Patient Preferences for Benefit and Risk Associated With High Intensity Focused Ultrasound for the Ablation of Prostate Tissue in Men With Localized Prostate Cancer.

INTRODUCTION: Food and Drug Administration must make decisions about emerging high intensity focused ultrasound (HIFU) devices that may lack relevant clinical oncologic data but present with known side effects. This study aims to capture patients' perspective by quantifying their preferences regarding the available benefit and important side effects associated with HIFU for localized prostate cancer. MATERIALS AND METHODS: Preferences for HIFU outcomes were examined using a discrete choice experiment survey. Participants were asked to choose a preferred treatment option in 9 choice questions. Each included a pair of hypothetical treatment profiles that have similar attributes/outcomes with varying levels. Outcomes included prostate biopsy outcome and treatment-related risks of erectile dysfunction (ED) and urinary incontinence (UI). We calculated the maximum risk of side effect patients were willing to tolerate in exchange for increased benefit. Preferences were further explored via clinical and demographic data. RESULTS: About 223 subjects with a mean age of 64.8 years completed the survey. Respondents were willing to accept a 1.51%-point increase in new ED risk for a 1%-point increase in favorable biopsy outcome. They were also willing to accept a 0.93%-point increase in new UI risk for a 1%-point increase in biopsy outcome. Subjects who perceived their cancer to be more aggressive had higher risk tolerance for UI. Younger men were willing to tolerate less ED risk than older men. Respondents with greater than college level of education had a lower risk tolerance for ED or UI. CONCLUSIONS: Results may inform development and regulatory evaluation for future HIFU ablation devices by providing supplemental information from the patient perspective.

Using Separate Single-Outcome Risk Presentations Instead of Integrated Multioutcome Formats Improves Comprehension in Discrete Choice Experiments.

INTRODUCTION: Despite decades of research on risk-communication approaches, questions remain about the optimal methods for conveying risks for different outcomes across multiple time points, which can be necessary in applications such as discrete choice experiments (DCEs). We sought to compare the effects of 3 design factors: 1) separated versus integrated presentations of the risks for different outcomes, 2) use or omission of icon arrays, and 3) vertical versus horizontal orientation of the time dimension. METHODS: We conducted a randomized study among a demographically diverse sample of 2,242 US adults recruited from an online panel (mean age 59.8 y, s = 10.4 y; 21.9% African American) that compared risk-communication approaches that varied in the 3 factors noted above. The primary outcome was the number of correct responses to 12 multiple-choice questions asking survey respondents to identify specific numbers, contrast options to recognize dominance (larger v. smaller risks), and compute differences. We used linear regression to test the effects of the 3 design factors, controlling for health literacy, graph literacy, and numeracy. We also measured choice consistency in a subsequent DCE choice module. RESULTS: Mean comprehension varied significantly across versions (P < 0.001), with higher comprehension in the 3 versions that provided separated risk information for each risk. In the multivariable regression, separated risk presentation was associated with 0.58 more correct responses (P < 0.001; 95% confidence interval: 0.39, 0.77) compared with integrated risk information. Neither providing icon arrays nor using vertical versus horizontal time formats affected comprehension rates, although participant understanding did correlate with DCE choice consistency. CONCLUSIONS: In presentations of multiple risks over multiple time points, presenting risk information separately for each health outcome appears to increase understanding. HIGHLIGHTS: When conveying information about risks of different outcomes at multiple time points, separate presentations of single-outcome risks resulted in higher comprehension than presentations that combined risk information for different outcomes.We also observed benefits of presenting single-outcome risks separately among respondents with lower numeracy and graph literacy.Study participants who scored higher on risk understanding were more internally consistent in their responses to a discrete choice experiment.

Non-Fusion Versus Fusion Surgery in Pediatric Idiopathic Scoliosis: What Trade-Offs in Outcomes Are Acceptable for the Patient and Family?

