter syndrome (i.e., self-doubt and fear of being exposed as a fraud), managing expectations, being empathetic, compassionate, authentic, and fostering an inclusive classroom. Lastly, we emphasize the need to focus on developing students’ critical thinking skills, integrating research and teaching where possible, and setting limits on class preparation time to maintain balance with your research and personal life. Collectively, we hope the examples provided herein offer a useful guide to ECRs new to teaching.

Searching for responsible and sustainable recreational fisheries in the Anthropocene

Recreational fisheries that use rod and reel (i.e., angling) operate around the globe in diverse freshwater and marine habitats, targeting many different gamefish species and engaging at least 220 million participants. The motivations for fishing vary extensively; whether anglers engage in catch-and-release or are harvest-oriented, there is strong potential for recreational fisheries to be conducted in a manner that is both responsible and sustainable. There are many examples of recreational fisheries that are well-managed where anglers, the angling industry and managers engage in responsible behaviours that both contribute to long-term sustainability of fish populations and the sector. Yet, recreational fisheries do not operate in a vacuum; fish populations face threats and stressors including harvest from other sectors as well as environmental change, a defining characteristic of the Anthropocene. We argue that the future of recreational fisheries and indeed many wild fish populations and aquatic ecosystems depends on having responsible and sustainable (R&S) recreational fisheries whilst, where possible, addressing, or at least lobbying for increased awareness about the threats to recreational fisheries emanating from outside the sector (e.g., climate change). Here, we first consider how the concepts of R&S intersect in the recreational fishing sector in an increasingly complex socio-cultural context. Next, we explore the role of the angler, angling industry and decision-makers in achieving R&S fisheries. We extend this idea further by considering the consequences of a future without recreational fisheries (either because of failures related to R&S) and explore a pertinent case study situated in Uttarakahand, India. Unlike other fisheries sectors where the number of participants is relatively small, recreational angling participants are numerous and widespread, such that if their actions are responsible, they have the potential to be a key voice for conservation and serve as a major force for good in the Anthropocene. What remains to be seen is whether this will be achieved, or if failure will occur to the point that recreational fisheries face increasing pressure to cease, as a result of external environmental threats, the environmental effects of recreational fishing and emerging ethical concerns about the welfare of angled fish.

Emerging threats and persistent conservation challenges for freshwater biodiversity

In the 12 years since Dudgeon et al. (2006) reviewed major pressures on freshwater ecosystems, the biodiversity crisis in the world's lakes, reservoirs, rivers, streams and wetlands has deepened. While lakes, reservoirs and rivers cover only 2.3% of the Earth's surface, these ecosystems host at least 9.5% of the Earth's described animal species. Furthermore, using the World Wide Fund for Nature's Living Planet Index, freshwater population declines (83% between 1970 and 2014) continue to outpace contemporaneous declines in marine or terrestrial systems. The Anthropocene has brought multiple new and varied threats that disproportionately impact freshwater systems. We document 12 emerging threats to freshwater biodiversity that are either entirely new since 2006 or have since intensified: (i) changing climates; (ii) e-commerce and invasions; (iii) infectious diseases; (iv) harmful algal blooms; (v) expanding hydropower; (vi) emerging contaminants; (vii) engineered nanomaterials; (viii) microplastic pollution; (ix) light and noise; (x) freshwater salinisation; (xi) declining calcium; and (xii) cumulative stressors. Effects are evidenced for amphibians, fishes, invertebrates, microbes, plants, turtles and waterbirds, with potential for ecosystem-level changes through bottom-up and top-down processes. In our highly uncertain future, the net effects of these threats raise serious concerns for freshwater ecosystems. However, we also highlight opportunities for conservation gains as a result of novel management tools (e.g. environmental flows, environmental DNA) and specific conservation-oriented actions (e.g. dam removal, habitat protection policies, managed relocation of species) that have been met with varying levels of success. Moving forward, we advocate hybrid approaches that manage fresh waters as crucial ecosystems for human life support as well as essential hotspots of biodiversity and ecological function. Efforts to reverse global trends in freshwater degradation now depend on bridging an immense gap between the aspirations of conservation biologists and the accelerating rate of species endangerment.

Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research

The Ebola outbreak that started in late 2013 is by far the largest and most sustained in history. It occurred in a part of the world where pre-existing health systems were already fragile, and these deteriorated further during the epidemic due to a large number of health worker deaths; temporary or permanent closure of health facilities; non-payment of health workers; intrinsic fear of contracting or being stigmatised by Ebola among the population, which negatively influenced health-seeking behaviour; enforced quarantine of Ebola-affected communities, restricting the access of vulnerable individuals to health facilities; and late response by the international community. There are also reports of drug and consumable stockouts due to deficiencies in the procurement and supply chain as a result of overriding Ebola-related priorities. Providing tuberculosis (TB) care and achieving favourable treatment outcomes require a fully functioning health system, accurate patient tracking and high patient adherence to treatment. Furthermore, as Ebola is easily transmitted through body fluids, the use of needles-essential for TB diagnosis and treatment-needs to be avoided during an outbreak. We highlight ways in which a sustained Ebola outbreak could jeopardise TB activities and suggest pre-emptive preventive measures while awaiting operational research evidence.

