A Piglet Perinatal Asphyxia Model to Study Cardiac Injury and Hemodynamics after Cardiac Arrest, Resuscitation, and the Return of Spontaneous Circulation

Neonatal piglets have been extensively used as translational models for perinatal asphyxia. In 2007, we adapted a well-established piglet asphyxia model by introducing cardiac arrest. This enabled us to study the impact of severe asphyxia on key outcomes, including the time taken for the return of spontaneous circulation (ROSC), as well as the effect of chest compressions according to alternative protocols for cardiopulmonary resuscitation. Due to the anatomical and physiological similarities between piglets and human neonates, piglets serve as good models in studies of cardiopulmonary resuscitation and hemodynamic monitoring. In fact, this cardiac arrest model has provided evidence for guideline development through research on resuscitation protocols, pathophysiology, biomarkers, and novel methods for hemodynamic monitoring. Notably, the incidental finding that a substantial fraction of piglets have pulseless electrical activity (PEA) during cardiac arrest may increase the applicability of the model (i.e., it may be used to study pathophysiology extending beyond the perinatal period). However, the model generation is technically challenging and requires various skill sets, dedicated personnel, and a fine balance of the measures, including the surgical protocols and the use of sedatives/analgesics, to ensure a reasonable rate of survival. In this paper, the protocol is described in detail, as well as experiences with adaptations to the protocol over the years.

Regression of Schistosoma mansoni associated morbidity among Ugandan preschool children following praziquantel treatment: A randomised trial

Preschool children suffer from morbidity attributable to Schistosoma mansoni. We compared a single and double dose of praziquantel treatment on the regression of S. mansoni associated morbidity in children less than six years in Uganda. We measured the sizes of spleen and liver as well as liver fibrosis before treatment and 8 months after treatment among children who either received one dose (n = 201) or two doses (n = 184) of praziquantel (standard oral dose of 40 mg/kg body weight). Heamoglobin measurements were also taken. Overall, liver enlargement reduced from 52.2% (95% CI (Confidence interval) 45.1, 59.3) to 17.9% (95% CI 12.9, 23.9) with a single dose and from 48.4 (95% CI 40.9, 55.8) to 17.9% (95% CI 12.7, 24.3) with a double dose and there was no significant difference between the changes in proportion of children with enlarged liver between the two treatment groups. The proportion of children with enlarged spleen was not significantly reduced in the group treated with either one or two doses, 47.8% (95% CI 41.7, 54.9) to 45.3% (95% CI 38.3, 52.4) and 48.4% (95% CI 40.9,55.8) to 40.8% 95% CI 33.6, 48.2), respectively. Liver fibrosis detected among children getting single dose (n = 9) or double doses (n = 13) resolved after treatment with praziquantel. The number of children with low heamoglobin significantly reduced from 51.2% (95% CI 44.1, 58.3) to 0.5% (0.2, 0.8) and 61.4% (95% CI 53.9,68.5) to 1.1% (95% CI 0.1, 3.9) after single and double dose treatment, respectively. These results suggest that there is no evidence of a difference in effect between one dose of praziquantel and two doses in reversing morbidity attributable to S. mansoni among children less than six years of age.

Clinically decisive (dis)agreement in multidisciplinary team assessment of esophageal squamous cell carcinoma; a prospective, national, multicenter study

BACKGROUND

Decisions regarding tumor staging, operability, resectability, and treatment strategy in patients with esophageal cancer are made at multidisciplinary team (MDT) conferences. We aimed to assess interobserver agreement from four national MDT conferences and whether this would have a clinical impact.

METHODS

A total of 20 patients with esophageal cancer were included across all four upper gastrointestinal (GI) cancer centers. Fully anonymized patient data were distributed among the MDT conferences which decided on TNM category, resectability, operability, curability, and treatment strategy blinded to each other's decisions. The interobserver agreement was expressed as both the raw observer agreement and with Krippendorff's α values. Finally, a case-by-case evaluation was performed to determine if disagreement would have had a clinical impact.

RESULTS

A total of 80 MDT evaluations were available for analysis. A moderate to near-perfect observer agreement of 79.2%, 55.8%, and 82.5% for TNM category was observed, respectively. Substantial agreement for resectability and moderate agreement for curability were found. However, an only fair agreement was observed for the operability category. The treatment strategies had a slight agreement which corresponded to disagreement having a clinical impact in 12 patients.

CONCLUSIONS

Esophageal cancer MDT conferences had an acceptable interobserver agreement on resectability and TM categories; however, the operability assessment had a high level of disagreement. Consequently, the agreement on treatment strategy was reduced with a potential clinical impact. In future MDT conferences, emphasis should be on prioritizing the relevant information being readily available (operability, T & M categories) to minimize the risk of disagreement in the assessments and treatment strategies, and thus, delayed or suboptimal treatment.

Impact of Different Mass Drug Administration Strategies for Gaining and Sustaining Control of Schistosoma mansoni and Schistosoma haematobium Infection in Africa

This report summarizes the design and outcomes of randomized controlled operational research trials performed by the Bill & Melinda Gates Foundation–funded Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) from 2009 to 2019. Their goal was to define the effectiveness and test the limitations of current WHO-recommended schistosomiasis control protocols by performing large-scale pragmatic trials to compare the impact of different schedules and coverage regimens of praziquantel mass drug administration (MDA). Although there were limitations to study designs and performance, analysis of their primary outcomes confirmed that all tested regimens of praziquantel MDA significantly reduced local Schistosoma infection prevalence and intensity among school-age children. Secondary analysis suggested that outcomes in locations receiving four annual rounds of MDA were better than those in communities that had treatment holiday years, in which no praziquantel MDA was given. Statistical significance of differences was obscured by a wider-than-expected variation in community-level responses to MDA, defining a persistent hot spot obstacle to MDA success. No MDA schedule led to elimination of infection, even in those communities that started at low prevalence of infection, and it is likely that programs aiming for elimination of transmission will need to add supplemental interventions (e.g., snail control, improvement in water, sanitation and hygiene, and behavior change interventions) to achieve that next stage of control. Recommendations for future implementation research, including exploration of the value of earlier program impact assessment combined with intensification of intervention in hot spot locations, are discussed.

SCORE Studies on the Impact of Drug Treatment on Morbidity due to Schistosoma mansoni and Schistosoma haematobium Infection

The Schistosomiasis Consortium for Operational Research (SCORE) was funded in 2008 to improve the evidence base for control and elimination of schistosomiasis—better understanding of the systemic morbidities experienced by children in schistosomiasis-endemic areas and the response of these morbidities to treatment, being essential for updating WHO guidelines for mass drug administration (MDA) in endemic areas. This article summarizes the SCORE studies that aimed to gauge the impact of MDA-based treatment on schistosomiasis-related morbidities. Morbidity cohort studies were embedded in the SCORE’s larger field studies of gaining control of schistosomiasis in Kenya and Tanzania. Following MDA, cohort children had less undernutrition, less portal vein dilation, and increased quality of life in Year 5 compared with baseline. We also conducted a pilot study of the Behavioral Assessment System for Children (BASC-2) in conjunction with the Kenya gaining control study, which demonstrated beneficial effects of treatment on classroom behavior. In addition, the SCORE’s Rapid Answers Project performed systematic reviews of previously available data, providing two meta-analyses related to morbidity. The first documented children’s infection-related deficits in school attendance and achievement and in formal tests of learning and memory. The second showed that greater reductions in egg output following drug treatment correlates significantly with reduced odds of most morbidities. Overall, these SCORE morbidity studies provided convincing evidence to support the use of MDA to improve the health of school-aged children in endemic areas. However, study findings also support the need to use enhanced metrics to fully assess and better control schistosomiasis-associated morbidity.

Lessons Learned in Conducting Mass Drug Administration for Schistosomiasis Control and Measuring Coverage in an Operational Research Setting

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was created to conduct research that could inform programmatic decision-making related to schistosomiasis. SCORE included several large cluster randomized field studies involving mass drug administration (MDA) with praziquantel. The largest of these were studies of gaining or sustaining control of schistosomiasis, which were conducted in five African countries. To enhance relevance for routine practice, the MDA in these studies was coordinated by or closely aligned with national neglected tropical disease (NTD) control programs. The study protocol set minimum targets of at least 90% for coverage among children enrolled in schools and 75% for all school-age children. Over the 4 years of intervention, an estimated 3.5 million treatments were administered to study communities. By year 4, the median village coverage was at or above targets in all studies except that in Mozambique. However, there was often a wide variation behind these summary statistics, and all studies had several villages with very low or high coverage. In studies where coverage was estimated by comparing the number of people treated with the number eligible for treatment, denominator estimation was often problematic. The SCORE experiences in conducting these studies provide lessons for future efforts that attempt to implement strong research designs in real-world contexts. They also have potential applicability to country MDA campaigns against schistosomiasis and other NTDs, most of which are conducted with less logistical and financial support than was available for the SCORE study efforts.