BACKGROUND: Vertebral body tethering and other non-fusion techniques for the treatment of pediatric idiopathic scoliosis are increasing in popularity. There is limited physician consensus on this topic as the result of a paucity of published data regarding which patients most benefit from non-fusion strategies. Thus, much of the decision-making is left to patients and parents, who must select a treatment based on their goals and values and the information available from health-care providers, the internet, and social media. We sought to understand patient and family preferences regarding the attributes of fusion versus non-fusion surgery that drive these choices. METHODS: Patients and families were recruited from 7 pediatric spine centers and were asked to complete a survey-based choice experiment that had been jointly developed with the U.S. Food and Drug Administration (FDA) to evaluate patient preferences. Choices between experimentally designed alternatives were analyzed to estimate the relative importance of outcomes and requirements associated with the choice options (attributes). The attributes included appearance, confidence in the planned correction, spinal motion, device failure, reoperation, and recovery period. The inclusion criteria were (1) an age of 10 to 21 years and (2) a diagnosis of adolescent idiopathic scoliosis in patients who were considering, or who had already undergone, treatment with fusion or non-fusion surgery. Preference weights were estimated from the expected changes in choice given changes in the attributes. RESULTS: A total of 344 respondents (124 patients, 92 parents, and 128 parent/patient dyads) completed the survey. One hundred and seventy-three patients were enrolled prior to surgery, and 171 were enrolled after surgery. Appearance and motion were found to be the most important drivers of choice. For the entire cohort, fusion was preferred over non-fusion. For patients who were considering surgery, the most important attributes were preservation of spinal motion and appearance. CONCLUSIONS: Patients and families seeking treatment for idiopathic scoliosis value appearance and preservation of spinal motion and, to a lesser extent, reoperation rates when considering fusion versus non-fusion surgery.

Household coverage of ivermectin distribution in birnin kudu local government area of Jigawa State, Nigeria.

Purpose: To assess community-directed treatment coverage with Ivermectin (CDTI) in Onchocerciasis-endemic communities in Birnin Kudu local government area (LGA) Jigawa state. Subjects and Methods: This was a community-based multistaged cross-sectional survey based on probability proportional to size. The study involved the administration of a questionnaire on 2021 respondents from 207 households. Also, 30 Community Leaders and Community Directed Distributors (CDDs) were purposively selected for interview from the communities visited. Results: Overall, 2021 respondents from the 2031 sampled population took part in the study giving a response rate of 99.6%. Slightly above half, 1130 (55.9%) were males. The geographic and therapeutic coverage of mass drug administration of Ivermectin achieved in the LGA was 100% and 79.9%, respectively. The key factors affecting coverage includes the unavailability of drugs (48.8%), absenteeism of some of the household members (31%), and inadequate incentives to the CDDs by the government and poor record keeping by the CDDs. Conclusion: This study found that the minimum geographic and therapeutic coverage of Ivermectin distribution was achieved by CDD as recommended by the World Health Organization for the control of onchocerciasis. For this to be sustained and to achieve elimination, there must be an adequate supply of ivermectin, training of CDDs, retraining of CDDs, adequate supervision in record keeping, and health education to the community.

Résumé Objectif: Évaluer la couverture du traitement sous direction communautaire à l'ivermectine (TIDC) dans les communautés endémiques de l'onchocercose de la zone d'administration locale de Birnin Kudu (LGA) dans l'État de Jigawa. Sujets et méthodes: Il s'agissait d'une enquête transversale communautaire à plusieurs degrés basée sur une probabilité proportionnelle à la taille. L'étude a impliqué l'administration d'un questionnaire sur 2021 répondants de 207 ménages. De plus, 30 leaders communautaires et distributeurs dirigés par la communauté (CDD) ont été délibérément sélectionnés pour un entretien dans les communautés visitées. Résultats: Globalement, 2021 répondants sur la population échantillonnée de 2031 ont participé à l'étude, soit un taux de réponse de 99,6 %. Un peu plus de la moitié, 1130 (55,9 %) étaient des hommes. La couverture géographique et thérapeutique de l'administration massive d'ivermectine obtenue dans la LGA était de 100 % et de 79,9 %, respectivement. Les principaux facteurs affectant la couverture comprennent l'indisponibilité des médicaments (48,8%), l'absentéisme de certains membres du ménage (31%), et les incitations inadéquates aux DC par le gouvernement et la mauvaise tenue des dossiers par les DC. Conclusion: Cette étude a révélé que la couverture géographique et thérapeutique minimale de la distribution d'ivermectine était atteinte par le CDD tel que recommandé par l'Organisation mondiale de la santé pour le contrôle de l'onchocercose. Pour que cela soit durable et pour parvenir à l'élimination, il doit y avoir un approvisionnement adéquat en ivermectine, une formation des DC, un recyclage des DC, une supervision adéquate de la tenue des dossiers et une éducation sanitaire de la communauté. Mots-clés: Distributeurs communautaires, TIDC, ivermectine, onchocercose.