Outcomes of antiretroviral therapy among younger versus older adolescents and adults in an urban clinic, Zimbabwe

SETTING

A non-governmental organisation-supported clinic offering health services including antiretroviral therapy (ART).

OBJECTIVE

To compare ART retention between younger (age 10-14 years) vs. older (age 15-19 years) adolescents and younger (age 20-29 years) vs. older (age ⩾30 years) adults and determine adolescent- and adult-specific attrition-associated factors among those initiated on ART between 2010 and 2011.

DESIGN

Retrospective cohort study.

RESULTS

Of 110 (7%) adolescents and 1484 (93%) adults included in the study, no differences in retention were observed between younger vs. older adolescents at 6, 12 and 24 months. More younger adolescents were initiated with body mass index <16 kg/m(2) compared with older adolescents (64% vs. 47%; P = 0.04). There were more females (74% vs. 52%, P < 0.001) and fewer patients initiating ART with CD4 count ⩽350 cells/mm(3) (77% vs. 81%, P = 0.007) among younger vs. older adults. Younger adults demonstrated more attrition than older adults at all time-points. No attrition risk factors were observed among adolescents. Attrition-associated factors among adults included being younger, having a lower CD4 count and advanced human immunodeficiency virus disease at initiation, and initiation on a stavudine-based regimen.

CONCLUSION

Younger adults demonstrated greater attrition and may require more attention. We were unable to demonstrate differences in attrition among younger vs. older adolescents. Loss to follow-up was the main reason for attrition across all age groups. Overall, earlier presentation for ART care appears important for improved ART retention among adults.

Novel oral anticoagulants in plastic surgery

Novel oral anticoagulants (NOACs) have emerged as a good alternative to warfarin in the prevention of stroke for patients with atrial fibrillation. NOAC use is increasing rapidly; therefore, greater understanding of their use in the perioperative period is important for optimal care. Studies and reviews that reported on the use of NOACs were identified, with particular focus on the perioperative period. PubMed was searched for relevant articles published between January 2000 and August 2015. The inevitable rise in the use of NOACs such as rivaroxaban (Xarelto™), apixaban (Eliquis™), edoxaban (Lixiana™) and dabigatran (Pradaxa™) may present a simplified approach to perioperative anticoagulant management due to fewer drug interactions, rapidity of onset of action and relatively short half-lives. Coagulation status, however, cannot reliably be monitored and no antidotes are currently available. When planning for discontinuation of NOACs, special consideration of renal function is required. Advice regarding the management of bleeding complications is provided for consideration in emergency surgery. In extreme circumstances, haemodialysis may be considered for bleeding with the use of dabigatran. NOACs will increasingly affect operative planning in plastic surgery. In order to reduce the incidence of complications associated with anticoagulation, the management of NOACs in the perioperative period requires knowledge of the time of last dose, renal function and the bleeding risk of the planned procedure. Consideration of these factors will allow appropriate interpretation of the current guidelines.

Does research through Structured Operational Research and Training (SORT IT) courses impact policy and practice?

SETTING

Structured Operational Research and Training Initiative (SORT IT) courses are well known for their output, with nearly 90% of participants completing the course and publishing in scientific journals.

OBJECTIVE

We assessed the impact of research papers on policy and practice that resulted from six SORT IT courses initiated between July 2012 and March 2013.

DESIGN

This was a cross-sectional study involving e-mail-based, self-administered questionnaires and telephone/skype/in-person responses from first and/or senior co-authors of course papers. A descriptive content analysis of the responses was performed and categorised into themes.

RESULTS

Of 72 participants, 63 (88%) completed the course. Course output included 81 submitted papers, of which 76 (94%) were published. Of the 81 papers assessed, 45 (55%) contributed to a change in policy and/or practice: 29 contributed to government policy/practice change (20 at national, 4 at subnational and 5 at hospital level), 11 to non-government organisational policy change and 5 to reinforcing existing policy. The changes ranged from modifications of monitoring and evaluation tools, to redrafting of national guidelines, to scaling up existing policies.

CONCLUSION

More than half of the SORT IT course papers contributed to a change in policy and/or practice. Future assessments should include more robust and independent verification of the reported change(s) with all stakeholders.

