Dosimetric and Clinical Results of a Volumetric-Based Skin-Sparing Planning Technique for Patients Treated to the Breast and Chest Wall with Pencil Beam Scanning Proton Therapy

PURPOSE/OBJECTIVE(S)

Given clinical concerns for more brisk acute skin toxicity with proton compared with photon RT due to differences in the energy deposition properties, our institution implemented a novel volumetric skin-sparing planning technique (SSPT) for intensity modulated proton therapy (IMPT) for patients treated to the breast or chest wall (CW). This study evaluates SSPT dosimetry and the hypothesis that a SSPT will reduce acute dermatitis during IMPT to the breast and CW.

MATERIALS/METHODS

Prior to the development of a consensus technique, skin dose evaluation in IMPT plans was limited to mitigation of skin hot spots and cropping off the skin surface by 3mm for CW and 5mm for intact breast targets (except indications for deliberate skin dosing). In January 2022 our center added volumetric-based skin sparing objectives in addition to hot-spot evaluation as a SSPT. A skin evaluation structure (skin-eval) was defined as a skin rind of 3 mm for CW and 5 mm for intact breast within 5mm of the CTV, bound by the patient's surface. The SSPT incorporated an objective to limit the volume of skin-eval receiving 95% of the prescription dose or more (V95%Rx) to ideally <50% (goal<60%) while still prioritizing CTV coverage and robustness. We compared target coverage, robustness, and skin-eval dosimetry as well as acute on-treatment skin toxicity in patients treated with and without incorporation of this SSPT. Patients with skin/dermal lymphatic invasion or inflammatory breast cancer were excluded.

RESULTS

84 patients who were planned to receive breast or CW IMPT were included (43 planned without and 41 with the SSPT). There was no difference in percentages of patients treated to the intact breast/CW/immediate CW reconstruction between the groups (37%/23%/40% without and 34%/27%/39% with SSPT, p>0.05). Mean skin-evalV95%Rx was 72% vs. 30%, p<0.0001, for those treated without vs. with a SSPT. Maximum %Rx to the skin volume of 0.03 cc, 0.3cc, and 1cc, was higher in patients treated without compared to those with a SSPT (103.1% vs. 101.5%; 101.3% vs. 100.4%; and 101.8% vs. 99.7% (all p=<0.0001)), respectively. There was a small statistical difference in the mean CTV V97.5%Rx in patients treated without vs. with the SSPT (97.8% vs. 96.5%, p=0.0003). Patients planned utilizing the SSPT demonstrated reduced rates of Grade 1 breast pain at Week 2 (12% vs. 33%, p=0.0424) and Grade 2 and 3 dermatitis at Week 5 (grade 2 38% vs. 42%; grade 3, 0% vs. 11%, p=0.0016). There were numerically more patients requiring a treatment break or not completing full intended prescription (4 vs. 1) in the pre-SSPT cohort.

CONCLUSION

A volumetric-based SSPT appears to reduce the frequency of brisk onset dermatitis and near-end of RT significant dermatitis while still maintaining acceptable target coverage and robustness in patients receiving IMPT to the breast and CW.

A randomized controlled trial of sequential vs simultaneous use of Foley balloon catheter and oxytocin for induction of labor in nulliparous pregnant women

BACKGROUND

Although recent evidence suggests the simultaneous approach use of oxytocin for induction of labor in nullipara, there is limited data from low-income settings that support this.

OBJECTIVE

This study aimed to determine whether induction of labor with simultaneous use of oxytocin and a Foley balloon catheter decreases the induction of labor to delivery interval in nulliparous women, compared with sequential use of a Foley balloon catheter followed by oxytocin.

STUDY DESIGN

This was a randomized controlled trial of nulliparous women with singleton pregnancies presenting for induction of labor at >28 weeks of gestation at St. Paul's Hospital Millennium Medical College (Addis Ababa, Ethiopia). The participants were randomly assigned to either the simultaneous group (the use of oxytocin and a Foley balloon catheter for induction of labor) or the sequential group (overnight intracervical Foley balloon catheter placement followed by the use of oxytocin the next morning). The primary outcome was induction of labor to delivery interval. Comparisons between the groups were made using the Student t test or Wilcoxon rank-sum test and chi-square test on Stata (version 15; StataCorp LLC, College Station, TX). This study is registered with the Pan African Clinical Trials Registry (identifier: PACTR201709002509200).

