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

PURPOSE/OBJECTIVE(S)

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

MATERIALS/METHODS

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

RESULTS

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

CONCLUSION

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

Global, but not chondrocyte-specific, MT1-MMP deficiency in adult mice causes inflammatory arthritis

Membrane-type I metalloproteinase (MT1-MMP/MMP14) plays a key role in various pathophysiological processes, indicating an unaddressed need for a targeted therapeutic approach. However, mice genetically deficient in Mmp14 show severe defects in development and growth. To investigate the possibility of MT1-MMP inhibition as a safe treatment in adults, we generated global Mmp14 tamoxifen-induced conditional knockout (Mmp14kd) mice and found that MT1-MMP deficiency in adult mice resulted in severe inflammatory arthritis. Mmp14kd mice started to show noticeably swollen joints two weeks after tamoxifen administration, which progressed rapidly. Mmp14kd mice reached a humane endpoint 6 to 8 weeks after tamoxifen administration due to severe arthritis. Plasma TNF-α levels were also significantly increased in Mmp14kd mice. Detailed analysis revealed chondrocyte hypertrophy, synovial fibrosis, and subchondral bone remodeling in the joints of Mmp14kd mice. However, global conditional knockout of MT1-MMP in adult mice did not affect body weight, blood glucose, or plasma cholesterol and triglyceride levels. Furthermore, we observed substantial expression of MT1-MMP in the articular cartilage of patients with osteoarthritis. We then developed chondrocyte-specific Mmp14 tamoxifen-induced conditional knockout (Mmp14chkd) mice. Chondrocyte MT1-MMP deficiency in adult mice also caused apparent chondrocyte hypertrophy. However, Mmp14chkd mice did not exhibit synovial hyperplasia or noticeable arthritis, suggesting that chondrocyte MT1-MMP is not solely responsible for the onset of severe arthritis observed in Mmp14kd mice. Our findings also suggest that highly cell-type specific inhibition of MT1-MMP is required for its potential therapeutic use.

Social determinants of tuberculosis in Nigeria: an ecological approach

Background: Nigeria is 4th among 22 tuberculosis high-burden countries. However, TB is not evenly distributed in the country, presumably due to state-specific risk factors. Objectives: This study maps TB and socioeconomic risk factors in Nigeria. Methods: State-level age/sex standardized tuberculosis notification data was utilized in an ecological design to evaluate the spatial distribution of TB in Nigeria and its social and economic consequences between 2012 and 2015. Negative binomial regression analysis examined the relationship between TB and five state-level covariates: HIV, BCG coverage, GDP per capita, percentage underweight, and percentage treatment success rate. Global and Local Moran’s I test statistics in R were used for spatial analysis. Results: The mean age/sex TB CNR was 54.4/100,000. Non-spatial ecological regression analysis found that TB was greater in states with high HIV, low BCG, low GDP per capita, and low TB death rates. Three states—Nasarawa, Benue, and Taraba—had high TB rates and spatially auto-correlated TB CNRs. Conclusions: TB case notification differed by age and gender. Economically-disadvantaged states exhibited higher TB case notification, HIV prevalence, lower BCG coverage, and lower mortality rates. The study found three TB hotspots. To reduce the national TB notification rate discrepancy, TB policies should incorporate social variables and target high-risk states with specific initiatives.

Identification of amino acid residues in the MT-loop of MT1-MMP critical for its ability to cleave low-density lipoprotein receptor

Low-density lipoprotein receptor (LDLR) mediates clearance of plasma LDL cholesterol, preventing the development of atherosclerosis. We previously demonstrated that membrane type 1-matrix metalloproteinase (MT1-MMP) cleaves LDLR and exacerbates the development of atherosclerosis. Here, we investigated determinants in LDLR and MT1-MMP that were critical for MT1-MMP-induced LDLR cleavage. We observed that deletion of various functional domains in LDLR or removal of each of the five predicted cleavage sites of MT1-MMP on LDLR did not affect MT1-MMP-induced cleavage of the receptor. Removal of the hemopexin domain or the C-terminal cytoplasmic tail of MT1-MMP also did not impair its ability to cleave LDLR. On the other hand, mutant MT1-MMP, in which the catalytic domain or the MT-loop was deleted, could not cleave LDLR. Further Ala-scanning analysis revealed an important role for Ile at position 167 of the MT-loop in MT1-MMP’s action on LDLR. Replacement of Ile167 with Ala, Thr, Glu, or Lys resulted in a marked loss of the ability to cleave LDLR, whereas mutation of Ile167 to a non-polar amino acid residue, including Leu, Val, Met, and Phe, had no effect. Therefore, our studies indicate that MT1-MMP does not require a specific cleavage site on LDLR. In contrast, an amino acid residue with a hydrophobic side chain at position 167 in the MT-loop is critical for MT1-MMP-induced LDLR cleavage.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pharmacologic IRE1/XBP1s activation promotes systemic adaptive remodeling in obesity