Patient Preferences Regarding Surgical Treatment Methods for Symptomatic Uterine Fibroids.

STUDY OBJECTIVE: The purpose of this study is to rank the factors that are most and least important to patients with symptomatic uterine fibroids when considering surgical treatment options. MATERIALS AND METHODS: Using a best worst scaling (BWS) preference elicitation approach, participants completed an online survey to rank factors associated with fibroid surgical treatments. Survey content was based on a literature review and included the following factors: symptom relief; surgical complications; repeat treatment; recovery time; cosmetic effects; risk of spreading undiagnosed cancer; sexual outcomes; maintenance of child-bearing; continuation of menses; unpredictable menses; and location of procedure. Participants completed 11 BWS tasks. For each task, we presented participants with a subset of 5 factors from the possible 11, and participants chose the most important and least important factor. Participants' responses were analyzed using conditional logistic regression to determine the relative importance of factors. Patient priorities were further explored via age and race. RESULTS: 285 respondents with symptomatic uterine fibroids (69 physician-confirmed and 216 self-reported) who had not undergone prior surgical treatment completed the survey. Respondents were enrolled from two clinical sites (clinical site cohort) and an online consumer panel (panel cohort). Both cohorts identified symptom relief, cancer risk, repeat treatment and complications as the most important factors in selecting surgical treatment options and location of procedure, return to normal activities after surgery, and cosmetic effects like presence of a scar after the surgical treatment as the least important factors. Of note, younger women (≤ 40) placed greater importance on the ability to have children after the procedure. CONCLUSION: Information regarding the factors most and least important to patients with symptomatic uterine fibroids might inform development and regulatory evaluation of new technologies and procedures. Study results may be useful in efforts to develop a set of outcomes to include in future fibroids clinical studies.

A Case of Absence of Meibomian Glands in the Lower Eyelids of A Middle-Aged Female in Abuja, Nigeria.

The absence of the Meibomian gland is a rare cause of evaporative dry eye disease. A 45year old Lady, a known patient of our clinic whom we have been managing for allergic conjunctivitis for the past 5 years, started complaining of her eyes feeling dry and foreign body sensation 2 years ago. Her ocular surface disease index was 12.5, dry eye symptom score was 7 out of 14. She had no Meibomian orifices on her lower lid margin, but the upper lid orifices were present in both eyes, with normal expression of fluid when expressed. There were 23 and 25 Meibomian orifices opening in the upper lids respectively, the meiboscore in both upper lids were 0 and in both lower lids were 3, the tear film breakup time was 2 seconds in both eyes, the Schirmer's test I was 5mm and 7mm, the Schirmer's test II was 3 and 6 mm in the right and left eye respectively. The conjunctiva was normal, the cornea in the right eye had punctate epithelial erosions in the inferior 1/3rd of the cornea, and the left cornea was not stained. Other than these findings the anterior and posterior segment were essentially normal. Anterior segment OCT pictures of the everted lids showed the Meibomian gland superiorly and these were absent inferiorly. She has been placed on Gutt Sodium Hyaluronate 0.2%, 3 hourly, and OcHypromellose Opthalmic Gel 0.3% enriched with Carbomer 980 USP 0.25% at night. She says her symptoms resolved while on these medications. Although the congenital absence of the Meibomian gland is rare, they can present late with dry eye symptoms and mimic allergic conjunctivitis symptoms. We should examine the Meibomian orifices of all our patients to identify those with these abnormalities early. The report also highlights the importance of anterior segment OCT in evaluating the Meibomian gland.

A Study of Visual Functions Amongst Primary Open-Angle Glaucoma Patients in Abuja, Nigeria.