Changes in Morbidity, Physical Fitness, and Perceived Quality of Life among Schoolchildren following Four Years of Different Mass Drug Administration Strategies against Schistosoma mansoni Infection in Mwanza Region, Northwestern Tanzania

Schistosoma mansoni infection negatively impacts children’s physical health and may influence general well-being. Schistosomiasis control programs aim at reducing morbidity through mass drug administration (MDA). This study aimed to compare morbidity markers between two cohorts of Tanzanian schoolchildren with initial high prevalence of S. mansoni infection. One cohort (N = 254 at baseline) received annual MDA for 4 years using community-wide treatment (CWT). The second cohort (N = 318 at baseline) received school-based treatment (SBT) every other year for 4 years. At year 5, the CWT cohort and the SBT cohort were reduced to 153 and 221 children, respectively. The characteristics of the 198 children lost to follow-up did not differ at baseline from those who were examined in year 5. Schistosoma mansoni infection, hemoglobin (Hb) and anemia, physical fitness, and perceived quality of life were investigated at baseline, year 3, and year 5, whereas liver and spleen pathology (ultrasound) were investigated only at baseline and year 5. Cohorts were compared using two-way mixed-model analysis of variance (ANOVA). Both treatment regimens significantly decreased individual-level mean intensity of S. mansoni infection, anemia, and hepatomegaly, and increased Hb levels after 5 years. Hepatomegaly was the only parameter affected by the treatment regimen as the CWT approach reduced the percentage of individuals with hepatomegaly significantly more than the SBT approach. Both treatment regimens led to reduced physical fitness at year 5 compared with baseline. The modest impact of the two control strategies are probably due to initial low intensity of infection, ensuring low level of schistosomiasis-related morbidity.

Five-Year Impact of Different Multi-Year Mass Drug Administration Strategies on Childhood Schistosoma mansoni-Associated Morbidity: A Combined Analysis from the Schistosomiasis Consortium for Operational Research and Evaluation Cohort Studies in the Lake Victoria Regions of Kenya and Tanzania

The WHO recommends mass treatment with praziquantel as the primary approach for Schistosoma mansoni-related morbidity control in endemic populations. The Schistosomiasis Consortium for Operational Research and Evaluation implemented multi-country, cluster-randomized trials to compare effectiveness of community-wide and school-based treatment (SBT) regimens on prevalence and intensity of schistosomiasis. To assess the impact of two different treatment schedules on S. mansoni-associated morbidity in children, cohort studies were nested within the randomized trials conducted in villages in Kenya and Tanzania having baseline prevalence ≥ 25%. Children aged 7-8 years were enrolled at baseline and followed to ages 11-12 years. Infection intensity and odds of infection were reduced both in villages receiving four years of annual community-wide treatment (CWT) and those who received biennial SBT over 4 years. These regimens were also associated with reduced odds of undernutrition and reduced odds of portal vein dilation at follow-up. However, neither hemoglobin levels nor the prevalence of the rare abnormal pattern C liver scores on ultrasound improved. For the combined cohorts, growth stunting worsened in the areas receiving biennial SBT, and maximal oxygen uptake as estimated by fitness testing scores declined under both regimens. After adjusting for imbalance in starting prevalence between study arms, children in villages receiving annual CWT had significantly greater decreases in infection prevalence and intensity than those villages receiving biennial SBT. Although health-related quality-of-life scores improved in both study arms, children in the CWT villages gained significantly more. We conclude that programs using annual CWT are likely to achieve better overall S. mansoni morbidity control than those implementing only biennial SBT.

Persistent Hotspots in Schistosomiasis Consortium for Operational Research and Evaluation Studies for Gaining and Sustaining Control of Schistosomiasis after Four Years of Mass Drug Administration of Praziquantel

Control of schistosomiasis presently relies largely on preventive chemotherapy with praziquantel through mass drug administration (MDA) programs. The Schistosomiasis Consortium for Operational Research and Evaluation has concluded five studies in four countries (Côte d’Ivoire, Kenya, Mozambique, and Tanzania) to evaluate alternative approaches to MDA. Studies involved four intervention years, with final evaluation in the fifth year. Mass drug administration given annually or twice over 4 years reduced average prevalence and intensity of schistosome infections, but not all villages that were treated in the same way responded similarly. There are multiple ways by which responsiveness to MDA, or the lack thereof, could be measured. In the analyses presented here, we defined persistent hotspots (PHS) as villages that achieved less than 35% reduction in prevalence and/or less than 50% reduction in infection intensity after 4 years of either school-based or community-wide MDA, either annually or twice in 4 years. By this definition, at least 30% of villages in each of the five studies were PHSs. We found no consistent relationship between PHSs and the type or frequency of intervention, adequacy of reported MDA coverage, and prevalence or intensity of infection at baseline. New research is warranted to identify PHSs after just one or a few rounds of MDA, and new adaptive strategies need to be advanced and validated for turning PHSs into responder villages.

Comparison of the Impact of Different Mass Drug Administration Strategies on Infection with Schistosoma mansoni in Mwanza Region, Tanzania-A Cluster-Randomized Controlled Trial

Annual school-based mass drug administration with praziquantel has been widely implemented to control schistosomiasis, but other treatment strategies could have a different impact. The aim of this study was to investigate the impact of six different treatment strategies on Schistosoma mansoni infection in a cluster-randomized controlled trial in schoolchildren, in a high transmission area of the Mwanza Region, Tanzania. A total of 150 villages were randomized into six arms with 25 villages in each arm. In each village, approximately 100 schoolchildren aged 9-12 years were randomly selected each year and investigated for S. mansoni prevalence and intensity based on three consecutive stool samples using the duplicate Kato-Katz technique. Four years of community-wide treatment (CWT) was the most intensive treatment strategy, whereas 2 years of school-based treatment (SBT) combined with 2 years without treatment (holiday) was the least intensive treatment. The remaining strategies constituted different combinations of CWT, SBT, and holiday years. Baseline results on S. mansoni infection were obtained from 14,620 schoolchildren from 148 villages, and mean prevalence and mean intensity among infected were 48.6-60.6% and 130.5-229.8 eggs per gram, respectively. Over the years, mean prevalence and mean intensities declined in all arms, but when comparing year 5 mean prevalence and mean intensity, there were no statistically significant differences between treatment arms. Thus, measured in a random selection of schoolchildren aged 9-12 years, four times CWT was not superior to four times SBT, while 2 years of treatment holiday combined with 2 years of SBT had the same impact as 4 years of SBT.

Use of nitrous oxide in children

BACKGROUND

In July 2013, the Department of Paediatric and Adolescent Medicine at Østfold Hospital Trust introduced nitrous oxide as an option for procedural sedation of children and adolescents.

MATERIAL AND METHOD

During the period 13 July 2013-25 August 2017, 311 procedures were performed with nitrous oxide in 238 patients aged 4-17 years. Age, sex, type and duration of procedure, any supplementary medications, complications and whether the procedure would previously have required general anaesthesia, were recorded in a form. The child rated the effectiveness of nitrous oxide using a graded age-appropriate 10-point pain scale, and the nurse rated it as good, moderate or none.

RESULTS

The children reported a median pain score of 2/10 (interquartile range 0-4), and nurses rated effectiveness as good in 247 of 304 (81 %) cases. For 43 % of procedures, the nurse felt that general anaesthesia would have been necessary had the department not had access to nitrous oxide. Adverse effects, most often dizziness, were reported in 110 of 311 procedures (35 %). In 7 of 311 procedures (2 %), the patient experienced adverse effects that resulted in stoppage of the procedure. The procedure was completed in 286 (92 %) children.

INTERPRETATION

Nitrous oxide is a useful option for children who require procedural sedation, and means that more procedures can be performed without general anaesthesia.

C-50 Influence of Childhood Maltreatment on Decision-Making in Adolescents

Objective

Decision-making requires weighing potential gains and losses. Adolescents who have experienced maltreatment may be more sensitive to potential gains or losses than other adolescents. The aim of these analyses was to examine trajectories of decision-making over time in adolescents based on maltreatment history and severity.

Method

The study included 69 adolescents 13 to 17 years old (M = 14.9). Maltreatment history and severity were assessed using the Childhood Trauma Questionnaire. Adolescents also completed a modified Iowa Gambling Task (mIGT). Outcomes of interest were the percentage of advantageous responses and net score (measure of overall performance integrating advantageous and disadvantageous plays) for each of three blocks.

Results

The trajectory of performance across blocks was defined using a conditional linear growth curve model with factor loadings fixed at block 1, block 2, and block 3. Greater maltreatment severity was associated with less increase in net score over time (M = -4.453, p < .001). In contrast, abuse severity (M = 6.675, p = .002) and the presence of neglect (M = 13.058, p = .002) were associated with sharper increases in net score. A regression revealed maltreatment severity, presence of abuse, presence of neglect, and abuse severity significantly predicted the percentage of advantageous plays only during the second block of the mIGT (R2 = .180, p = .030).