Effect of increased ART-CPT uptake on tuberculosis outcomes and associated factors, Burundi, 2009-2013

We retrospectively examined 3579 records of human immunodeficiency virus infected tuberculosis (TB) patients diagnosed from January 2009 to June 2013 in 55 TB treatment facilities in Burundi, to demonstrate whether improvement of combined cotrimoxazole preventive therapy and antiretroviral therapy (ART) uptake was accompanied by improvement of treatment outcomes, and to describe associated factors. Treatment success rates increased from 71% to 80% (P < 0.001). While loss to follow-up and transfer-out rates declined significantly, death rates decreased modestly, and remained high, at 14%. ART uptake was worse in suburban areas and private for-profit institutions. World Health Organization targets could be achieved if peripheral health facilities were prioritised.

Research output after participants complete a Structured Operational Research and Training (SORT IT) course

Eighteen months after successfully completing one of six Structured Operational Research and Training Initiative (SORT IT) courses, e-mail questionnaires assessing post-course research output were returned by 63 participants (100% response rate). Thirty-two (51%) participants had completed new research projects, 24 (38%) had published papers, 28 (44%) had presented abstracts at conferences, 15 (24%) had facilitated at further OR courses, and 21 (33%) had reviewed scientific papers. Seven (11%) had secured further research funding and 22 (35%) stated that their institutions were involved in implementation or capacity building in operational research. Significant research output continues beyond course completion, further endorsing the value of the SORT IT model.

Mentorship for operational research capacity building: hands-on or hands-off?

Mentorship is a key feature of operational research training courses run by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières. During the recent South Pacific paper writing module, the faculty discussed 'hands-on' mentorship (direct technical assistance) vs. 'hands-off' mentorship (technical advice). This article explores the advantages and disadvantages of each approach. Our collective experience indicates that 'hands-on' mentorship is a valuable learning experience for the participant and a rewarding experience for the mentor. This approach increases the likelihood of successful course completion, including publishing a well written paper. However, mentors must allow participants to lead and take ownership of the paper, in keeping with a first author position.

Do non-monetary incentives for pregnant women increase antenatal attendance among Ethiopian pastoralists?

In a pastoralist setting in Ethiopia, we assessed changes in attendance between the first and subsequent antenatal care (ANC) visits following the implementation of non-monetary incentives in a primary health care centre over a 3-year period from October 2009 to September 2012. Incentives included the provision of a bar of soap, a bucket, a mosquito net, sugar, cooking oil, a jerrycan and a delivery kit. The first ANC visits increased by 48% in the first year to 60% in the second. Subsequent visits did not show a similar pattern due to ruptures in incentive stocks. Incentives appear to increase ANC attendance; however, ruptures in stock should be avoided to sustain the effect.

What happens after participants complete a Union-MSF structured operational research training course?

SETTING

Eight operational research (OR) courses run by the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) for participants from low- and middle-income countries. There is a knowledge gap about whether participants continue OR after course completion.

OBJECTIVES

To determine 1) the research output of participants and their institutions after course completion; 2) the influence of OR fellowships on output; and 3) the output of non-OR fellows stratified by sex, region and staff position.

DESIGN

A self-administered e-mail questionnaire survey.

RESULTS

Of 83 participants who completed a course, 76 (92%) responded to the questionnaire. Following course completion, 47 (62%) participants completed new research projects, 38 (50%) published papers (vs. 25 [33%] who had published before the course), 42 (55%) presented posters or oral abstracts at conferences, 33 (43%) facilitated at further OR courses, 29 (38%) reviewed scientific papers, 25 (33%) secured further OR funding and 55 (72%) said their institutions were involved in OR implementation or capacity building. OR fellows performed better than non-OR fellows. Among the latter, males and participants from Asia had better output than females and participants from Africa (P < 0.05).

CONCLUSION

The significant proportion of participants continuing to engage in OR after course completion provides encouraging evidence of the long-term value of this capacity building model.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Antibiotic use in a district hospital in Kabul, Afghanistan: are we overprescribing?

SETTING

A district hospital in Kabul, Afghanistan, supported by Médecins Sans Frontières (MSF).

OBJECTIVES

To assess antibiotic prescribing practices in the out-patient department in summer (August 2013) and winter (January 2014).

DESIGN

Cross-sectional study, using routinely collected hospital data and using World Health Organization (WHO) defined daily dose (DDD) methodology.

RESULTS

An analysis of 4857 prescriptions (summer) and 4821 prescriptions (winter) showed that respectively 62% and 50% of all out-patients were prescribed at least one antibiotic. Prescriptions without a recorded diagnosis represented a sizeable proportion of all antibiotics prescribed. For upper respiratory tract infections (URTI), dental indications, urinary tract infections (UTI) and diarrhoea, good adherence to dosages recommended in the MSF standard treatment guidelines was observed when measured by DDD. However, certain drugs not indicated in the guidelines were prescribed, such as amoxicillin and metronidazole for UTI and azithromycin for URTI.

CONCLUSION

Rates of antibiotic prescriptions for out-patients in a district hospital in Afghanistan were high, double the WHO recommendation of 30%. While systematic non-adherence to recommended dosages was not observed, inappropriate prescriptions for specific conditions may have occurred. This study suggests that knowledge about context-specific determinants of antibiotic prescribing is a first step towards promoting rational prescribing practices in such settings.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Causes of pediatric mortality and case-fatality rates in eight Médecins Sans Frontières-supported hospitals in Africa

SETTING

Eight pediatric hospital in-patient wards in remote, rural and/or insecure areas in Africa.