Background: To objectively measure visual function amongst Primary Open Angle Glaucoma (POAG) patients and compare these with age and sex-matched controls by describing the characteristics of visual function in relation to the severity of POAG. Methodology: A case-control study was carried out among 106 POAG patients and an equal number of age-sex matched controls attending Asokoro District Hospital, Abuja, and Eye Foundation Hospital Abuja from Nov 2012 to April 2013. The objective measures of visual function assessed include visual acuity (VA), contrast sensitivity (CS), colour vision (CV), and visual fields (MD) in the better eye (BE)]. Results: All measures of visual function were found to be reduced comparing cases to controls and this was statistically significant. VABE (0.39±0.73; 0.0017±0.02p<0.001); MDBE (-8.02±6.80; 0.17±0.3P<0.001); CSBE (1.46±0.59; 1.90±0.16p<0.001): Colour vision defects (54.7%; 6.6% p<0.001). In comparing mild; moderate; severe glaucoma: VABE (0.0053±0.03; 0.057±0.08; 0.766±0.90 p<0.001); MDBE (-3.46±1.93;-8.17±3.55;-16.43±6.01p <0.001); CSBE (1.88±0.26; 1.69± 0.37; 1.11±0.59 p<0.001): Color vision defects (20.6%; 31.6%; 86.9%) respectively (BE: Better Eye). While looking at the two independent groups above, mild and moderate were not statistically significant except for the visual field, but comparing mild with severe and moderate with severe, they had a statistically significant relationship across all the visual functions tested. In comparing controls with mild, color vision and visual field had a statistically significant difference. Comparing the groups with mild and moderate glaucoma, only visual fields as a visual function were statistically significant. Whereas comparing both groups with the severe group independently, they had statistically significant in all the visual functions tested. Conclusion: In conclusion, visual function was reduced in glaucoma patients as compared to controls. Visual acuity, contrast sensitivity and colour vision differed significantly in comparing mild with severe and moderate with severe. Color vision differed significantly in comparing mild to controls.

Correlation between Health-Related Quality Of Life Scores and Measures of Visual Function in an Abuja Cohort of Primary Open Angle Glaucoma Patients.

Background: This study aims to correlate quality of life measures with visual function parameters and to determine the visual function parameters that independently affect the quality of Life in primary open angle glaucoma patients (POAG) in Abuja. Methodology: A cross sectional study carried out among 106 POAG patients attending Asokoro District Hospital, Abuja and Eye Foundation Hospital Abuja from Nov 2012 to April 2013. National Eye Institute Visual Function Questionnaire 25 (NEIVFQ25) and Glaucoma Symptom Scale (GSS) were used to assess Quality of Life (QoL) after biodata was obtained. The objective measures of visual function assessed include: visual acuity (VA), contrast sensitivity (CS), colour vision (CV) and visual fields (Mean Deviation). Data was analysed using SPSS Version 20 using Spearman Rho Correlation and linear regression. Results: There was a strong correlation between the NEIVFQ25 scores and all the measures of visual function. There was also a strong correlation between GSS and contrast sensitivity in both eyes, and mean deviation of the better eye while the others showed a moderate correlation with the scale. On multivariate analysis of the NEIVFQ25 scores by visual function, the independent visual functions that affects the NEIVFQ25 QoL measures were the visual acuity better eye and contrast sensitivity better eye. Contrast sensitivity in the better eye had a stronger correlation than visual acuity in the better eye. On multivariate analysis of GSS scores by visual function parameters, contrast sensitivity in the better and worse eye were the independent visual function parameters that affect the GSS. The contrast sensitivity of the better eye had a stronger correlation with NEIVFQ25 and GSS. Conclusion: The study revealed the impact of contrast sensitivity on the quality of life and glaucoma symptoms the patients have. It is important that measures of contrast sensitivity be incorporated into evaluating glaucoma patients. Key Messages: Contrast sensitivity of the better eye was the visual function parameter that affected the vision related quality of life scale the most.

A case of Subconjunctival Filariasis in Abuja,Nigeria.

The report presents a case of subconjunctival filariasis in a 20-year-old female student who schools in Oye-Ekiti, Ekiti State, a known loa loa endemic region in Nigeria, and resident in Abuja. The patient presented on the 20th of February 2020, with a history of foreign body sensation and itching on two occasions within a 6-month period and had video evidence of a worm in her left eye. The worm was however not visualized in the clinic. She was placed on tabs Albendazole 20mg twice daily for 21 days and has not felt or seen the worm since she completed the medications. Subconjunctival filariasis is still an issue of concern in the rainforest region of Nigeria.

Comparing Central Corneal Thickness Using Ultrasound and Anterior Segment Optical Coherence Tomography Pachymetry in Adults Attending A Private Eye Clinic in Abuja.