Conclusions

This study provides evidence that maltreatment history and severity are associated with the trajectory of decision-making over time. It also provides support for the importance of examining performance trajectory and heterogeneity in maltreatment regarding cognitive processing.

Pattern of mortality after menopausal hormone therapy: long-term follow up in a population-based cohort

OBJECTIVE

To investigate long-term pattern of mortality in menopausal women according to different modalities of hormone therapy.

DESIGN

Population-based prospective cohort study.

SETTING

Denmark 1993-2013.

POPULATION

A total of 29 243 women aged 50-64 years at entry into the Diet, Cancer and Health Cohort, enrolled 1993-97 and followed through 31 December 2013.

METHODS

Cox' proportional hazards models for increasingly longer periods of follow-up time were used to estimate mortality pattern according to baseline hormone use adjusted for relevant potential confounders.

MAIN OUTCOME(S)

All-cause and cause-specific mortality. Outcome information was obtained from the Danish Register of Causes of Death (linkage 99.6%).

RESULTS

A total of 4098 women died during a median follow up of 17.6 years. After adjustment for relevant lifestyle risk factors, hormone use had no impact on all-cause mortality, regardless of modality. Among baseline users, lower cardiovascluar disease mortality was only evident after 5 years [hazard ratio (HR) 0.54; 95% CI 0.32-0.92], but dissipated with additional follow up. Conversely, lower colorectal cancer mortality (HR 0.64; 95% CI 0.46-0.89) and higher breast cancer mortality (HR 1.34; 95% CI 1.05-1.72) only became evident after 15 years of follow up. There were no significant associations for mortality from other types of cancer or from stroke.

CONCLUSIONS

In this long-term follow-up study, taking hormones during menopause was not associated with overall mortality among middle-aged women. Investigating cause-specific mortality revealed significant, albeit weak, differential associations according to both causes of death and over time, underlining the importance of carefully considering individual risks and duration of treatment when making decisions on hormone therapy.

TWEETABLE ABSTRACT

Long-term follow-up study confirms no association between menopausal hormone therapy and overall mortality.

Acceptance of texture-modified in-between-meals among old adults with dysphagia

BACKGROUND AND AIMS

Old adults suffering from dysphagia have difficulties swallowing, chewing and/or eating, and are therefore at high risk of undernutrition. In-between-meals that are texture modified are of particular importance for people suffering from dysphagia. To meet their adequate daily amount of food intake they are recommended to eat 3-5 in-between-meals daily. The aim of the current pilot study was to identify the most liked in-between-meals for old adults based on flavour and describe the basic sensory properties of these in-between-meals. Following, the equality between flavour and appearance-based preferences was investigated.

METHODS

From three nursing homes 30 old adults aged 70 years or older suffering from dysphagia were recruited. They were assessing 20 texture modified in-between-meals based on their flavour and appearance on a 3 point hedonic scale.

RESULTS

When participants were asked to assign liking based on flavour, the most liked in-between-meals were frozen, cold and sweet (vanilla ice cream, strawberry parfait and panna cotta). These meals were among the in-between-meals richest in fat and energy. Liking based on flavour and appearance was equal in 18 out of 20 samples. Furthermore, nutritional and sensory characteristics of the preferred meals were described.

CONCLUSION

Flavour and sensory-based ranking of in-between-meals opens the possibility to design new in-between-meals to old adults with dysphagia, by choosing the most liked in-between-meals to offer the target group.

Reliability and consistency of a validated sun exposure questionnaire in a population-based Danish sample

An important feature of questionnaire validation is reliability. To be able to measure a given concept by questionnaire validly, the reliability needs to be high.

The objectives of this study were to examine reliability of attitude and knowledge and behavioral consistency of sunburn in a developed questionnaire for monitoring and evaluating population sun-related behavior.

Sun related behavior, attitude and knowledge was measured weekly by a questionnaire in the summer of 2013 among 664 Danes. Reliability was tested in a test-retest design. Consistency of behavioral information was tested similarly in a questionnaire adapted to measure behavior throughout the summer.

The response rates for questionnaire 1, 2 and 3 were high and the drop out was not dependent on demographic characteristic. There was at least 73% agreement between sunburns in the measurement week and the entire summer, and a possible sunburn underestimation in questionnaires summarizing the entire summer. The participants underestimated their outdoor exposure in the evaluation covering the entire summer as compared to the measurement week. The reliability of scales measuring attitude and knowledge was high for majority of scales, while consistency in protection behavior was low.

To our knowledge, this is the first study to report reliability for a completely validated questionnaire on sun-related behavior in a national random population based sample. Further, we show that attitude and knowledge questions confirmed their validity with good reliability, while consistency of protection behavior in general and in a week's measurement was low.

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Objectively validated questionnaires tested for reliability/behavioral consistency.

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Strong reliability of the knowledge and attitude items was shown.

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Knowledge about behavioral consistency between questionnaire measurement periods

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A recommendable design for short term evaluation of skin cancer prevention campaigns

Schistosoma mansoni-Associated Morbidity among Preschool-Aged Children along the Shores of Lake Victoria in Uganda

Schistosoma mansoni causes morbidity in human beings, with the highest prevalence in rural sub-Saharan Africa. Prolonged S. mansoni infection with egg deposition in intestinal blood vessels leads to liver and spleen enlargement, and thus chronic morbidity. The objective of this study was to assess whether preschool-aged children develop severe S. mansoni-related morbidity. Parasitological, clinical, and ultrasonographic examinations were carried out in 916 preschool-aged children in five schistosomiasis-endemic districts (Bugiri, Buikwe, Jinja, Mayuge, and Namayingo) along the Lake Victoria shoreline in east-central Uganda. Anaemia and anthropometry measurements were also taken. Using the Kato-Katz technique on one stool sample collected on three consecutive days, 74.9% (686/916) were found infected with S. mansoni; the majority were lightly infected (57.9%), while 22.7% and 19.4% were moderately and heavily infected, respectively. The overall geometric mean intensity (GMI) of infected children was 294.2 eggs per gram faeces. Mayuge and Jinja districts had the highest (51.2%) and lowest (2.2%) number of infected children, respectively. Hookworm infection was found in 7.8% (71/916) of the children. Both liver and spleen were significantly more enlarged in the infected children than in the uninfected children (p < 0.0005), as measured by ultrasonography. Physical palpation of the spleen was more often detected in the uninfected children. A significantly (p < 0.0005) higher proportion of S. mansoni-positive children were anaemic (359/686; 52.3%) compared to the children who had no eggs in their stool samples (81/230; 35.2%). Schistosoma mansoni infection did not have any severe effect on the nutrition status of preschool-aged children. Neither infected nor uninfected children were found to be underweight or stunted. Liver fibrosis with distinct Symmer's 'pipe stems' was found in a few heavily-infected children (0.3%). In a linear multivariable regression analysis, age of the child, anaemia, liver fibrosis, and size of the left liver lobe were associated with S. mansoni intensity of infection (adjusted R² = 0.11; p < 0.0005). Our results demonstrate that S. mansoni-related morbidity does develop in children less than six years of age, and that older children (37⁻60 months) are at higher risk (regression coefficient 0.33; p <0.0005) compared to younger ones (12⁻36 months). We recommend that preschool-aged children be included in the target population for schistosomiasis mass treatment so as to prevent the childhood chronic form of schistosomiasis.

Protocol and baseline data for a multi-year cohort study of the effects of different mass drug treatment approaches on functional morbidities from schistosomiasis in four African countries

BACKGROUND

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) focus is on randomized trials of different approaches to mass drug administration (MDA) in endemic countries in Africa. Because their studies provided an opportunity to evaluate the effects of mass treatment on Schistosoma-associated morbidity, nested cohort studies were developed within SCORE's intervention trials to monitor changes in a suite of schistosomiasis disease outcomes. This paper describes the process SCORE used to select markers for prospective monitoring and the baseline prevalence of these morbidities in four parallel cohort studies.

METHODS

In July 2009, SCORE hosted a discussion of the potential impact of MDA on morbidities due to Schistosoma infection that might be measured in the context of multi-year control. Candidate markers were reviewed and selected for study implementation. Baseline data were then collected from cohorts of children in four country studies: two in high endemic S. mansoni sites (Kenya and Tanzania), and two in high endemic S. haematobium sites (Niger and Mozambique), these cohorts to be followed prospectively over 5 years.

RESULTS

At baseline, 62% of children in the S. mansoni sites had detectable eggs in their stool, and 10% had heavy infections (≥ 400 eggs/g feces). Heavy S. mansoni infections were found to be associated with increased baseline risk of anemia, although children with moderate or heavy intensity infections had lower risk of physical wasting. Prevalence of egg-positive infection in the combined S. haematobium cohorts was 27%, with 5% of individuals having heavy infection (≥50 eggs/10 mL urine). At baseline, light intensity S. haematobium infection was associated with anemia and with lower scores in the social domain of health-related quality-of-life (HRQoL) assessed by Pediatric Quality of Life Inventory.