OBJECTIVES

To describe, in children aged <5 years, 1) overall and individual mortality rates, 2) the 10 most common causes of mortality, and 3) their case-fatality rates.

DESIGN

Retrospective analysis of routinely collected standardized program data for 2010.

RESULTS

During 2010, 21 357 children aged <5 years were admitted and 1520 died, resulting in an overall in-patient mortality rate among under-fives of 7%. This remained the same after considering the three most common causes of mortality per hospital. One hospital with a neonatal unit showed a mortality rate of 14%. Of the 10 most common causes of mortality in the eight hospitals, severe malaria, acute lower respiratory tract infection and neonatal infection counted for about 77% of total deaths. Ranking the 10 most common causes of mortality according to case-fatality rates, septicemia, meningitis, low birth weight with pathology, neonatal infection and neonatal asphyxia were the most common (case-fatality rates 15-40%).

CONCLUSION

Despite widely different contexts, mortality rates for pediatric in-patients were consistently under 10%. To further reduce mortality, emphasis should be placed on treating sepsis and introducing implementable and/or adapted care packages for neonatal-related pathologies.

Notified tuberculosis among Singapore residents by ethnicity, 2002-2011

SETTING

The National Tuberculosis Programme in Singapore where, among resident cases, higher tuberculosis (TB) rates have been reported in ethnic Malays.

OBJECTIVE

To describe the socio-demographic and clinical characteristics of resident TB cases by ethnicity, and to assess whether Malays differ from other groups in terms of the above parameters.

DESIGN

Cross-sectional review of records from the tuberculosis registry's electronic database.

RESULTS

Among 15 622 resident cases notified, 72.2% were Chinese, 18.7% Malay, 5.8% Indian and 2.9% were from other minorities. Compared to other ethnicities, Malays were more likely to be incarcerated at the time of notification (odds ratio [OR] 3.70, 95%CI 3.03-4.52) and clustered at the same residential address (OR 1.65, 95%CI 1.44-1.89), but were less likely to be aged ≥65 years (OR 0.61, 95%CI 0.54-0.70) or to reside in high-cost housing (OR 0.11, 95%CI 0.07-0.17). In terms of disease characteristics, more Malays had diabetes mellitus (OR 1.54, 1.37-1.73), a highly-positive acid-fast bacilli smear (OR 1.64, 95%CI 1.47-1.83) and cavitary disease on chest X-ray (OR 1.41, 95%CI 1.28-1.55).

CONCLUSION

Compared to other ethnicities, reported TB cases among Malays were more severe and were likely to be more infectious. Increased vigilance in case management and contact investigations, as well as an improvement in the socio-economic conditions of this community, are required to reduce TB rates in this ethnic group.

High quit rate among smokers with tuberculosis in a modified smoking cessation programme in Dhaka, Bangladesh

SETTING

BRAC, a non-governmental organisation, implemented a modified smoking cessation programme for tuberculosis (TB) patients based on International Union Against Tuberculosis and Lung Disease (The Union) guidelines in 17 peri-urban centres of Dhaka, Bangladesh.

OBJECTIVE

To determine whether a modified version of The Union's smoking cessation intervention was effective in promoting cessation among TB patients and determinants associated with quitting smoking.

DESIGN

Cohort study of routinely collected data.

RESULTS

A total of 3134 TB patients were registered from May 2011 to April 2012. Of these, 615 (20%) were current smokers, with a mean age of 38 years (±13.8). On treatment completion, 562 patients were analysed, with 53 (9%) lost to follow-up or dead, while 82% of smokers had quit. Patients with extra-pulmonary TB were less likely to quit than those with pulmonary TB. Patients with high-intensity dependence were less likely to quit than those with low-intensity dependence.

CONCLUSION

This study suggests that a simplified smoking cessation intervention can be effective in promoting smoking cessation among TB patients in Bangladesh. This is encouraging for other low-resource settings; the Bangladesh National Tuberculosis Control Programme should consider nationwide scaling up and integration of this smoking cessation plan.

References for scientific papers: why not standardise to one global style?

The different reference styles demanded by journals, both for in-text citations and manuscript bibliographies, require that significant time and attention be paid to minute detail that constitute a tedious obstacle on the road to publication for all authors, but especially for those from resource-limited countries and/or writing in a second language. To illustrate this, we highlight different reference styles requested by five popular journals to which operational research papers are often submitted. We call for a simpler, standardised format for in-text and bibliography reference citations, so that researchers can concentrate on the science and its interpretation rather than fonts and punctuation.