Background: Central Corneal Thickness (CCT) measurement is useful in the management of glaucoma, ocular hypertension, corneal lesions and kerato-refractive surgeries. The study aims to compare the CCT measurements between Ultrasound Sonography (USS) and Optical Coherence Tomography (OCT), to analyze correlation and agreement between these instruments as well as repeatability of each instrument. Methodology: A cross sectional comparative study carried in 100 eyes of 50 patients attending Rachel Eye Center in Abuja from January to March 2021. The CCT were taken using the USS and OCT. CCT was measured using the Pachscan ultrasound and the Optovue machine utilised for the OCT technique. Data was analysed using SPSS version 20 using Paired Sample t Test, Pearson's correlation, Interclass Correlation and Bland Altman Methods. Results: Patients were aged between 18 and 79 (mean age of 39.1), 72 males and 28 females. The mean CCT was 537.36 ±33.26 and 510.94 ±33.13 for USS and OCT respectively with a mean difference of (26.42±9.53 p<0.001). There was a very strong correlation of the 2 sets of measurement r = 0.997 p<0.001. There was a high average mean intraclass correlation coefficient of 0.843 between the two instruments and this was excellent (0.961) within the 95 percentile upper limit but poor in the (0.096) lower limit. There was a high correlation and no statistical significant difference in the comparing repeated mean USS and OCT measurements. There was an excellent average mean Intraclass Correlation Coefficient of 0.999/0.997 for the repeated OCT and USS values and this was found to be excellent(0.999/0.998) within the 95 percentile upper limit and (0.997/0.994)lower limit respectively. Conclusion: We find that measurements of CCT using the Pachscan ultrasound and the Optovue OCT correlate well, but the mean Pachscan measures were significantly higher than Optovue measures.

A Case of Frequent Blinking and Abnormal Eyeball Movement Associated with Generalized Epilepsy.

Eyelid myoclonus is an idiopathic generalized epileptic syndrome that can occur with or without absence seizures. The features include frequent blinking, an upward roll of the eyeballs, and slight backward movement of the head. It can be spontaneous or stimulated by light. Light and eyelid closure are triggers to the seizures. A 13-year-old young male student presented with a four months history of frequent blinking and abnormal eye movements. There was a positive history of leg tapping while asleep which started a year prior to presentation, but there was no loss of consciousness. On presentation, the patient was a young healthy looking myope who frequently blinks with sudden upward and left jerky movements of the eyeballs. Visual acuity was CF at 2 meters in both eyes improving with -4.50DS to 6/6. Intraocular pressures were 12 mmHg bilaterally. Anterior and posterior segment findings were normal. Brain MRI was normal, but EEG was abnormal with features suggestive of generalized epilepsy. He was co-managed with the neurologist and placed initially on Tabs Sodium valproate 250mg for 3 months. This was modified to Tabs Sodium Valproate (controlled release) 500mg at night since there was little change. This resulted in an appreciable reduction in blinking and abnormal eye movement. The leg tapping stopped on this dose. Eyelid myoclonus (EM) is a rare form of epilepsy. It is of utmost importance to create awareness of the disease among physicians. Early diagnosis and treatment are important prognostic factors of the disease. Key Messages: There is a need to create awareness of Eyelid Myoclonus among physicians as this can easily be missed or misdiagnosed.

Intravitreal linezolid in the management of vancomycin-resistant enterococcal endophthalmitis.

PURPOSE: Linezolid is a synthetic antibiotic, the first of the oxazolidinone class, used for the treatment of infections caused by multi-resistant bacteria including Streptococcus, methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). We report on a case of endophthalmitis caused by vancomycin-resistant Enterococcus feacium treated with intravitreal linezolid. It has proved efficacious in animal models but its safety in humans is not fully known. OBSERVATIONS: An 84-year-old man who had phacoemulsification surgery and anterior chamber intraocular lens due to posterior capsule rent. Visual acuity (VA) following surgery was 6/24 uncorrected. The following week he developed signs of endophthalmitis, characterized by corneal infiltration and keratic precipitates, with anterior chamber and vitreous haze. Cultures yielded no growth, while repeated treatments with intravitreal vancomycin, ceftazidime, and amphotericin B did not control the infection. Vitrectomy was performed twice during the patient's course, with intravitreal amikacin injection after the second vitrectomy, but poor control of the endophthalmitis persisted. After several weeks of limited response to treatments, the diagnosis was finally made using Giemsa stain of direct smear which showed characteristic morphology of Enterococcus faecium. Linezolid, one of the oxazo-lidinones, was initially given in oral form 600 mg BID for three weeks, but did not prove efficacious. Subsequently, intravitreal linezolid 200 mcg in 0.1ml was injected, which cleared the vitreous and cornea infection within a week. However, there was a residual exudative detachment of the retina in the posterior pole, leaving the patient with a final vision of hand movement. CONCLUSION AND IMPORTANCE: Vancomycin-resistant enterococcus is a rare cause of endophthalmitis. Intravitreal linezolid is an effective treatment, but the subsequent exudative retinal detachment may have been related to this novel therapy.