CONCLUSIONS

Our consensus on practical markers of Schistosoma-associated morbidity indicated that height, weight, hemoglobin, exercise tolerance, HRQoL, and ultrasound abnormalities could be used as reference points for gauging treatment impact. Data collected over five years of program implementation will provide guidance for future evaluation of morbidity control in areas endemic for schistosomiasis.

TRIAL REGISTRATION

These cohort studies are registered and performed in conjunction with the International Standard Randomised Controlled Trial Registry trials ISRCTN16755535 , ISRCTN14117624 , ISRCTN95819193 , and ISRCTN32045736 .

Defining Persistent Hotspots: Areas That Fail to Decrease Meaningfully in Prevalence after Multiple Years of Mass Drug Administration with Praziquantel for Control of Schistosomiasis

Preventive chemotherapy with praziquantel for schistosomiasis morbidity control is commonly done by mass drug administration (MDA). MDA regimen is usually based on prevalence in a given area, and effectiveness is evaluated by decreases in prevalence and/or intensity of infection after several years of implementation. Multiple studies and programs now find that even within well-implemented, multiyear, annual MDA programs there often remain locations that do not decline in prevalence and/or intensity to expected levels. We term such locations “persistent hotspots.” To study and address persistent hotspots, investigators and neglected tropical disease (NTD) program managers need to define them based on changes in prevalence and/or intensity. But how should the data be analyzed to define a persistent hotspot? We have analyzed a dataset from an operational research study in western Tanzania after three annual MDAs using four different approaches to define persistent hotspots. The four approaches are 1) absolute percent change in prevalence; 2) percent change in prevalence; 3) change in World Health Organization guideline categories; 4) change (absolute or percent) in both prevalence and intensity. We compare and contrast the outcomes of these analyses. Our intent is to show how the same dataset yields different numbers of persistent hotspots depending on the approach used to define them. We suggest that investigators and NTD program managers use the approach most suited for their study or program, but whichever approach is used, it should be clearly stated so that comparisons can be made within and between studies and programs.

Dietary intake of whole grains and plasma alkylresorcinol concentrations in relation to changes in anthropometry: the Danish diet, cancer and health cohort study

BACKGROUND/OBJECTIVES

Whole grain intake has been associated with a small but significant lower body weight gain in observational studies, but there is limited knowledge about the associations with specific whole grain types. The objective was to investigate the association between whole grains, different sources of whole grains and biomarkers of whole grain intake (alkylresorcinols) in relation to subsequent changes in waist circumference (WC) and body weight.

SUBJECTS/METHODS

Cohort study of 57 053 participants with baseline information on whole grain intake from questionnaires (FFQ) and biomarkers of whole grain rye and wheat intake, plasma alkylresorcinols, for a subset. WC and body weight were measured at baseline and again at follow-up. The associations were estimated using multiple linear regression analyses and logistic regression.

RESULTS

For women, overall whole grain intake was not related to changes in WC or body weight. For men, total whole grain intake was associated with gains in WC (ΔWC per 25 g increment: 0.44 cm, 95% CI: 0.34 cm; 0.54 cm) and body weight (Δweight per 25 g increment: 150 g, 95% CI: 78 g; 222 g), but the results changed to null or changed direction when adjusting for baseline anthropometry. For the different sources of whole grains, rye (women) and crispbread was significantly associated with gains in WC and body weight. Plasma alkylresorcinol concentration was associated with reduced WC, but not body weight, for women (ΔWC per 50 nmol/l increment: -0.69 cm, 95% CI:-1.26 cm;-0.13 cm), but no association was found for men.

CONCLUSIONS

Overall, no strong relationship between whole grain intake, measured from questionnaires or using biomarkers was found in relation to changes in body weight and WC.

Prediagnostic enterolactone concentrations and mortality among Danish men diagnosed with prostate cancer

BACKGROUND/OBJECTIVES

Evidence on the role of diet in relation to prostate cancer progression is sparse. Foods rich in lignans have shown beneficial effects on prostate cancer progression in both animal studies and small human intervention studies, including beneficial effects on prostate-specific antigen levels and tumour growth. The lignan metabolite, enterolactone, has further shown to slow prostate cancer cell growth in vitro. The aim was to investigate the association between prediagnostic enterolactone concentrations and mortality among men with prostate cancer.Subljects/Methods:Prediagnostic plasma concentrations of enterolactone from 1390 men diagnosed with prostate cancer from the Danish Diet, Cancer and Health cohort were related to all-cause or prostate cancer-specific death, using Cox proportional hazards models with follow-up time (from the date of diagnose until the date of death, emigration or end of follow-up by December 2013) as the underlying time axis.

RESULTS

The hazard ratios for enterolactone concentrations assessed linearly by 20 nmol/l increments was 0.95 (0.90, 1.02) for all-cause mortality and 0.98 (0.92, 1.05) for prostate cancer-specific mortality. Categorisation of enterolactone concentrations into quartiles did not reveal a different pattern. No effect modifications by smoking, body mass index or sport were observed, and the associations did not differ by prostate cancer aggressiveness.

CONCLUSIONS

We found no association between enterolactone concentrations and mortality among men diagnosed with prostate cancer.

Validity of physical activity and cardiorespiratory fitness in the Danish cohort "Diet, Cancer and Health-Next Generations"

Valid assessments of physical activity (PA) and cardiorespiratory fitness (CRF) are essential in epidemiological studies to define dose-response relationship for formulating thorough recommendations of an appropriate pattern of PA to maintain good health. The aim of this study was to validate the Danish step test, the physical activity questionnaire Active-Q, and self-rated fitness against directly measured maximal oxygen uptake (VO₂ max). A population-based subsample (n=125) was included from the "Diet, Cancer and Health-Next Generations" (DCH-NG) cohort which is under establishment. Validity coefficients, which express the correlation between measured and "true" exposure, were calculated, and misclassification across categories was evaluated. The validity of the Danish step test was moderate (women: r=.66, and men: r=.56); however, men were systematically underestimated (43% misclassification). When validating the questionnaire-derived measures of PA, leisure-time physical activity was not correlated with VO₂ max. Positive correlations were found for sports overall, but these were only significant for men: total hours per week of sports (r=.26), MET-hours per week of sports (r=.28) and vigorous sports (0.28) alone were positively correlated with VO₂ max. Finally, the percentage of misclassification was low for self-rated fitness (women: 9% and men: 13%). Thus, self-rated fitness was found to be a superior method to the Danish step test, as well as being less cost prohibitive and more practical than the VO₂ max method. Finally, even if correlations were low, they support the potential for questionnaire outcomes, particularly sports, vigorous sports, and self-rated fitness to be used to estimate CRF.

Alcohol consumption and the risk of renal cancers in the European Prospective Investigation into Cancer and Nutrition (EPIC). Wozniak MB, Brennan P, Brenner DR, Overvad K, Olsen A, Tjønneland A, Boutron-Ruault MC, Clavel-Chapelon F, Fagherazzi G, Katzke V, Kühn T, Boeing H, Bergmann MM, Steffen A, Naska A, Trichopoulou A, Trichopoulos D, Saieva C, Grioni S, Panico S, Tumino R, Vineis P, Bueno-de-Mesquita HB, Peeters PH, Hjartåker A, Weiderpass E, Arriola L, Molina-Montes E, Duell EJ, Santiuste C, Alonso de la Torre R, Barricarte Gurrea A, Stocks T, Johansson M, Ljungberg B, Wareham N, Khaw KT, Travis RC, Cross AJ, Murphy N, Riboli E, Scelo G.Int J Cancer. 2015 Oct 15;137(8):1953-66. [Epub 2015 Apr 28]. doi: 10.1002/ijc.29559

Epidemiologic studies have reported that moderate alcohol consumption is inversely associated with the risk of renal cancer. However, there is no information available on the associations in renal cancer subsites. From 1992 to 2010, 477,325 men and women in the European Prospective Investigation into Cancer and Nutrition cohort were followed for incident renal cancers (n = 931). Baseline and lifetime alcohol consumption was assessed by country-specific, validated dietary questionnaires. Information on past alcohol consumption was collected by lifestyle questionnaires. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated from Cox proportional hazard models. In multivariate analysis, total alcohol consumption at baseline was inversely associated with renal cancer; the HR and 95% CI for the increasing categories of total alcohol consumption at recruitment vs. the light drinkers category were 0.78 (0.62-0.99), 0.82 (0.64-1.04), 0.70 (0.55-0.90), and 0.91 (0.63-1.30), respectively, (ptrend = 0.001). A similar relationship was observed for average lifetime alcohol consumption and for all renal cancer subsites combined or for renal parenchyma subsite. The trend was not observed in hypertensive individuals and not significant in smokers. In conclusion, moderate alcohol consumption was associated with a decreased risk of renal cancer.