RESULTS

From November 2019 to March 2020, a total of 140 women were randomly assigned to the simultaneous group (70 women) or the sequential group (70 women). The median oxytocin initiation to delivery intervals were 6.09 hours (range, 4.03-10.7) in the sequential group and 8.1 hours (range, 4.7-11.6) in the simultaneous group (P=.46). The mean Foley balloon catheter insertion to delivery intervals were 16.09±5.7 hours in the sequential group and 8.06±4.2 hours in the simultaneous group (P<.001). Cesarean delivery rate, composite neonatal outcomes, and chorioamnionitis were not different between the 2 groups.

CONCLUSION

In nulliparous pregnant women, induction of labor using the simultaneous approach did not shorten the oxytocin initiation to delivery interval compared with the sequential approach. Moreover, both approaches showed no difference in the rates of adverse maternal and neonatal outcomes.

Effect of Package of Interventions on the Use and Quality of Postpartum Family Planning Services at Yekatit 12 Hospital Medical College (Y12HMC), Addis Ababa, Ethiopia

Background

Postpartum Family Planning (PPFP), which aims to prevent high risk unintended and closely spaced pregnancies during the first year following childbirth, is one of the highest impact interventions to avoid increased risk of premature birth, low birth weight, fetal and neonatal death, and adverse maternal health outcomes. This study aimed to assess the combined effect of a package of interventions on the use and quality of PPFP services at Y12HMC, Addis Ababa Ethiopia.

Method

Cross-sectional study design was conducted to evaluate the effect of the package of chosen interventions: creating a private counseling space near the postpartum ward and providing training for health care providers on the WHO decision tool kit and Long Acting Contraceptive Methods (LACM). Interviews were conducted with 470 women (235 before and 235 after the intervention). Frequency tables and graphs were used to describe the study variables and statistical significance between pre and post intervention indicators was declared at P value <.05.

Results

From 470 participants, 421 respondents participated which makes response rate of 90%. The majority of the participants were in the age category 20 to 29 years, married/lived together, completed at least primary education and had more than one child both at baseline and post intervention. The proportion of women who chose PPFP increased from 55.8% at baseline to 69% after the intervention. The most preferred contraceptive method was implant. The overall service satisfaction level of the study participants was 95.4% post intervention, significantly higher than at baseline (78%, P < .05). Providers indicated that clients are satisfied with the service and that the institutional structure is appropriate for delivering integrated services following the intervention.

Conclusion

This study demonstrated that quality improvement interventions like creating a private counseling space and providing training using WHO decision tool kit can achieve significant improvement on satisfaction of clients and PPFP uptake.

Genetic and molecular analysis reveals that two major loci and their interaction confer clubroot resistance in canola introgressed from rutabaga

Clubroot disease caused by Plasmodiophora brassicae is one of the serious threats to canola (Brassica napus L. subsp. napus) production. The evolution of new pathotypes rendering available resistances ineffective compel the introgression of new resistance into canola and extend our understanding of the genetic and molecular basis of the resistance. In this paper, we report the genetic and molecular basis of clubroot resistance in canola, introgressed from a rutabaga (B. napus L. subsp. rapifera Metzg. 'Polycross'), by using a doubled-haploid (DH) mapping population. Whole-genome resequencing (WGRS)-based bulked segregant analysis followed by genetic mapping and expression analysis of the genes in resistant and susceptible DH lines at 7 and 14 d after inoculation were carried out. Following this approach, two major quantitative trait loci (QTL) located at 14.41-15.44 Mb of A03 and at 9.96-11.09 Mb of A08 chromosomes and their interaction was observed to confer resistance to pathotypes 3H, 3A, and 3D. Analysis of the genes from the two QTL regions suggested that decreased expression of sugar transporter genes (BnaA03g29290D and BnaA03g29310D) may play an important role in resistance conferred by the A03 QTL, while increased expression of the toll/interleukin-1 receptor (TIR)-nucleotide binding (NB)-leucine rich repeat (LRR) (TNL) genes (BnaA08g10100D, BnaA08g09220D, and BnaA08g10540D) could be the major determinant of the resistance conferred by the A08 QTL. Single-nucleotide polymorphism (SNP) allele-specific polymerase chain reaction (PCR)-based markers, which could be detected by agarose gel electrophoresis, were also developed from the two QTL regions for use in breeding including pyramiding of multiple clubroot resistance genes.