Correction: Temperature extremes and infant mortality in Bangladesh: Hotter months, lower mortality.

[This corrects the article DOI: 10.1371/journal.pone.0189252.].

Prostate Ablation Using High Intensity Focused Ultrasound: A Literature Review of the Potential Role for Patient Preference Information.

PURPOSE: The FDA (Food and Drug Administration) recently allowed the marketing of 2 high intensity focused ultrasound devices for prostate tissue ablation indications after previous rejections for a prostate cancer indication due to insufficient data on clinical effectiveness or direct patient benefit. We reviewed the safety and effectiveness of high intensity focused ultrasound and knowledge regarding patient preferences, such as tolerance for adverse events associated with high intensity focused ultrasound ablation of tissue, in men with prostate cancer. This may inform decision making for device developers and the FDA. MATERIALS AND METHODS: We searched PubMed® and gray literature, including FDA reports for relevant data on 1) the safety and effectiveness of primary and salvage high intensity focused ultrasound of localized prostate cancer in studies performed in or outside the United States and 2) patient preference information on high intensity focused ultrasound related safety and effectiveness outcomes. RESULTS: We found no high intensity focused ultrasound effectiveness data relevant to clinical decision making, such as overall or prostate cancer specific survival, in the United States. Long-term effectiveness data from outside the United States were sparse and outcomes varied. We also found no patient preference data on high intensity focused ultrasound treatment in men with prostate cancer. CONCLUSIONS: The lack of long-term high intensity focused ultrasound oncological data in an American population has brought new challenges to prostate cancer stakeholders, including clinicians, patients and the FDA. Patient preference information from future patient studies on high intensity focused ultrasound could provide additional information to patients, clinicians, and current and prospective device developers. In addition, it can be used by regulators in benefit-risk evaluations of this class of treatment devices.

Temperature extremes and infant mortality in Bangladesh: Hotter months, lower mortality.

BACKGROUND: Our study aims to obtain estimates of the size effects of temperature extremes on infant mortality in Bangladesh using monthly time series data. METHODS: Data on temperature, child and infant mortality were obtained for Matlab district of rural Bangladesh for January 1982 to December 2008 encompassing 49,426 infant deaths. To investigate the relationship between mortality and temperature, we adopted a regression with Autoregressive Integrated Moving Average (ARIMA) errors model of seasonally adjusted temperature and mortality data. The relationship between monthly mean and maximum temperature on infant mortality was tested at 0 and 1 month lags respectively. Furthermore, our analysis was stratified to determine if the results differed by gender (boys versus girls) and by age (neonates (≤ 30 days) versus post neonates (>30days and <153days)). Dickey Fuller tests were performed to test for stationarity, and since the time series were non-stationary, we conducted the regression analysis based on the first differences of mortality and temperature. RESULTS: Hotter months were associated with lower infant mortality in Bangladesh. Each degree Celsius increase in mean monthly temperature reduced monthly mortality by 3.672 (SE 1.544, p<0.05) points. A one degree increase in mean monthly temperature one month prior reduced mortality by 0.767 (SE 0.439, p<0.1) for boys and by -0.0764 (SE 0.366, NS) for girls. Beneficial effects of maximum monthly temperature were on the order of 0.623 to -0.712 and statistically significant for girls and boys respectively. Effect sizes of mean monthly temperature were larger for neonates at 1.126 (SE 0.499, p<0.05) than for post-neonates at 0.880 (SE 0.310, p<0.05) reductions in mortality per degree. CONCLUSION: There is no evidence that infant survival is adversely affected by monthly temperature extremes in Bangladesh. This may reflect a more heightened sensitivity of infants to hypothermia than hyperthermia in this environment.

Using best-worst scaling to rank factors affecting vaccination demand in northern Nigeria.