Characteristics and mortality of neonates in an emergency obstetric and neonatal care facility, rural Burundi

SETTING

A Médecins Sans Frontières emergency obstetric and neonatal care facility specialising as a referral centre for three districts for women with complications during pregnancy or delivery in rural Burundi.

OBJECTIVE

To describe the characteristics and in-facility mortality rates of neonates born in 2011.

DESIGN

Descriptive study involving a retrospective review of routinely collected facility data.

RESULTS

Of 2285 women who delivered, the main complications were prolonged labour 331 (14%), arrested labour 238 (10%), previous uterine intervention 203 (9%), breech 171 (8%) and multiple gestations 150 (7%). There were 175 stillbirths and 2110 live neonates, of whom 515 (24%) were of low birth weight, 963 (46%) were delivered through caesarean section and 267 (13%) required active birth resuscitation. Overall, there were 102 (5%) neonatal deaths. A total of 453 (21%) neonates were admitted to dedicated neonatal special services for sick and low birth weight babies. A high proportion of these neonates were delivered by caesarean section and needed active birth resuscitation. Of 67 (15%) neonatal deaths in special services, 85% were due to conditions linked to low birth weight and birth asphyxia.

CONCLUSION

Among neonates born to women with complications during pregnancy or delivery, in-facility deaths due to low birth weight and birth asphyxia were considerable. Sustained attention is needed to reduce these mortality rates.

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

OBJECTIVES

1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya.

DESIGN

Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya.

RESULTS

Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/μl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants.

CONCLUSION

This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

Operational research training: the course and beyond

Insufficient operational research (OR) is generated within programmes and health systems in low- and middle-income countries, partly due to limited capacity and skills to undertake and publish OR in peer-reviewed journals. To address this, a three-module course was piloted by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières in 2009-2010, with 12 participants. Five received mentorship and financial support as OR Fellows. Eleven of 12 participants submitted a paper to a peer-reviewed journal within 4 weeks of the end of the course. Evaluation shows that participants continued OR activities beyond the course. During the subsequent year, they submitted and/or published 19 papers, made 10 posters and/or presentations, and many participated in training, mentoring and/or paper reviewing. Some described changes in policy and practice influenced by their research, and changes in their organisation's approach to OR. They provided recommendations for improving and expanding OR. We conclude that participants can, with certain enabling conditions, take research questions through to publication, use skills gained to undertake and promote OR thereafter and contribute to improvement in policy and practice. An internet-based network will provide participants and graduates with a platform for collection of course outcomes and ongoing mentor- and peer-based support, resources and incentives.

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals, Uganda

SETTING

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

OBJECTIVE

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

DESIGN

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

RESULTS

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

CONCLUSION

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.

How effective is the integration of facility and community-based management of severe acute malnutrition in India?

SETTING

All children admitted to two nutritional rehabilitation centres (NRCs) during 2011-2012 in Madhya Pradesh, India.

OBJECTIVE

To determine 1) adherence to in-patient care and follow-up visits, 2) attainment and maintenance of target weight gain, and 3) association with the children's demographic characteristics.

DESIGN

A retrospective record review. The 74-day programme included 14 days of in-patient care, with subsequent home-based care and four follow-up visits to the NRC at 15-day intervals. The first three visits were part of the treatment, while the fourth was for assessment of sustained weight gain.

RESULTS

Of the 1027 children admitted, 900 (88%) completed in-patient care. Of these, 685 (76%) attended the first three follow-up visits, 482 (70%) of whom gained >15% of their admission weight. Of these, 409 (85%) completed four visits, 314 (77%) of whom were able to sustain their weight gain. Those unable to gain >15% weight by the third visit had a significantly lower proportion of sustained weight gain at the fourth visit. Children aged ⩾6 months had significantly higher odds (OR 4.5, 95%CI 3.1-6.2, P < 0.05) of completing in-patient care.

CONCLUSION

In-patient care combined with community-based follow-up was effective in adherence to follow-up visits; however, there is still room for improvement in attaining and sustaining the target weight.

Double trouble: tuberculosis and substance abuse in Nagaland, India

The diagnosis and treatment of tuberculosis (TB) in people who use and/or inject illicit drugs (PWUIDs) remains a barrier to achieving universal coverage for TB in India and globally. This report describes treatment outcomes in PWUIDs who received treatment for drug-susceptible TB at the Mon District Hospital in Nagaland, India, during 2012-2013. The median age of the patients was 39 years, and most (92%) were male. Two thirds (33/49) of the patients had a successful TB treatment outcome. A previous TB episode and residence in a semi-urban area were associated with unsuccessful treatment outcomes. Separate diagnostic and treatment algorithms, including regular adherence counselling and opioid substitution therapies, should be considered for PWUIDs.

'I'm fed up': experiences of prior anti-tuberculosis treatment in patients with drug-resistant tuberculosis and HIV

OBJECTIVES

To understand the impact of past experiences of anti-tuberculosis treatment among patients co-infected with the human immunodeficiency virus and multidrug-resistant tuberculosis (MDR-TB) on perceptions and attitudes towards treatment.