Covid-19 Vaccine Acceptance and Predictors of Hesitance among Antenatal care Booked Pregnant in North West Ethiopia 2021: Implications for Intervention and Cues to Action

Despite efforts to decrease the burden, vaccine hesitancy is increasing worldwide and deterring efforts to control the spread of COVID-19 after the approval of SARS-CoV-2 vaccines. This study aims to assess levels of COVID-19 vaccine acceptance and predictors of hesitancy for pregnant women attending antenatal care in Ethiopia. Methods: Facility-based cross-sectional study was employed among 336 pregnant women from April 7 to June 10, 2021. The systematic random sampling technique was used to select pregnant from three health centers. Epi-Data version 3.2 and STATA/14 software were used for both data entry and analysis, respectively. A Logistic regression model was used to identify predictors of COVID-19 vaccine hesitance. Adjusted odds ratio (AOR) with a 95% confidence interval was used to estimate the strength of association at P<0.05. Result: This study included 336 pregnant mothers who were booked ANC in three health centers. The overall levels of COVID-19 vaccine acceptance among pregnant mothers were 79.17 %(95%CI: 74.5 --83.2). Whereas, having poor attitude towards COVID-19 vaccines (AOR=9.4; 95%CI: 3.7--21.1, P<0.001), monthly income ≤118.5 US dollar (AOR =6.3; 95%CI: 2.9--12.2, P<0.002), Mother who are illiterate and started ANC (AOR=9.5; 95%CI: 4.6--22.6, P<0.001), Being unplanned pregnant (AOR =7.5; 95%CI: 3.6-11.2, P<0.002), first time ANC initiated (AOR =4.2; 95%CI: 2.9--15.1, P<0.001), and pregnant didn’t used social media (AOR= 6.0: 95%CI: 2.5--14.6, P< 0.02) were significantly associated with COVID-19 Vaccine hesitance. Conclusion: The acceptability of the COVID-19 vaccine among pregnant mothers was insufficient compared with previous research. Health care workers should provide health education during ANC visits to change their negative attitude and reassurance for the safety and effectiveness of the COVID-19 vaccine.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 ) IgG-antibody seroprevalence among quarantined population, during the first wave of COVID-19 pandemic, In North West Ethiopia (from 30 April to 30 May 2020)

Objective:

The spread of Severe Acute Respiratory Syndrome Corona Virus-2 (SARS-CoV-2) in Ethiopia is below par understood and to date has been poorly characterized by a lower number of confirmed cases and deaths as compared with other regions of the Sub-Saharan African (SSA) countries. We aimed to investigate the seroprevalence of SARS-CoV-2 specific IgG antibodies, using the Abbott anti-nucleocapsid IgG chemiluminescent microparticle immunoassay, in two COVID-19 diagnosed and treatment centers of quarantined population during the first wave of the COVID-19 pandemic (since 30 April–30 May 2020).

Methods:

We analyzed data of 446 quarantined individuals during the first wave of COVID-19 pandemic. The data were collected using both interviewed and blood sample collection. Participants asked about demographic characteristics, COVID-19 infection symptoms, and its practice of preventive measures. Seroprevalence was determined using the severe acute respiratory syndrome coronavirus 2 IgG test.

Results:

The mean (± standard deviation) age of the respondent was 37.5 (±18.5) years. The estimated SARS-CoV-2 infection seroprevalence was found 4.7% (95% confidence interval: 3.1–6.2) with no significant difference on age and gender of participants. Severe acute respiratory syndrome coronavirus 2 antibody seroprevalence was significantly associated with individuals who have been worked by moving from home to work area (adjusted odds ratio = 7.8, 95% confidence interval: 4.2–14.3, p < 0.019), not wearing masks (adjusted odds ratio = 2.4, 95% confidence interval: 1.9–3.8, p < 0.02), and baseline comorbidity (adjusted odds ratio = 6.3, 95% confidence interval: 2.3–17.1, p < 0.01) as compared to their counter groups, respectively.

Conclusion:

Our study concluded that lower coronavirus disease 2019 seroprevalence, yet the large population in the community to be infected and insignificant proportion of seroprevalence, was observed between age and sex of respondents. Protective measures like contact tracing, face covering, and social distancing are therefore vital to demote the risk of community—strengthening factors should be continued as effect modification of anticipation for severe course of coronavirus disease 2019.

Exploring the variability of soil nutrient outflows as influenced by land use and management practices in contrasting agro-ecological environments