BACKGROUND: Understanding and ranking the reasons for low vaccination uptake among parents in northern Nigeria is critical to implement effective policies to save lives and prevent illnesses. This study applies best-worst scaling (BWS) to rank various factors affecting parents' demand for routine childhood immunization. METHODS: We conducted a household survey in Nahuche, Zamfara State in northern Nigeria. Nearly two hundred parents with children under age five were asked about their views on 16 factors using a BWS technique. These factors focused on known attributes that influence the demand for childhood immunization, which were identified from a literature review and reviewed by a local advisory board. The survey systematically presented parents with subsets of six factors and asked them to choose which they think are the most and least important in decisions to vaccinate children. We used a sequential best-worst analysis with conditional logistic regression to rank factors. RESULTS: The perception that vaccinating a child makes one a good parent was the most important motivation for parents in northern Nigeria to vaccinate children. Statements related to trust and social norms were ranked higher in importance compared to those that highlighted perceived benefits and risks, healthcare service, vaccine information, or opportunity costs. Fathers ranked trust in the media and views of their leaders to be of greatest importance, whereas mothers placed greater importance on social perceptions and norms. Parents of children without routine immunization ranked their trust in local leaders about vaccines higher in considerations, and the media's views lower, compared to parents with children who received routine immunization. CONCLUSIONS: Framing immunization messages in the context of good parenting and hearing these messages from trusted information sources may motivate parental uptake of childhood vaccines. These results are useful to policymakers to prioritize resources in order to increase awareness and demand for childhood immunization.

Impact assessment study after 27 years of community-directed treatment with ivermectin in Galadimawa, Kaduna State, Nigeria.

PURPOSE: To assess the impact on blindness after 27 years of community-directed treatment with ivermectin (CDTI) in the Galadimawa community of Kauru Local Government in Kaduna state, Nigeria. The population of Galadimawa constituted about 12% of the total population examined during the ivermectin randomised control trial (RCT) in 1989. The RCT population of 8000 individuals was scattered over 36 villages in Kaduna state. Thus, longitudinal data are available on blindness. MATERIALS AND METHODS: After 27 years of dosing with ivermectin, the people in the community of Galadimawa were re-examined for the prevalence and causes of blindness. This was achieved by an examination of the visually disabled. The findings were compared with the situation in 1989 before the dosing commenced. RESULTS: The population of the village increased from 711 to 1419. The prevalence of blindness dropped from 4.9 to 0.96%. The most common causes of blindness were now cataract (55.2%) and optic atrophy (27.6%), whereas the most common causes in 1989 were onchocerciasis (28.3%), glaucoma (17.4%) and cataract (10.9%). People with optic atrophy were more likely to have taken fewer doses of ivermectin over the years. The blind people encountered in 2016 were on average 17 years older than those seen in 1989, which suggests that blindness, when it occurs, is delayed by almost two decades. CONCLUSION: CDTI has reduced the prevalence of blindness significantly in Galadimawa and may reflect the situation elsewhere in the Kaduna state, which is an oncho-endemic zone.

Micropulse diode laser trabeculoplasty in Nigerian patients.

INTRODUCTION: The term micropulse laser trabeculoplasty suggests that only a fraction of the laser power is applied to the trabeculum to effect pressure lowering. It has not yet been exclusively used in Negroes, and we wish to report on our experience in Nigerian patients. METHODS: The study design is a retrospective chart review of our patients at the Rachel Eye Center in Abuja. The 810 diode Optos FastPulse laser was used to apply 34 cycles of treatment to 30 eyes of 16 individuals. Patients were selected based on the failure of maximal medical therapy. One patient had two extra rounds of treatment, while two patients were treated in only one eye. The pressure change at 1 hour after the treatment was analyzed. Patients were followed up for a mean period of 160 days with continuous monitoring of pressure changes. Patients' original therapy was not disturbed. RESULTS: Postlaser immediate drop in intraocular pressure (IOP) averaged 3.2 mmHg (CI 1.6-4.7, P<0.0001) representing 17.2% drop from baseline prelaser IOP. The drop in IOP was sustained over varying periods, from a few weeks to several months. There was a temporary spike in three instances. No serious side effects were noted. CONCLUSION: Micropulse diode laser trabeculoplasty is a useful adjunct in the management of open-angle glaucoma in Nigerians. This corroborates the findings of other researchers in western populations.

Length of hospitalisation for people with severe mental illness.