Infection with Schistosoma mansoni has an Effect on Quality of Life, but not on Physical Fitness in Schoolchildren in Mwanza Region, North-Western Tanzania: A Cross-Sectional Study

Background

Infection with Schistosoma mansoni negatively impact children’s physical health and may influence their general well-being. The aim of this study was to investigate the effect of S. mansoni infections on a panel of morbidity indicators with emphasis on quality of life (PedsQL; measured in four different dimensions) and physical fitness (measured as VO₂ max) among 572 schoolchildren aged 7–8 years.

Methodology/Principal findings

Prevalence of S. mansoni infections was 58.7%, with an arithmetic mean (95% CI) among positives of 207.3 (169.2–245.4) eggs per gram (epg). Most infections were light (56.5%), while 16.4% had heavy infections. Girls had significantly higher arithmetic mean intensities (95% CI) than boys (247.4 (189.2–305.6) vs. 153.2 (110.6–195.8); P = 0.004). A total of 30.1% were anaemic with no sex difference. Stunting and wasting was found in less than 10% of the population. There was no association between S. mansoni prevalence or intensities and the following parameters: anthropometry, anaemia, liver or spleen pathology in neither univariable nor multivariable linear regression analyses. However, in univariable analyses children with S. mansoni infection had a significantly lower score in emotional PedsQL (95% CI) than uninfected (77.3 (74.5–80.1) vs. 82.7 (79.9–85.5); P = 0.033) and infected children had a higher VO₂ max (95% CI) compared to uninfected (51.4 (51.0–51.8) vs. 50.8 (50.3–51.3); P = 0.042). In multivariable linear regression analyses, age, S. mansoni infection, haemoglobin and VO₂ max were significant predictors for emotional PedsQL while significant predictors for VO₂ max were physical PedsQL, height, age and haemoglobin. S. mansoni infection was thus not retained in the multivariable regression analyses on VO₂ max.

Conclusions/Significance

Of the measured morbidity parameters, S. mansoni infection had a significant effect on the emotional dimension of quality of life, but not on physical fitness. If PedsQL should be a useful tool to measure schistosome related morbidity, more in depth studies are needed in order to refine the tool so it focuses more on aspects of quality of life that may be affected by schistosome infections.

Millions of school-age children in Tanzania are infected with Schistosoma mansoni which have an impact on their physical health by reducing growth and fitness, causing anaemia and liver and spleen pathology. Apart from these measurable physical parameters, self-rating of well-being by administration of quality of life questionnaires has been proposed for measuring schistosome related morbidity. A total of 572 schoolchildren aged 7–8 years were examined for S. mansoni infection, anaemia, malnutrition and liver/spleen enlargement. Furthermore, the children participated in a 20 metres shuttle run fitness test and answered a quality of life questionnaire for children. While there was no association between S. mansoni prevalence or intensities and anaemia, malnutrition, fitness or organ enlargement, S. mansoni infected children had a significantly lower self-perceived emotional quality of life. Thus, infected children were more often scared, sad, angry or worried about their future compared to their uninfected peers. More in depth studies are needed in order to refine the questionnaire so it focuses more on aspects of quality of life that may be affected by schistosome infections.

The validated sun exposure questionnaire: association of objective and subjective measures of sun exposure in a Danish population-based sample

BACKGROUND

Few questionnaires used in monitoring sun-related behaviour have been tested for validity.

OBJECTIVES

We established the criteria validity of a questionnaire developed for monitoring population sun-related behaviour.

METHODS

During May-August 2013, 664 Danes wore a personal electronic ultraviolet radiation (UVR) dosimeter for 1 week that measured their outdoor time and dose of erythemal UVR exposure. In the following week, they answered a questionnaire on their sun-related behaviour in the measurement week.

RESULTS

Outdoor time measured by dosimetry correlated strongly with both outdoor time and the developed exposure scale measured in the questionnaire. Exposure measured in standard erythema dose (SED) by dosimetry correlated strongly with the exposure scale. In a linear regression model of UVR (SED) received, 41% of the variation was explained by skin type, age, week of participation and exposure scale, with exposure scale as the main contributor. The weekly sunburn fraction correlated strongly with the number of ambient sun hours (r = 0·73, P < 0·001).

CONCLUSIONS

This criteria-validated questionnaire provides evidence of the exposure that the questionnaire aimed to measure. The evidence provided showed a strong link between the objectively measured behaviour and the behaviour measured by this survey construct. The questionnaire is the first validated tool to measure the UVR exposure in a national population-based sample.

Impact of combined intermittent preventive treatment of malaria and helminths on anaemia, sustained attention, and recall in Northern Ghanaian schoolchildren

BACKGROUND

The benefits of integrated control of malaria, schistosomiasis, and soil-transmitted helminth infections have not been fully explored in Ghanaian schoolchildren.

OBJECTIVE

To assess the impact of co-administered artemether-lumefantrine plus albendazole, and artemether-lumefantrine plus albendazole plus praziquantel compared to albendazole plus praziquantel on anaemia, sustained attention, and recall in schoolchildren.

DESIGN

This three-arm, open-label intervention study was carried out in Ghana among class three schoolchildren. Artemether-lumefantrine and albendazole were co-administered to 131 schoolchildren in Study Arm 1; artemether-lumefantrine, albendazole, and praziquantel to 90 children in Study Arm 2 versus albendazole and praziquantel to 127 children in Control Arm 3. Medicines were administered to all children at least 30 min after a meal. A HemoCue(®) photometer was used to measure haemoglobin (Hb), while the code transmission test (CTT), adapted from the Test of Everyday Attention for Children (TEA-Ch), was used to measure sustained attention and recall before-and-after interventions in June 2011 and June 2012.

RESULTS

We observed significant malaria parasite prevalence reductions of 62.8 and 59.2% in Study Arm 1 from 24.2 to 9.0%, p<0.01, and 59.2% in Study Arm 2 from 26.7 to 10.9%, p<0.01), respectively, compared to 8.93% in Control Arm 3 (from 34.7 to 31.6%, p>0.05). Meanwhile, anaemia prevalence reduced significantly (p<0.01) in all three study arms after interventions by 38.4% (from 19.8 to 12.2%), 20.7% (from 26.6 to 21.1%), and 36.0% (from 28.3 to 18.1%) in Study Arms 1, 2, and 3, respectively. Although the interventions had no significant effects on Hb levels, anaemia prevalence reduced insignificantly by 38.4 and 20.7% in Study Arms 1 and 2, respectively, compared to 36.0% in Control Arm 3. Among schoolchildren in Study Arms 1 and 2, mean CTT score improved significantly after interventions by 10.4% (from 3.18 to 3.55, p=0.01) and 20.5% (from 2.83 to 3.56, p=0.01) respectively, compared to 5.75% in Control Arm 3 (from 2.95 to 3.13, p=0.09). Likewise, mean recall test score improvements after interventions were 16.9% (from 2.07 to 2.49, p=0.01) and 27.9% (from 1.91 to 2.65, p=0.01) in Study Arms 1 and 2, respectively, compared to 18.3% (from 1.92 to 2.35, p=0.01) in Control Arm 3.

CONCLUSION

Combined intermittent preventive treatment of malaria and deworming reduced prevalence of anaemia and improved sustained attention and recall in schoolchildren. Best results for sustained attention and recall were seen in Study Arm 2.

Renal Medullary Cystic Disease

Medullary cystic disease (MCD) is an uncommon renal disease with adult onset and autosomal inheritance, eventually progressing to terminal renal failure. It may be difficult to identify because of insufficient diagnostic tools. At urography, the same ring- shaped accumulation of contrast medium at the corticomedullary junction was observed in two patients (mother and son) suffering from MCD. To our knowledge this observation has not been reported before.

Evaluation and optimization of the Circulating Cathodic Antigen (POC-CCA) cassette test for detecting Schistosoma mansoni infection by using image analysis in school children in Mwanza Region, Tanzania

There is a need for diagnostic techniques which are sensitive, specific, rapid and easy to perform at the point-of-care. The aim of this study was to evaluate the diagnostic performance of the Circulating Cathodic Antigen (POC-CCA) assay for Schistosoma mansoni in four schools along the coast of Lake Victoria in Mwanza Region, Tanzania, and to optimize the reading of the POC-CCA test lines by using a computer software image analysis. Initially, a pilot study in 106 school children indicated that time of urine collection did not have an impact on CCA results as 84.9% (90) had identical scores from a urine collected in the morning and a urine taken at midday after drinking 0.5 L of water. The main study was conducted among 404 school children (aged 9–12 years) where stool and urine samples were collected for three consecutive days. For S. mansoni diagnosis, stool samples were examined for eggs with duplicate Kato-Katz smears, whereas urine samples were tested for presence of antigen by POC-CCA. The proportion of positive individuals for S. mansoni by one POC-CCA was higher compared to two Kato-Katz smears (66.1% vs. 28.7%; p < 0.0001). Both proportions increased expectedly when three POC-CCAs were compared to six Kato-Katz smears (75.0% vs. 42.6%; p < 0.0001). Three POC-CCAs were more sensitive (94.7%) than six Kato-Katz smears (53.8%) using the combined results of three POC-CCAs and six Kato-Katz smears as the ‘gold standard’. To optimize the reading of the POC-CCA, a Software tool (Image Studio Lite®) was used to read and quantify the colour (expressed as pixels) of the test line on all positive tests, showing a positive correlation between number of pixels and the visually scored intensities and between number of pixels and egg counts. In conclusion, the POC-CCA assay seems to be a more appropriate tool for S. mansoni diagnosis compared to the Kato-Katz method in endemic communities such as Mwanza Region. Optimization of the tool in terms of cassette-reading could be assessed by computer software which was able to quantify the colour of the lines in the strip of the cassette.