In obesity, signaling through the IRE1 arm of the unfolded protein response exerts both protective and harmful effects. Overexpression of the IRE1-regulated transcription factor XBP1s in liver or fat protects against obesity-linked metabolic deterioration. However, hyperactivation of IRE1 engages regulated IRE1-dependent decay (RIDD) and TRAF2/JNK pro-inflammatory signaling, which accelerate metabolic dysfunction. These pathologic IRE1-regulated processes have hindered efforts to pharmacologically harness the protective benefits of IRE1/XBP1s signaling in obesity-linked conditions. Here, we report the effects of a XBP1s-selective pharmacological IRE1 activator, IXA4, in diet-induced obese (DIO) mice. IXA4 transiently activates protective IRE1/XBP1s signaling in liver without inducing RIDD or TRAF2/JNK signaling. IXA4 treatment improves systemic glucose metabolism and liver insulin action through IRE1-dependent remodeling of the hepatic transcriptome that reduces glucose production and steatosis. IXA4-stimulated IRE1 activation also enhances pancreatic function. Our findings indicate that systemic, transient activation of IRE1/XBP1s signaling engenders multi-tissue benefits that integrate to mitigate obesity-driven metabolic dysfunction.

Membrane-type I matrix metalloproteinase (MT1-MMP), lipid metabolism and therapeutic implications

Lipids exert many essential physiological functions, such as serving as a structural component of biological membranes, storing energy, and regulating cell signal transduction. Dysregulation of lipid metabolism can lead to dyslipidemia related to various human diseases, such as obesity, diabetes, and cardiovascular disease. Therefore, lipid metabolism is strictly regulated through multiple mechanisms at different levels, including the extracellular matrix. Membrane-type I matrix metalloproteinase (MT1-MMP), a zinc-dependent endopeptidase, proteolytically cleaves extracellular matrix components, and non-matrix proteins, thereby regulating many physiological and pathophysiological processes. Emerging evidence supports the vital role of MT1-MMP in lipid metabolism. For example, MT1-MMP mediates ectodomain shedding of low-density lipoprotein receptor and increases plasma low-density lipoprotein cholesterol levels and the development of atherosclerosis. It also increases the vulnerability of atherosclerotic plaque by promoting collagen cleavage. Furthermore, it can cleave the extracellular matrix of adipocytes, affecting adipogenesis and the development of obesity. Therefore, the activity of MT1-MMP is strictly regulated by multiple mechanisms, such as autocatalytic cleavage, endocytosis and exocytosis, and post-translational modifications. Here, we summarize the latest advances in MT1-MMP, mainly focusing on its role in lipid metabolism, the molecular mechanisms regulating the function and expression of MT1-MMP, and their pharmacotherapeutic implications.

Atherosclerosis-associated hepatic secretion of VLDL but not PCSK9 is dependent on cargo receptor protein Surf4

Plasma LDL is produced from catabolism of VLDL and cleared from circulation mainly via the hepatic LDL receptor (LDLR). Proprotein convertase subtilisin/kexin type 9 (PCSK9) promotes LDLR degradation, increasing plasma LDL-C levels. Circulating PCSK9 is mainly secreted by the liver, whereas VLDL is exclusively secreted by hepatocytes. However, the mechanism regulating their secretion is not completely understood. Surfeit 4 (Surf4) is a cargo receptor localized in the ER membrane. It recruits cargos into coat protein complex II vesicles to facilitate their secretion. Here, we investigated the role of Surf4 in VLDL and PCSK9 secretion. We generated Surf4 liver-specific knockout mice and found that knockout of Surf4 did not affect PCSK9 secretion, whereas it significantly reduced plasma levels of cholesterol, triglyceride, and lipid-binding protein apolipoprotein B (apoB). In cultured human hepatocytes, Surf4 coimmunoprecipitated and colocalized with apolipoprotein B100, and Surf4 silencing reduced secretion of apolipoprotein B100. Furthermore, knockdown of Surf4 in LDLR knockout (Ldlr^−/−) mice significantly reduced triglyceride secretion, plasma levels of apoB and non-HDL-C, and the development of atherosclerosis. However, Surf4 liver-specific knockout mice and Surf4 knockdown in Ldlr^−/− mice displayed similar levels of liver lipids and plasma alanine aminotransferase activity as control mice, indicating that inhibition of Surf4 does not cause notable liver damage. Expression of stearoyl-CoA desaturase-1 was also reduced in the liver of these mice, suggesting a reduction in de novo lipogenesis. In summary, hepatic deficiency of Surf4 reduced VLDL secretion and the development of atherosclerosis but did not cause significant hepatic lipid accumulation or liver damage.