METHODS

Qualitative study using in-depth interviews with 12 HIV-MDR-TB co-infected patients in Mumbai, India.

RESULTS

Patients reported unnecessarily long pathways to care and fatigue with diagnostic and treatment procedures. In particular, they expressed concerns over the lack of efficacy of their current treatment regimen based on their experiences with anti-tuberculosis treatment regimens in the past.

CONCLUSION

Patients reported negative experiences with previous HIV and anti-tuberculosis treatment. Access to early diagnosis and rapid initiation of integrated care for HIV-MDR-TB co-infected patients, with a strong, patient-centered support system, could help to combat the low morale and lack of faith in treatment described in this group of patients.

Prevalence and incidence of cervical intra-epithelial neoplasia among female sex workers in Korogocho, Kenya

SETTING

Sex Workers Outreach Programme Clinic, Korogocho, Nairobi, Kenya.

OBJECTIVE

In a cohort of sex workers, to determine 1) the prevalence of cervical intra-epithelial neoplasia (CIN) and its association with human immunodeficiency virus-1 (HIV-1) infection, and 2) the incidence rate of CIN during the 3-year follow-up from December 2009 to December 2012.

DESIGN

Prospective nested cohort study.

RESULTS

Of the 350 women enrolled, the median age was 29 years (range 18-49); 84 (24%) were HIV-1-infected. At enrollment, 54 (15%) had an abnormal cytology, 39 (11%) had low-grade intra-epithelial lesions (LSIL) and 15 (4%) high-grade intraepithelial lesions (HSIL). HIV-1-infected women were 2.7 times (95%CI 1.7-4.4) more likely to have CIN than non-HIV-1-infected women. Among HIV-1-infected women, the prevalence of LSIL and HSIL was 2.5 times (95%CI 1.2-5.1) and seven times (95%CI 2.3-23.3) greater than among non-HIV-infected women. During the follow-up period, 39 (11%) women had incident CIN (6.6/100 person years [py]), with no difference by HIV status, i.e., respectively 7.9/100 py and 6.3/100 py in HIV-1-infected and non-HIV-1-infected women.

CONCLUSION

The prevalence and incidence of CIN among HIV-1-infected sex workers was high; early, regular screening and follow-up of this life-threatening condition is therefore recommended.

Important co-morbidity in patients with diabetes mellitus in three clinics in Western Kenya

SETTING

Diabetes clinics in three hospitals in Western Kenya: Moi Teaching and Referral Hospital and two associated district hospitals.

OBJECTIVE

To determine the proportion of diabetes patients with a history of tuberculosis (  TB), human immunodeficiency virus (HIV  ) infection and tobacco smoking.

DESIGN

A descriptive study using routinely collected data from patient records in the three diabetes clinics.

RESULTS

Of 1376 patients analyzed, 750 (55%) were female. The mean age of the patients in the clinics was 53.5 years (95%CI 52.2-54.8), with an average duration of diabetes of 8.1 years (95%CI 7.6-8.7). Of all patients, 5.6% reported a history of TB, similar to the frequency about 20 years earlier (1990) in Tanzania. Only 30% of the patients reported knowing their HIV status; 6% were HIV-positive. A history of tobacco smoking was reported by 3.8% of the patients.

CONCLUSION

The HIV epidemic does not seem to have significantly changed the relationship between TB and diabetes mellitus (DM) in this cohort of diabetes patients. The frequency of HIV and TB in this special population was comparable to that in the general population, and only a small proportion of patients reported a history of tobacco smoking.

Nerve repair with adipose-derived stem cells protects dorsal root ganglia neurons from apoptosis

Novel approaches are required in the clinical management of peripheral nerve injuries because current surgical techniques result in deficient sensory recovery. Microsurgery alone fails to address extensive cell death in the dorsal root ganglia (DRG), in addition to poor axonal regeneration. Incorporation of cultured cells into nerve conduits may offer a novel approach in which to combine nerve repair and enhance axonal regeneration with neuroprotective therapies. We examined apoptotic mediator expression in rat DRG neurons following repair of a 10-mm sciatic nerve gap using a novel synthetic conduit made of poly ε-caprolactone (PCL) and primed with adipose-derived stem cells (ADSC) differentiated towards a Schwann cell phenotype or with primary adult Schwann cells. Differentiated ADSC expressed a range of neurotrophic factors including nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), glial-derived neurotrophic factor (GDNF), and neurotrophin-4 (NT4). Incorporation of either differentiated ADSC or Schwann cells significantly increased anti-apoptotic Bcl-2 mRNA expression (P<0.001) in the DRG, while significantly decreasing pro-apoptotic Bax (P<0.001) and caspase-3 mRNA (P<0.01) expression. Cleaved caspase-3 protein was observed in the DRG following nerve injury which was attenuated when nerve repair was performed using conduits seeded with cells. Cell incorporation into conduit repair of peripheral nerves demonstrates experimental promise as a novel intervention to prevent DRG neuronal loss.