Gaining and sustaining schistosomiasis control: study protocol and baseline data prior to different treatment strategies in five African countries

BACKGROUND

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was established in 2008 to answer strategic questions about schistosomiasis control. For programme managers, a high-priority question is: what are the most cost-effective strategies for delivering preventive chemotherapy (PCT) with praziquantel (PZQ)? This paper describes the process SCORE used to transform this question into a harmonized research protocol, the study design for answering this question, the village eligibility assessments and data resulting from the first year of the study.

METHODS

Beginning in 2009, SCORE held a series of meetings to specify empirical questions and design studies related to different schedules of PCT for schistosomiasis control in communities with high (gaining control studies) and moderate (sustaining control studies) prevalence of Schistosoma infection among school-aged children. Seven studies are currently being implemented in five African countries. During the first year, villages were screened for eligibility, and data were collected on prevalence and intensity of infection prior to randomisation and the implementation of different schemes of PZQ intervention strategies.

RESULTS

These studies of different treatment schedules with PZQ will provide the most comprehensive data thus far on the optimal frequency and continuity of PCT for schistosomiasis infection and morbidity control.

CONCLUSIONS

We expect that the study outcomes will provide data for decision-making for country programme managers and a rich resource of information to the schistosomiasis research community.

TRIAL REGISTRATION

The trials are registered at International Standard Randomised Controlled Trial registry (identifiers: ISRCTN99401114 , ISRCTN14849830 , ISRCTN16755535 , ISRCTN14117624 , ISRCTN95819193 and ISRCTN32045736 ).

No association between adherence to the healthy Nordic food index and cardiovascular disease amongst Swedish women: a cohort study

BACKGROUND

In several intervention trials, a healthy Nordic diet showed beneficial effects on markers of cardiovascular disease. We investigated the association between a healthy Nordic diet and clinical diagnosis of cardiovascular disease.

OBJECTIVE

Our aim was first to examine the association between a healthy Nordic food index (wholegrain bread, oatmeal, apples/pears, root vegetables, cabbages and fish) and the incidence of overall cardiovascular disease (ischaemic heart disease, stroke, arrhythmia, thrombosis and hypertensive disease), and secondly to test for possible effect modification by smoking, body mass index (BMI), alcohol consumption and age.

METHODS

We conducted an analysis of data from the prospective Swedish Women's Lifestyle and Health cohort, including 43 310 women who completed a food frequency questionnaire in 1991-1992, and followed up until 31 December 2012 through Swedish registries. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models.

RESULTS

During follow-up, 8383 women developed cardiovascular disease. We found no association between the healthy Nordic food index and overall cardiovascular disease risk or any of the subgroups investigated. There was a statistically significant interaction with smoking status (P = 0.02), with a beneficial effect only amongst former smokers (HR 0.96, 95% CI 0.94-0.99 per 1-point increment).

CONCLUSION

The present results do not support an association between a healthy Nordic food index and risk of cardiovascular disease in Swedish women. There was also no effect modification by alcohol intake, BMI or age. Our finding of an interaction with smoking status requires reproduction.

Reduced uptake of mass treatment for schistosomiasis control in absence of food: beyond a randomized trial

Background

Sustaining high uptake of praziquantel is key for long-term control of schistosomiasis. During mass treatment in 2013, we randomized 12 primary schools into two groups; one group received education messages for schistosomiasis prevention for two months prior to mass treatment, while the other, in addition to the education messages, received a pre-treatment snack shortly before mass treatment. The uptake of praziquantel in the snack schools was 94 % compared to 79 % in the non-snack schools. During mass treatment in 2014, no snack was provided. We compared the uptake of praziquantel in 2014 to that in 2013 and attempt to explain the reasons for the observed differences.

Methods

Serial cross sectional surveys were conducted among a random sample of children from the 12 primary schools, 1 month after mass treatment in 2013 and 2014 to measure uptake of praziquantel, reported side effects attributable to praziquantel and prevalence and intensity of schistosomiasis infection. Differences in the demographic and descriptive variables between the 2013 and 2014 samples were compared using chi squared tests for categorical variables and student’s t-test for geometric mean intensity of S. mansoni infection.

Results

Uptake of praziquantel reduced from 93.9 to 78.0 % (p = 0.002) in the snack schools but was unchanged in the non-schools 78.7 and 70.4 % (p = 0.176). The occurence of side-effects attributable to praziquantel increased from 34.4 to 61.2 % (p = 0.001) in the snack schools but was unchanged in the non-snack schools; 46.9 and 53.2 % (p = 0.443). Although the prevalence of S. mansoni infection increased in both the snack and non-snack schools, the differences did not reach statistical significance;1.3 and 7.5 % (p = 0.051) and 14.1 and 22.0 % (p = 0.141), respectively. Similarly, the difference in the geometric mean intensity of S. mansoni infection in both the snack and non-snack schools was not statistically significant; 38.3 eggs per gram of stool (epg) and 145.7 epg (p = 0.197) and 78.4 epg and 322.5 epg (p = 0.120), respectively.

Conclusion

Our results show that in absence of food, uptake of praziquantel reduced and the side-effects of the drug increased. However, the reduced uptake did not affect the prevalence and intensity of schistosomiasis among school children. Rescinding of the provision of the snack is what probably caused the reduction in uptake of treatment in the subsequent mass treatment cycle.

Cryptosporidium and Giardia in Danish organic pig farms: Seasonal and age-related variation in prevalence, infection intensity and species/genotypes

Although pigs are commonly infected with Cryptosporidium spp. and Giardia duodenalis, including potentially zoonotic species or genotypes, little is known about age-related infection levels, seasonal differences and genetic variation in naturally infected pigs raised in organic management systems. Therefore, the current study was conducted to assess seasonal and age-related variations in prevalence and infection intensity of Cryptosporidium and Giardia, evaluate zoonotic potential and uncover correlations between species/genotypes, infection intensity and faecal consistency. Shedding of oocysts and cysts ((oo-)cysts) was monitored at quarterly intervals (September 2011-June 2012) in piglets (n = 152), starter pigs (n = 234), fatteners (n = 230) and sows (n = 240) from three organic farms in Denmark. (oo-)Cysts were quantified by immunofluorescence microscopy; and 56/75 subsamples from Cryptosporidium infected pigs were successfully analysed by PCR amplification and partial sequencing of the small subunit (SSU) 18S rRNA and hsp70genes, while 13/67 Giardia subsamples were successfully analysed by amplification and partial sequencing of the 18S rRNA and the gdh genes. Altogether, Cryptosporidium or Giardia infections were observed in 40.9% (350/856) and 14.0% (120/856) of the pigs, respectively, including 8.2% (70/856) infected with both parasites. Prevalence, intensity of infections and presence of Cryptosporidium species varied significantly between age-groups; 53.3% piglets, 72.2% starter pigs, 40.4% fatteners and 2.9% sows were infected with Cryptosporidium, whereas 2.0% piglets, 27.4% starter pigs, 17.8% fatteners and 5.0% sows were infected with Giardia. The overall prevalence was stable throughout the year, except for dual-infections that were more prevalent in September and December (p < 0.05). The infection intensity was age-related for both parasites, and dual-infected pigs tended to excrete lower levels of oocysts compared to pigs harbouring only Cryptosporidium. Likewise, pigs infected with Cryptosporidium scrofarum excreted fewer oocysts (mean CPG: 54,848 ± 194,508CI: 9085-118,781) compared to pigs infected with Cryptosporidium suis (mean OPG: 351,035 ± 351,035CI: 67,953-634,117). No correlation between faecal consistency and (oo-)cyst excretion levels was observed. Of the successfully genotyped isolates, 38/56 (67.9%) were C. scrofarum and 18/56 (32.1%) were C. suis, while the livestock specific G. duodenalis Assemblage E was detected in 11/13 (84.6%) isolates and the potentially zoonotic Assemblage A was identified in 2/13 (15.4%) isolates. Piglets exclusively hosted C. suis, with one exception, while starter pigs and fatteners predominantly hosted C. scrofarum. As organic pigs are partly reared outdoors, environmental contamination with Cryptosporidium and Giardia is inevitable. Nevertheless, the present data indicate that the potential public health risk associated with both of these parasites in Danish organic pig production seems to be negligible.