Improving our understanding of how different land uses and management practices affect soil nutrient outflows in sub-Saharan Africa could aid in developing sustainable practices. The objective of this study was to analyse the variation in outflows of soil total nitrogen (TN) and available phosphorus (P_av) as influenced by land use types (cropland, grazing land, and bushland) and land management practices (soil bunds for cropland and exclosures for non-croplands) in the three contrasting agro-ecological zones of the Upper Blue Nile basin, Ethiopia. Field data were collected for TN and P_av outflows by water erosion (Eo), leaching (Lo), product harvest (Ho), and gaseous emissions (Go) from 18 runoff plots (30 m × 6 m) for two years (2018-2019). TN and P_av losses significantly varied (p < 0.05, p < 0.01) among agro-ecological zones, land use types, and management practices. Losses of TN ranged from 39.6 to 55.5 kg ha^-1 yr^-1 and those of P_av from 4.1 to 5.9 kg ha^-1 yr^-1, with a total replacement cost of US$26-38 ha^-1 yr^-1. Nutrient losses and cost generally increased from lowland (Dibatie) to midland (Aba Gerima) to highland (Guder), although the highland and midland sites did not differ significantly (p > 0.05) in nutrient losses. Cropland showed significantly higher TN and P_av losses than other land use types, but TN loss did not differ significantly between grazing and bushland. In all land use types at all sites, the magnitude of nutrient losses was Ho >Eo >Lo >Go. In plots with land management practices, TN and P_av losses associated with Eo, Lo, and Go were reduced on average by 44-76%, 9-47%, and 1%-36%, respectively. These practices were most effective to reduce Eo nutrient losses. Further study is required to analyzing the soil nutrient balance and identify priority areas for implementing mitigation measures.

Patient preferences for prenatal testing and termination of pregnancy for congenital anomalies and genetic diseases in Ethiopia

OBJECTIVE

As prenatal diagnostic services expand throughout low-income countries, an important consideration is the appropriateness of these services for patients. In these countries, services now include prenatal ultrasound and occasionally genetic testing. To assess patient interest, we surveyed pregnant patients at a hospital in Addis Ababa, Ethiopia, on their preferences for prenatal testing and termination of affected pregnancies for congenital anomalies and genetic diseases.

METHOD

One hundred one pregnant patients were surveyed on their preferences for prenatal testing and termination of affected pregnancies using a survey covering various congenital anomalies and genetic diseases.

RESULTS

Eighty-nine percent of patients reported interest in testing for all conditions. Three percent of patients were not interested in any testing. Over 60% of patients reported interest in termination for anencephaly, early infant death, severe intellectual disability, hemoglobinopathy, and amelia. Patients were more likely to express interest in prenatal testing and termination for conditions associated with a shortened lifespan.

CONCLUSION

Ethiopian patients were interested in prenatal testing and termination of pregnancy for many conditions. Advancing prenatal diagnostic capacities is a potential strategy for addressing the incidence of congenital anomalies and genetic disease in Ethiopia. Importantly, there exist many factors and technological limitations to consider before implementation.

A survey of healthcare providers' knowledge and attitudes regarding pain relief in labor for women in Ethiopia

Background

To explore healthcare providers’ knowledge and attitudes to the need for pain relief for women in labor.

Methods

A structured questionnaire (n = 200) distributed to healthcare providers working in the obstetric departments, including theatres, of three public hospitals in different settings (rural, peri-urban and urban) in Ethiopia. Descriptive analysis was performed using Excel 2013 and SPSS version 22 for associations.

Results

The response rate was 81.5% with 164 questionnaires completed. The majority, 79% of respondents, understood that women can feel moderate to severe pain in labor and 77% were of the opinion that labor pain should be relieved. However, common practices included only supportive measures such as breathing and relaxation exercises, back massage and support from family. The general attitude of healthcare providers is that labor is a natural process, women should be able to cope and that pain relief is not a priority for women in labor. More than half, 52% of healthcare providers had safety concerns with using pharmacological methods to relieve pain in labor.

Conclusion

The majority of healthcare providers understand that women suffer significant pain during labor. However, providing effective pain relief is currently not provided as part of routine intra-partum care in Ethiopia.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1237-4) contains supplementary material, which is available to authorized users.

Mortality and Disability-Adjusted Life-Years (Dalys) for Common Neglected Tropical Diseases in Ethiopia, 1990-2015: Evidence from the Global Burden of Disease Study 2015

INTRODUCTION

Neglected tropical diseases (NTDs) are important public health problems in Ethiopia. In 2013, the Federal Ministry of Health (FMOH) has launched a national NTD master plan to eliminate major NTDs of public health importance by 2020. Benchmarking the current status of NTDs in the country is important to monitor and evaluate the progress in the implementation of interventions and their impacts. Therefore, this study aims to assess the trends of mortality and Disability-adjusted Life-Years (DALY) for the priority NTDs over the last 25 years.

METHODS

We used the Global Burden of Disease (GBD) 2015 estimates for this study. The GBD 2015 data source for cause of death and DALY estimation included verbal autopsy (VA), Demographic and Health Surveys (DHS), and other disease specific surveys, Ministry of Health reports submitted to United Nations (UN) agencies and published scientific articles. Cause of Death Ensemble modeling (CODEm) and/or natural history models were used to estimate NTDs mortality rates. DALY were estimated as the sum of Years of Life Lost (YLL) due to premature mortality and Years Lived with Disability (YLD).