Membrane type 1 matrix metalloproteinase promotes LDL receptor shedding and accelerates the development of atherosclerosis

Plasma low-density lipoprotein (LDL) is primarily cleared by LDL receptor (LDLR). LDLR can be proteolytically cleaved to release its soluble ectodomain (sLDLR) into extracellular milieu. However, the proteinase responsible for LDLR cleavage is unknown. Here we report that membrane type 1-matrix metalloproteinase (MT1-MMP) co-immunoprecipitates and co-localizes with LDLR and promotes LDLR cleavage. Plasma sLDLR and cholesterol levels are reduced while hepatic LDLR is increased in mice lacking hepatic MT1-MMP. Opposite effects are observed when MT1-MMP is overexpressed. MT1-MMP overexpression significantly increases atherosclerotic lesions, while MT1-MMP knockdown significantly reduces cholesteryl ester accumulation in the aortas of apolipoprotein E (apoE) knockout mice. Furthermore, sLDLR is associated with apoB and apoE-containing lipoproteins in mouse and human plasma. Plasma levels of sLDLR are significantly increased in subjects with high plasma LDL cholesterol levels. Thus, we demonstrate that MT1-MMP promotes ectodomain shedding of hepatic LDLR, thereby regulating plasma cholesterol levels and the development of atherosclerosis.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Identification of amino acid residues in the ligand binding repeats of LDL receptor important for PCSK9 binding

Proprotein convertase subtilisin/kexin type 9 (PCSK9) promotes LDL receptor (LDLR) degradation, increasing plasma levels of LDL cholesterol and the risk of cardiovascular disease. We have previously shown that, in addition to the epidermal growth factor precursor homology repeat-A of LDLR, at least three ligand-binding repeats (LRs) of LDLR are required for PCSK9-promoted LDLR degradation. However, how exactly the LRs contribute to PCSK9’s action on the receptor is not completely understood. Here, we found that substitution of Asp at position 172 in the linker between the LR4 and LR5 of full-length LDLR with Asn (D172N) reduced PCSK9 binding at pH 7.4 (mimic cell surface), but not at pH 6.0 (mimic endosomal environment). On the other hand, mutation of Asp at position 203 in the LR5 of full-length LDLR to Asn (D203N) significantly reduced PCSK9 binding at both pH 7.4 and pH 6.0. D203N also significantly reduced the ability of LDLR to mediate cellular LDL uptake, whereas D172N had no detectable effect. These findings indicate that amino acid residues in the LRs of LDLR play an important role in PCSK9 binding to the receptor.

An Assessment of Cancer Pain Control in an LMIC Oncology Clinic

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

The Unmet Supportive Care Needs of Nigerian Patients With Cancer

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

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

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

Awareness and Perception of Strabismus Among the Youths and Women of Child-Bearing Age in a Local Government in South Western Nigeria: A Qualitative Study

Purpose To determine the awareness and perception of strabismus among the youths and women of child-bearing age in Ikenne Local Government Area (LGA) of Ogun State, South Western Nigeria. Methodology Fifteen focus group discussions (FGDs) were carried out in the LGA on the perceptions and attitudes of people to strabismus. Their responses were tape-recorded and later transcribed. A thematic phenomenological approach was used for the analysis. Result A total of 139 people participated in the FGDs, with a male:female ratio of 1:∼4. Although there was a fairly high level of awareness of strabismus in the populace, their knowledge and perception of the disease were poor. Attitudes toward the disease were based on unfounded fears and misconceptions of the disease. Conclusions We conclude that the perception and acceptance of people with strabismus by the people of Ikenne LGA was based on their poor knowledge of the disease. This in turn interfered with the uptake of health-care services for the condition.

Awareness and Perception of Strabismus Among the Youths And Women of Child-Bearing Age in a Local Government in South Western Nigeria: A Qualitative Study

Purpose To determine the level of awareness, attitudes, and perceptions of strabismus among youth and women of child-bearing age in southwestern Nigeria. Methodology Fifteen Focus Group Discussions were carried out in Ogun State Nigeria on awareness, attitudes, and perceptions of people toward strabismus. A thematic phenomenological approach was used for the analysis. Results A total of 139 people participated in the Focus Group Discussions, with a male:female ratio of 1:∼4. Although there was a fairly high level of awareness of strabismus in the populace, their attitudes and perceptions of the disease were poor, based on unfounded fears and misconceptions of the disease. Conclusions We conclude that the negative perception and acceptance of people with strabismus by the people in southwestern Nigeria is based on poor knowledge of the disease. As a result, the stigma attached to the condition appears to interfere with accessing health-care services for treatment.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Literacy, education and adherence to antiretroviral therapy in The Gambia

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

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

OBJECTIVE

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

METHOD

PubMed and MEDLINE search was performed.

RESULTS

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

CONCLUSION

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