Single Versus Double Dose Praziquantel Comparison on Efficacy and Schistosoma mansoni Re-Infection in Preschool-Age Children in Uganda: A Randomized Controlled Trial

BACKGROUND

Schistosoma mansoni infection is proven to be a major health problem of preschool-age children in sub-Saharan Africa, yet this age category is not part of the schistosomiasis control program. The objective of this study was to compare the impact of single and double dose praziquantel (PZQ) treatment on cure rates (CRs), egg reduction rates (ERRs) and re-infection rates 8 months later, in children aged 1-5 years living along Lake Victoria, Uganda.

METHODOLOGY/PRINCIPAL FINDINGS

Infected children (n= 1017) were randomized to receive either a single or double dose of PZQ. Initially all children were treated with a single standard oral dose 40 mg/kg body weight of PZQ. Two weeks later a second dose was administered to children in the double dose treatment arm. Side effects were monitored at 30 minutes to 24 hours after each treatment. Efficacy in terms of CRs and ERRs for the two treatments was assessed and compared 1 month after the second treatment. Re-infection with S. mansoni was assessed in the same children 8 months following the second treatment. CRs were non-significantly higher in children treated with two 40 mg/kg PZQ doses (85.5%; 290/339) compared to a single dose (83.2%; 297/357). ERRs were significantly higher in the double dose with 99.3 (95%CI: 99.2-99.5) compared with 98.9 (95%CI: 98.7-99.1) using a single dose, (P = 0.01). Side effects occurred more frequently during the first round of drug administration and were mild and short-lived; these included vomiting, abdominal pain and bloody diarrhea. Overall re-infection rate 8 months post treatment was 44.5%.

CONCLUSIONS

PZQ is efficacious and relatively safe to use in preschool-age children but there is still an unmet need to improve its formulation to suit small children. Two PZQ doses lead to significant reduction in egg excretion compared to a single dose. Re-infection rates with S. mansoni 8 months post treatment is the same among children irrespective of the treatment regimen.

Fruit and vegetable consumption in relation to hepatocellular carcinoma in a multi-centre, European cohort study

BACKGROUND

Vegetable and/or fruit intakes in association with hepatocellular carcinoma (HCC) risk have been investigated in case-control studies conducted in specific European countries and cohort studies conducted in Asia, with inconclusive results. No multi-centre European cohort has investigated the indicated associations.

METHODS

In 486,799 men/women from the European Prospective Investigation into Cancer and nutrition, we identified 201 HCC cases after 11 years median follow-up. We calculated adjusted hazard ratios (HRs) for HCC incidence for sex-specific quintiles and per 100 g d(-1) increments of vegetable/fruit intakes.

RESULTS

Higher vegetable intake was associated with a statistically significant, monotonic reduction of HCC risk: HR (100 g d(-1) increment): 0.83; 95% CI: 0.71-0.98. This association was consistent in sensitivity analyses with no apparent heterogeneity across strata of HCC risk factors. Fruit intake was not associated with HCC incidence: HR (100 g d(-1) increment): 1.01; 95% CI: 0.92-1.11.

CONCLUSIONS

Vegetable, but not fruit, intake is associated with lower HCC risk with no evidence for heterogeneity of this association in strata of important HCC risk factors. Mechanistic studies should clarify pathways underlying this association. Given that HCC prognosis is poor and that vegetables are practically universally accessible, our results may be important, especially for those at high risk for the disease.

Schistosoma mansoni infection along the coast of Lake Victoria in Mwanza region, Tanzania

Prevalence and intensity of Schistosoma mansoni infection according to age, sex, and occupation were investigated in 100 first-year students (aged 7-8 years), 100 schoolchildren (aged 9-12 years), and 50 adults (aged 20-55 years) from 149 villages. The schoolchildren provided three stool specimens while the rest provided only one specimen. A total of 31,865 individuals provided at least one specimen with an overall prevalence of 38.5% and geometric mean intensity of positives of 107.0 eggs per gram of feces. With the exception of first-year students, males had higher prevalence than females (P < 0.0005). Schoolchildren had higher prevalence than first-year students that again had higher prevalence than adults. There was no sex difference in intensities among the children, but adult males had higher intensities than adult females. Intensity among the children was higher than that of the adults (P < 0.0005). Prevalence was significantly higher in those having fishing as their main occupation. Three stools samples were obtained from 13,119 schoolchildren, resulting in a prevalence of 38.1% if only one sample was included, 47.5% including two samples, and 52.6% if all three samples were included.

Intestinal schistosomiasis among preschool children along the shores of Lake Victoria in Uganda

Schistosomiasis, a disease caused by Schistosoma trematode parasites, affects hundreds of millions of people and accounts for more than 40% of the global health burden due to neglected tropical diseases. In Uganda, intestinal schistosomiasis is endemic in 73 out of 112 districts and about 55% of the population of 36 million individuals are at risk. There is scanty information on the status and burden of schistosomiasis in preschool children less than six years of age in Uganda. This study aimed to assess the status of Schistosoma mansoni infections in children aged 1-5 years in Uganda. S. mansoni prevalence and intensity of infection were examined in 3058 children from 5 districts along Lake Victoria shoreline, eastern Uganda. For each child one stool sample was collected on three consecutive days. The Kato-Katz technique was used to prepare stool smears on slides for microscopic examination. Short interviews with a standardized pre-tested questionnaire prepared in the local language (Lusoga) were administered to each caregiver to identify risk factors associated with S. mansoni infection. An overall S. mansoni prevalence of 39.3% (95% CI: 38.0-41.1%) was estimated out of the 3058 stool samples examined. The geometric mean intensity of S. mansoni among the infected children was 273 (95% CI: 241-305) eggs per gram of faeces. Both prevalence and intensity of infection increased linearly with age (P<0.0001) and were highest in the age group 49-60 months. Majority (61%) of the children, especially in the age group 12-24 months (84.2%; 95% CI: 75.6-90.1%), were lightly infected. Short interviews with caregivers revealed that preschool children, 1-5 years old, get exposed to S. mansoni infested waters through bathing, playing or swimming. It is important that the Uganda national control programme for schistosomiasis takes preschool children into consideration and that health education on transmission of schistosomiasis is delivered to the endemic communities regularly.

White matter microstructure in chronic moderate-to-severe traumatic brain injury: Impact of acute-phase injury-related variables and associations with outcome measures

This study examines how injury mechanisms and early neuroimaging and clinical measures impact white matter (WM) fractional anisotropy (FA), mean diffusivity (MD), and tract volumes in the chronic phase of traumatic brain injury (TBI) and how WM integrity in the chronic phase is associated with different outcome measures obtained at the same time. Diffusion tensor imaging (DTI) at 3 T was acquired more than 1 year after TBI in 49 moderate-to-severe-TBI survivors and 50 matched controls. DTI data were analyzed with tract-based spatial statistics and automated tractography. Moderate-to-severe TBI led to widespread FA decreases, MD increases, and tract volume reductions. In severe TBI and in acceleration/deceleration injuries, a specific FA loss was detected. A particular loss of FA was also present in the thalamus and the brainstem in all grades of diffuse axonal injury. Acute-phase Glasgow Coma Scale scores, number of microhemorrhages on T2*, lesion volume on fluid-attenuated inversion recovery, and duration of posttraumatic amnesia were associated with more widespread FA loss and MD increases in chronic TBI. Episodes of cerebral perfusion pressure <70 mmHg were specifically associated with reduced MD. Neither episodes of intracranial pressure >20 mmHg nor acute-phase Rotterdam CT scores were associated with WM changes. Glasgow Outcome Scale Extended scores and performance-based cognitive control functioning were associated with FA and MD changes, but self-reported cognitive control functioning was not. In conclusion, FA loss specifically reflects the primary injury severity and mechanism, whereas FA and MD changes are associated with objective measures of general and cognitive control functioning.

PREVALENCE OF LYMPHATIC FILARIASIS, MALARIA AND SOIL TRANSMITTED HELMINTHIASIS IN A COMMUNITY OF BARDIYA DISTRICT, WESTERN NEPAL

Lymphatic filariasis (LF), malaria and soil transmitted helminthiasis (STH) cause major health problems in Nepal, but in spite of this very few stud- ies have been carried out on these parasitic infections in Nepal. A cross sectional survey of all three categories of parasitic infections was carried out in Deuda- kala Village of Bardiya District, western Nepal. A total of 510 individuals aged 5 years and above were examined from finger prick blood for circulating filarial antigen (CFA), malaria antigen using a rapid diagnostic test (RDT), and malaria DNA using a PCR-based assay. In addition, 317 individuals were examined for soil-transmitted helminth (STH) eggs by the Kato-Katz technique. Prevalence of LF, malaria (antigen) and STH infection was 25.1%, 0.6% and 18.3%, respectively. PCR analysis did not detect any additional malaria cases. The prevalence of LF and STH infections differ significantly among different age groups and ethnic communities. The high prevalence of LF in the community studied indicates an immediate need for implementing a mass drug administration program for its control in this particular geographical area of Nepal.