Patch depletion behavior differs between sympatric folivorous primates

Food competition in group-living animals is commonly accepted as a critical determinant of foraging strategies and social organization. Here we examine food patch depletion behavior in a leaf-eating (folivorous) primate, the guereza (Colobus guereza). Snaith and Chapman (2005) studied the sympatric folivorous red colobus (Procolobus rufomitratus), which shares many food resources with the guereza. They determined that red colobus deplete the patches (feeding trees) they use, while we found contrary evidence for guerezas using the same methods. We found that the time guerezas spent feeding in a patch was affected by neither tree size, an indicator of food abundance, nor the size of the feeding group, an indicator of feeding competition. For their principal food item (young leaves), intake rate remained constant and coincided with a decrease in the distance moved to find food within a patch, implying that guerezas do not deplete patches. This points to a fundamental difference in the use of food by guerezas and red colobus, which may be linked to the large difference in their group sizes and/or to a disparity in their digestive physiologies. However, further analyses revealed that the number of feeders within a patch did not affect patch depletion patterns in either species, leaving the potential for a physiological basis as the most plausible explanation. Our research highlights the need for a more critical examination of folivorous primate feeding ecology and social behavior, as all folivorous primates are typically lumped into a single category in socioecological models, which may account for conflicting evidence in the literature.

In vitro and in vivo testing of novel ultrathin PCL and PCL/PLA blend films as peripheral nerve conduit

In an attempt to obviate the drawbacks of nerve autograft, ultrathin microporous biodegradable PCL and PCL/PLA films were tested for their compatibility with motor neuron-like NG108-15 cells and primary Schwann cells. Data obtained from MTS colorimetric and DNA fluorimetric assays showed that both cell lines readily attached and proliferated on these materials. Images taken using scanning electron microscope and fluorescence microscope confirmed these observations. Enhanced cell-surface interaction was achieved by pretreating the films in NaOH solution. Importantly, NG108-15 cells could be induced into differentiated phenotype with long, un-branched neurites growing across the surface of the materials. The bipolar spindle-shaped phenotype of Schwann cells was also retained on these scaffolds. Positive immunochemical staining using antibodies against neurofilament for NG108-15 cells and S100 for Schwann cells indicated the expression of these marker proteins. In a small-scaled pilot testing, the performance of PCL conduits in bridging up a 10 mm gap in rat sciatic nerve model was assessed. Immunohistochemical staining showed that regenerated nerve tissue and penetrated Schwann cells have the potential to span the whole length of the conduit in 2 weeks.

Elastic Behavior of Porcine Coronary Artery Tissue Under Uniaxial and Equibiaxial Tension

The aim of this study was to characterize the nonlinear anisotropic elastic behavior of healthy porcine coronary arteries under uniaxial and equibiaxial tension. Porcine coronary tissue was chosen for its availability and similarity to human arterial tissue. A biaxial test device previously used to test human femoral arterial tissue samples (Prendergast, P. J., C. Lally, S. Daly, A. J. Reid, T. C. Lee, D. Quinn, and F. Dolan. ASME J. Biomech. Eng., Vol. 125, pp. 692-699, 2003) was further developed to test porcine coronary tissue specimens. The device applies an equal force to the four sides of a square specimen and therefore creates a biaxial stretch that demonstrates the anisotropy of arterial tissue. The nonlinear elastic behavior was marked in both uniaxial and biaxial tests. The tissue demonstrated higher stiffness in the circumferential direction in four out of eight cases subjected to biaxial tension. Even though anisotropy is demonstrated it is proposed that an isotropic hyperelastic model may adequately represent the properties of an artery, provided that an axial stretch is applied to the vessel to simulate the in vivo longitudinal tethering on the vessel. Isotropic hyperelastic models based on the Mooney-Rivlin constitutive equation were derived from the test data by averaging the longitudinal and circumferential equibiaxial data. Three different hyperelastic models were established to represent the test specimens that exhibited a high stiffness, an average stiffness, and a low stiffness response; these three models allow the analyst to account for the variability in the arterial tissue mechanical properties. These models, which take account of the nonlinear elastic behavior of coronary tissue, may be implemented in finite element models and used to carry out preclinical tests of intravascular devices. The errors associated with the hyperelastic models when fitting to both the uniaxial and equibiaxial data for the low stiffness, average stiffness, and high stiffness models were found to be 0.836, 5.206, and 2.980, respectively.