RESULTS

All NTDs caused an estimated of 6,293 deaths (95% uncertainty interval (UI): 3699-10,080) in 1990 and 3,593 deaths (95% UI: 2051 - 6178) in 2015, a 43% reduction over the 25 years. Age-standardized mortality rates due to schistosomiasis, STH and leshmaniasis have declined by 91.3%, 73.5% and 21.6% respectively between 1990 to 2015. The number of DALYs due to all NTDs has declined from 814.4 thousand (95% UI: 548 thousand-1.2million) in 1990 to 579.5 thousand (95%UI: 309.4 thousand-1.3 million) in 2015. Age-standardized DALY rates due to all NTDs declined by 30.7%, from 17.6 per 1000(95%UI: 12.5-26.5) in 1990 to 12.2 per 1000(95%UI: 6.5 - 27.4) in 2015. Age-standardized DALY rate for trachoma declined from 92.7 per 100,000(95% UI: 63.2 - 128.4) in 1990 to 41.2 per 100,000(95%UI: 27.4-59.2) in 2015, a 55.6% reduction between 1990 and 2015. Age-standardized DALY rates for onchocerciasis, schistosomiasis and lymphiaticfilariasis decreased by 66.2%, 29.4% and 12.5% respectively between 1990 and 2015. DALY rate for ascariasis fell by 56.8% over the past 25 years.

CONCLUSIONS

Ethiopia has made a remarkable progress in reducing the DALY rates for most of the NTDs over the last 25 years. The rapid scale of interventions and broader system strengthening may have a lasting impact on achieving the 2020 goal of elimination of most of NTDs. Ethiopia should strengthen the coverage of integrated interventions of NTD through proper coordination with other health programs and sectors and community participation to eliminate NTDs by 2020.

The Ethiopian initiative to build sustainable capacity for operational research: overview and lessons learned

SETTING

Programme-based operational research is instrumental for the enhancement of tuberculosis (TB) control. In 2012, the Ethiopian Federal Ministry of Health launched an initiative for capacity building in operational research (OR).

OBJECTIVE

To develop sustainable capacity for OR in Ethiopia in a multiyear initiative.

DESIGN

The initiative was developed in collaboration with regional, national and international experts. Teams representing regions in Ethiopia conducted OR addressing national and regional priorities. To make use of local expertise and increase sustainability, a domestic mentor training programme was included. Existing capacity was enhanced through a competitive grant scheme providing TB researchers with financial and technical support. The Ethiopian Tuberculosis Research Advisory Committee was also supported in its functions. Regional ethics review bodies were strengthened or established where they did not exist.

RESULTS

Fifty-two people were trained and conducted 13 OR projects, of which six have been published to date. In addition, eight protocols were supported through grants. Ethics review bodies were strengthened in all regions.

CONCLUSION

The initiative trained participants from all regions and succeeded in the completion of all stages of the OR process. The success of the programme can be attributed to the team approach, 'learning while doing', integrated mentorship programme and strong national ownership.

Aggressive angiomyxoma of the pelvis and perineum: case study

Aggressive angiomyxoma (AAM) is a rare locally aggressive tumor affecting the pelvis and perineum of young females. Histopathologically, it is characterized by fibreoblasts in a myxoid background with vascular proliferation, scanty mitotic figure and no real capsule. AAM needs to be considered in the differential diagnosis of vulval mass in a reproductive age woman. We describe the first Ethiopian case of huge, recurrent, AAM of the pelvis and perineum in a 35 year old para II lady and stress that early diagnosis offers a better option for treatment by wide local excision and low recurrence rate.

Urinary phenolic glycolipid 1 in the diagnosis and management of leprosy

A simplified assay to measure the phenolic glycolipid 1 (PGL-1) of Mycobacterium leprae in the urine was applied to the diagnosis of leprosy and the monitoring of antileprosy chemotherapy. One hundred seventy-nine previously untreated patients and 25 normal controls were tested. The specificity of the assay was 100%. There were no false-positive results. The sensitivity of the assay varied with the type of leprosy from 92% for lepromatous leprosy to 56% for borderline lepromatous and 18% for borderline tuberculoid patients. After the onset of chemotherapy in lepromatous leprosy patients, there was often a transient increase of urinary PGL-1, followed by a steady decline. Within 3 months of multiple drug therapy, urinary PGL-1 levels were reduced by 90%-99% and were often undetectable. This assay appears to have considerable potential for monitoring chemotherapy and detecting treatment failure and relapse in patients with Hansen's disease.