Dietary intake of acrylamide and endometrial cancer risk in the European Prospective Investigation into Cancer and Nutrition cohort

BACKGROUND

Three prospective studies have evaluated the association between dietary acrylamide intake and endometrial cancer (EC) risk with inconsistent results. The objective of this study was to evaluate the association between acrylamide intake and EC risk: for overall EC, for type-I EC, and in never smokers and never users of oral contraceptives (OCs). Smoking is a source of acrylamide, and OC use is a protective factor for EC risk.

METHODS

Cox regression was used to estimate hazard ratios (HRs) for the association between acrylamide intake and EC risk in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort. Acrylamide intake was estimated from the EU acrylamide monitoring database, which was matched with EPIC questionnaire-based food consumption data. Acrylamide intake was energy adjusted using the residual method.

RESULTS

No associations were observed between acrylamide intake and overall EC (n=1382) or type-I EC risk (n=627). We observed increasing relative risks for type-I EC with increasing acrylamide intake among women who both never smoked and were non-users of OCs (HRQ5vsQ1: 1.97, 95% CI: 1.08-3.62; likelihood ratio test (LRT) P-value: 0.01, n=203).

CONCLUSIONS

Dietary intake of acrylamide was not associated with overall or type-I EC risk; however, positive associations with type I were observed in women who were both non-users of OCs and never smokers.

Seasonal increase in sea temperature triggers pancreas disease outbreaks in Norwegian salmon farms

Pancreas disease (PD) is a viral disease causing negative impacts on economy of salmon farms and fish welfare. Its transmission route is horizontal, and water transport by ocean currents is an important factor for transmission. In this study, the effect of temperature changes on PD dynamics in the field has been analysed for the first time. To identify the potential time of exposure to the virus causing PD, a hydrodynamic current model was used. A cohort of salmon was assumed to be infected the month it was exposed to virus from other infective cohorts by estimated water contact. The number of months from exposure to outbreak defined the incubation period, which was used in this investigation to explore the relationship between temperature changes and PD dynamics. The time of outbreak was identified by peak in mortality based on monthly records from active sites. Survival analysis demonstrated that cohorts exposed to virus at decreasing sea temperature had a significantly longer incubation period than cohorts infected when the sea temperature was increasing. Hydrodynamic models can provide information on the risk of being exposed to pathogens from neighbouring farms. With the knowledge of temperature-dependent outbreak probability, the farmers can emphasize prophylactic management, avoid stressful operations until the sea temperature is decreasing and consider removal of cohorts at risk, if possible.

Circulating prolactin and breast cancer risk among pre- and postmenopausal women in the EPIC cohort

BACKGROUND

Experimental and epidemiological evidence suggests that prolactin might play a role in the etiology of breast cancer. We analyzed the relationship of prediagnostic circulating prolactin levels with the risk of breast cancer by menopausal status, use of postmenopausal hormone replacement therapy (HRT) at blood donation, and by estrogen and progesterone receptor status of the breast tumors.

PATIENTS AND METHODS

Conditional logistic regression was used to analyze the data from a case-control study nested within the prospective European EPIC cohort, including 2250 invasive breast cancer and their matched control subjects.

RESULTS

Statistically significant heterogeneity in the association of prolactin levels with breast cancer risk between women who were either pre- or postmenopausal at the time of blood donation was observed (Phet = 0.04). Higher serum levels of prolactin were associated with significant increase in the risk of breast cancer among postmenopausal women [odds ratio (OR)Q4-Q1 = 1.29 (95% confidence interval, CI, 1.05-1.58), Ptrend = 0.09]; however, this increase in risk seemed to be confined to women who used postmenopausal HRT at blood donation [ORQ4-Q1 = 1.45 (95% CI 1.08-1.95), Ptrend = 0.01], whereas no statistically significant association was found for the non-users of HRT [ORQ4-Q1 = 1.11 (95%CI 0.83-1.49), Ptrend = 0.80] (Phet = 0.08). Among premenopausal women, a statistically non-significant inverse association was observed [ORQ4-Q1 = 0.70 (95% CI 0.48-1.03), Ptrend = 0.16]. There was no heterogeneity in the prolactin-breast cancer association by hormone receptor status of the tumor.

CONCLUSION

Our study indicates that higher circulating levels of prolactin among the postmenopausal HRT users at baseline may be associated with increased breast cancer risk.

Uptake of benzimidazoles by Trichuris suis in vivo in pigs

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The low uptake of FBZ by Trichuris suis in vitro was confirmed in vivo in pigs.

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High correlation between plasma and worm concentrations of OXF and FBZSO₂.

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No correlation between plasma and worm concentrations of FBZ.

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The blood–enterocyte pathway seems important for FBZ-metabolites to reach T. suis.

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FBZ may enter T. suis from the blood–enterocyte pathway and the intestinal content.

It is recognized that the clinical efficacy of single dose benzimidazoles (BZs) against the nematode, Trichuris suis of pigs and the closely related Trichuris trichiura in humans is only poor to moderate. Recent in vitro studies have indicated that a low uptake of fenbendazole (FBZ) in T. suis may be responsible for its poor efficacy. The aim of this study was to investigate this hypothesis by measuring the concentrations of FBZ and its metabolites, oxfendazole (OXF) and FBZ sulphone (FBZSO₂), in T. suis isolated from FBZ treated pigs and in plasma of the pigs. The highest concentration of FBZ measured in T. suis was 66.6 pmol/mg dry worm tissue which was approximately half of what was measured in a previous in vitro study. The correlation between drug concentrations in plasma and in T. suis worms was highly positive for OXF (r = 0.93, P = 0.0007) and FBZSO₂ (r = 0.85, P = 0.007), but no correlation was found for FBZ. This study shows that the low uptake of FBZ observed for T. suis in vitro, also takes place in vivo. The high and significant correlations between OXF and FBZSO₂ concentrations in plasma of the pigs and T. suis (and the lack of this correlation for FBZ) suggests that the metabolites reach the worms via the blood–enterocyte interface while FBZ primarily reaches the worms via the intestinal lumen of the host.

Trichuris suis and Oesophagostomum dentatum show different sensitivity and accumulation of fenbendazole, albendazole and levamisole in vitro

Background

The single-dose benzimidazoles used against Trichuris trichiura infections in humans are not satisfactory. Likewise, the benzimidazole, fenbendazole, has varied efficacy against Trichuris suis whereas Oesophagostomum dentatum is highly sensitive to the drug. The reasons for low treatment efficacy of Trichuris spp. infections are not known.

Methodology

We studied the effect of fenbendazole, albendazole and levamisole on the motility of T. suis and O. dentatum and measured concentrations of the parent drug compounds and metabolites of the benzimidazoles within worms in vitro. The motility and concentrations of drug compounds within worms were compared between species and the maximum specific binding capacity (B_max) of T. suis and O. dentatum towards the benzimidazoles was estimated. Comparisons of drug uptake in living and killed worms were made for both species.

Principal findings

The motility of T. suis was generally less decreased than the motility of O. dentatum when incubated in benzimidazoles, but was more decreased when incubated in levamisole. The B_max were significantly lower for T. suis (106.6, and 612.7 pmol/mg dry worm tissue) than O. dentatum (395.2, 958.1 pmol/mg dry worm tissue) when incubated for 72 hours in fenbendazole and albendazole respectively. The total drug concentrations (pmol/mg dry worm tissue) were significantly lower within T. suis than O. dentatum whether killed or alive when incubated in all tested drugs (except in living worms exposed to fenbendazole). Relatively high proportions of the anthelmintic inactive metabolite fenbendazole sulphone was measured within T. suis (6–17.2%) as compared to O. dentatum (0.8–0.9%).

Conclusion/Significance

The general lower sensitivity of T. suis towards BZs in vitro seems to be related to a lower drug uptake. Furthermore, the relatively high occurrence of fenbendazole sulphone suggests a higher detoxifying capacity of T. suis as compared to O. dentatum.

The human whipworm Trichuris trichiura is together with the roundworm Ascaris lumbricoides and the hookworms Ancylostoma duodenale and Necator Americanus the most common intestinal worms worldwide. Together they place more than 5 billion people at risk of infection. The current global control strategy against these worms is regular administration of anthelmintic drugs, mostly albendazole and mebendazole, both belonging to the drug-class benzimidazoles. Both drugs have a low effect against T. trichiura infections, but the reasons for this are not known. We evaluated the in vitro effect of two benzimidazoles; i.e., albendazole, fenbendazole, and another type of anthelmintic, levamisole, on the whipworm (T. suis) and the nodular worm (Oesophagostomum dentatum) of the pig. Oesophagostomum dentatum is highly sensitive towards benzimidazoles in comparison to T. suis. We measured and compared the drug uptake in both species in both living and killed worms. Our results suggest that the reason for the difference in sensitivity is due to a lower drug uptake into T. suis as compared to O. dentatum. Furthermore, T. suis was able to metabolise fenbendazole into an inactive metabolite to a much larger extent than O. dentatum, suggesting a higher detoxifying capacity of T. suis as compared to O. dentatum.