BACKGROUND: In high-income countries, over the last three decades, the length of hospital stays for people with serious mental illness has reduced drastically although considerable variation remains. In lower-income countries this variation may be greater. Some argue that reduction in hospital stay leads to 'revolving door admissions' and worsening mental health outcomes despite apparent cost savings, whilst others suggest longer stays may be more harmful by institutionalising people to hospital care. OBJECTIVES: To evaluate the effect of short stay/brief admission hospital care with long stay/standard in-patient care in people with serious mental illness. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's register of trials, July 2007 and updated this search in May 2012. SELECTION CRITERIA: We included all randomised controlled trials comparing planned short/brief with long/standard hospital stays for people with serious mental illnesses. DATA COLLECTION AND ANALYSIS: We extracted data independently. For dichotomous data we calculated risk ratios (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis based using a fixed-effect model. For continuous data, had we identified such data, we planned to calculate fixed-effect mean differences (MD). We assessed risk of bias for included studies and rated quality of evidence using GRADE. MAIN RESULTS: We included six relevant trials undertaken between 1969 and 1980. We found no significant difference in death (n = 175, 1 RCT, RR in the longer term 0.42, CI 0.10 to 1.83, very low quality evidence). In the long term, there was no difference in improvement of mental state (n = 61, 1 RCT, RR 3.39, CI 0.76 to 15.02, very low quality evidence). There was no difference in readmission to hospital (n = 651, 4 RCTs, RR by the long term 1.26, CI 1.00 to 1.57, low quality evidence). Data for leaving the study prematurely by the longer term showed no difference (n = 229, 2 RCTs, (RR 0.77, CI 0.34 to 1.77, low quality evidence). There was a significant difference favouring short stay (P = 0.01) in numbers of participants with delayed discharge from hospital exceeding the time planned in study (n = 404, 3 RCTs, RR in the longer term 0.54, CI 0.33 to 0.88, low quality evidence). There was no difference in numbers of participants lost to follow-up (n = 404, 3 RCTs, RR by the longer term 1.07, CI 0.70 to 1.62, low quality evidence). Finally, there was a significant difference favouring short-stay hospitalisation for social functioning, including unemployment, unable to housekeep, or unknown employment status (n = 330, 2 RCTs, RR by longer term 0.61, CI 0.50 to 0.76, very low quality evidence). AUTHORS' CONCLUSIONS: The effects of hospital care and the length of stay is important for mental health policy. We found limited low and very low quality data which were all over 30 years old. Outcomes from these studies do suggest that a planned short-stay policy does not encourage a 'revolving door' pattern of admission and disjointed care for people with serious mental illness. More large, well-designed and reported trials are justified especially where a short-stay policy is not routine care.

Ocular onchocerciasis: current management and future prospects.

This paper reviews the current management of onchocerciasis and its future prospects. Onchocerciasis is a disease affecting millions of people in Africa, South and Central America, and Yemen. It is spread by the blackfly as a vector and caused by the filarial nematode, Onchocerca volvulus. A serious attempt was made by the Onchocerciasis Control Program between 1975 and 2002 to eliminate the vector in eleven of the endemic countries in West Africa, and with remarkable success. Formerly, the treatment was with diethyl carbamazine for the microfilaria and suramin for the adult worm. These drugs are now known to be toxic and unsuitable for mass distribution. In particular, they precipitate optic nerve disease. With the discovery of ivermectin, a much safer microfilaricide, and the decision of Merck to distribute the drug free of charge for as long as needed, the strategy of control switched to mass drug administration through community-directed treatment with ivermectin. So far, millions have received this annual or biannual treatment through the African Program for Onchocerciasis Control and the Onchocerciasis Elimination Program for the Americas. However, the problem with ivermectin is that it is a monotherapy microfilaricide which has limited effect on the adult worm, and thus will need to be continued for the life span of the adult worm, which may last up to 15 years. There are also early reports of resistance. Serious encephalopathy and death may occur when ivermectin is used in subjects heavily infested with loiasis. It seems unlikely that a break in transmission will occur with community-directed treatment with ivermectin in Africa because of population migrations and the highly efficient vector, but in the Americas some countries such as Columbia and the Oaxaca focus in Mexico have reported eradication. Vector control is only now applicable in selected situations, and particularly to control the nuisance value of the blackfly. Trials are ongoing for alternatives to ivermectin. Candidate drugs include moxidectin, a macrofilaricide, doxycycline which targets the Wolbachia endosymbiont, and flubendazole, which shows promise with the newer oral cyclodextrin formulation.