Endothelial cell alignment on cyclically-stretched silicone surfaces

Endothelial cells at the interface between the bloodstream and the vessel wall are continuously subjected to mechanical stimulation in vivo, and it widely recognised that such stimulation plays an important role in cardiovascular physiology. Cell deformation is induced by mechanical forces such as cyclic stretch, fluid shear stress, and transmural pressure. Although much of the work in this field has dealt with the effect of fluid shear stress, very little is known about how cyclic forces modulate and alter the morphology of single endothelial cells, and thereafter, how they effect the confluent layer of endothelial cells lining the vessel wall. The aim of this study is to investigate the response of endothelial cells when subjected to substrate deformation of similar magnitude to those experienced in vivo. Human umbilical vein endothelial cells (HUVEC) were cultured on plasma-treated silicone strips and uni-axially cyclically stretched using a custom made mechanical device. Results showed that endothelial cells subject to 10% deformation for as little as 4 h reoriented perpendicular to the stretch direction. In addition, although no integrin coating was applied to the substrate, it was found that plasma-treated silicone provided a cell adhesion substrate comparable to the commonly used collagen type I. Thus the results show that the stretch stimulus alone affects the morphology of endothelial cells. Further studies are required to establish the relative importance of substrate strain vs. fluid flow stimuli.

Analysis of Prolapse in Cardiovascular Stents: A Constitutive Equation for Vascular Tissue and Finite-Element Modelling

The effectiveness of a cardiovascular stent depends on many factors, such as its ability to sustain the compression applied by the vessel wall, minimal longitudinal contraction when it is expanded, and its ability to flex when navigating tortuous blood vessels. The long-term reaction of the tissue to the stent is also device dependant; in particular some designs provoke in-stent restenosis (i.e., regrowth of the occlusion around the stent). The mechanism of restenosis is thought to involve injury or damage to the vessel wall due to the high stresses generated around the stent when it expands. Because of this, the deflection of the tissue between the struts of the stent (called prolapse or “draping”) has been used as a measure of the potential of a stent to cause restenosis. In this paper, uniaxial and biaxial experiments on human femoral artery and porcine aortic vascular tissue are used to develop a hyperelastic constitutive model of vascular tissue suitable for implementation in finite-element analysis. To analyze prolapse, four stent designs (BeStent 2, Medtronic AVE; NIROYAL, Boston Scientific; VELOCITY, Cordis; TETRA, Guidant) were expanded in vitro to determine their repeating-unit dimensions. This geometric data was used to generate a finite element model of the vascular tissue supported within a repeating-unit of the stent. Under a pressure of 450 mm Hg (representing the radial compression of the vessel wall), maximum radial deflection of 0.253 mm, 0.279 mm, 0.348 mm and 0.48 mm were calculated for each of the four stents. Stresses in the vascular wall were highest for the VELOCITY stent. The method is proposed as a way to compare stents relative to their potential for restenosis and as a basis for a biomechanical design of a stent repeating-unit that would minimize restenosis.

Structure of the histone-core octamer in KCl/phosphate crystals at 2.15 A resolution

The structure of the native chicken histone octamer, crystallized in 2 M KCl, 1.35 M potassium phosphate pH 6.9, has been refined at 2.15 A resolution to a final R factor of 21.4% and an R(free) of 25.2%. Unique crystal-packing interactions between histone-core octamers are strong and one of them (area 4000 A(2)) involves two chloride ions and direct interactions between six acidic amino-acid residues on one octamer and the equivalent number of basic residues on the next. These interactions are on the structured part of the octamer (not involving tails). Five phosphate ions, 23 chloride ions and 437 water molecules have been identified in the structure. The phosphate and some chloride ions bind to basic amino-acid residues that interact with DNA in the nucleosome. The binding of most of the anions and the packing interactions are unique to these crystals. In other respects, and including the positions of four chloride ions, the octamer structure is very close to that of octamers in nucleosome-core particle crystals, particularly with respect to 'docking' sequences of the histone H2As and H4s. These sequences together with the H2B-H4 four-helix bundles stabilize the histone structure in the nucleosome and prevent the dissociation of the (H2A-H2B) dimers from the (H3-H4)(2) tetramer. Possible reasons why this happens at high salt in the absence of DNA are given.

The diagnosis of leprosy is delayed in the United Kingdom

Diagnostic delay in leprosy can have serious neurological consequences for the patient. We studied the presentation of leprosy patients, focusing on delays in diagnosis, in a retrospective case-note review of 28 patients referred to The Hospital for Tropical Diseases during 1995-1998. The median ages at onset of symptoms and at diagnosis were 25.1 years (range 9-77.7) and 30.1 years (range 9-78.3), respectively. The median time from symptom onset to diagnosis was 1.8 years (0.2-15.2). Prior to referral to a leprologist, patients had seen a dermatologist (20), neurologist (9), orthopaedic surgeon (5) and rheumatologist (2). Delay in diagnosis occurred in 82% of cases. Misdiagnoses as dermatological and neurological conditions were important causes of delay, and 68% of patients had nerve damage resulting in disability. Leprosy can be difficult to diagnose outside endemic areas. Increased awareness amongst general practitioners and hospital specialists would lead to more rapid diagnosis, thus minimizing damage and disability.