Intra-Rater Reliability and Agreement of the Indurometer When Used to Assess Mid-Calf Tissue Compressibility Among People Affected by Moderate to Severe Lymphedema in Bangladesh and Ethiopia.

Background: Lymphedema is a chronic skin disease that induces tissue fibrosis (stiffness). Tissue tonometry has been used to assess skin and tissue compressibility in lymphedema, primarily in research on arm lymphedema after breast cancer. A digital tonometer, the Indurometer (Flinders and SA Biomedical Engineering, Australia), has shown excellent intra-rater reliability in young healthy people in Australia and Myanmar and was able to detect covert changes in young, asymptomatic Myanmar people infected with lymphatic filariasis. It has not been tested in overt lower-limb lymphedema. Methods and Results: The Indurometer was used in a cluster randomized trial in Bangladesh and Ethiopia to measure tissue compressibility among adults affected by moderate to severe lymphatic filariasis- or podoconiosis-related leg lymphedema. The study compared different self-care intervention and after baseline there were follow-ups at 4, 12, and 24 weeks. Three consecutive Indurometer scores were collected by two data collection teams in each country at the mid-calf of each leg. Indurometer scores were available for three time-points in Bangladesh and four time-points in Ethiopia. An intra-class correlation coefficient (ICC) was calculated for each data collection team, and a coefficient of variation (CV) was used to assess measurement agreement in moderate and severe stages of lymphedema. The intra-rater reliability among local research assistants was good to excellent in both countries at all time-points (ICC range 0.829 [95% confidence interval; CI 0.730-0.896]-0.992 [95% CI 0.989-0.995]). In Bangladesh, agreement between measures was highest among unaffected legs (range 16%-22%) and lowest in severe lymphedema (range 19%-39%). CV scores in Ethiopia showed no distinct pattern for lymphedema stage (range 15%-32%). Conclusion: The Indurometer is an inexpensive and easy-to-use device to assess skin and tissue compressibility and should be considered in clinical research on lower-limb lymphedema.

Addition of Lymphatic Stimulating Self-Care Practices Reduces Acute Attacks among People Affected by Moderate and Severe Lower-Limb Lymphedema in Ethiopia, a Cluster Randomized Controlled Trial.

Lymphedema causes disability and exacerbates poverty in many countries. The management of lymphatic filariasis (LF) and podoconiosis-related lymphedema involves daily hygiene to reduce secondary infections, but self-massage and deep-breathing, which have proven beneficial in cancer-related lymphedema, are not included. A cluster randomized trial in northern Ethiopia investigated the effects of lymphatic stimulation for people affected by moderate to severe lymphedema. Participants were allocated to either standard (control n = 59) or enhanced (intervention n = 67) self-care groups. Primary outcomes were lymphedema stage, mid-calf circumference, and tissue compressibility. Secondary outcomes were the frequency and duration of acute attacks. After 24 weeks, fewer patients were assessed as severe (control -37.8%, intervention -42.4%, p = 0.15) and there were clinically relevant changes in mid-calf tissue compressibility but not circumference. There was a significant between-group difference in patients who reported any acute attacks over the study period (control n = 22 (38%), intervention n = 7 (12%), p = 0.014). Daily lymphedema self-care resulted in meaningful benefits for all participants with a greater reduction in acute episodes among people performing lymphatic stimulation. Observations of a change in lymphedema status support earlier findings in Bangladesh and extend the demonstrated benefits of enhanced self-care to people affected by podoconiosis.

Defaulters from antiretroviral treatment in Jimma University Specialized Hospital, Southwest Ethiopia.

OBJECTIVE: To determine the prevalence of and factors associated with defaulting from antiretroviral treatment (ART) in Jimma, Ethiopia. METHODS: Unmatched case control study: cases were individuals who had missed two or more clinical appointments (i.e. had not been seen for the last 2 months) between January 2005 and February 2007; controls were individuals who had been on ART at least for 1 year and were rated as excellent adherers by the providers. Data were collected from patient records, and by telephone call and home visit to identify the reason for defaulting. RESULTS: Of 1270 patients who started ART, 915 (72.0%) were active ART users and 355 (28.0%) had missed two or more clinical appointments. The latter comprised 173 (13.6%) defaulters, 101 (8.0%) who transferred out, 75 (5.9%) who died, and 6 (0.5%) who restarted ART. Reasons for defaulting were unclear in most cases. Reasons given were loss of hope in medication, lack of food, mental illness, holy water, no money for transport, and other illnesses. Tracing was not successful because of incorrect address on the register in 61.6% of the cases. Taking hard drugs (cocaine, cannabis and IV drugs), excessive alcohol consumption, being bedridden, living outside Jimma town and having an HIV negative or unknown HIV status partner were associated with defaulting ART. CONCLUSION: A significant proportion of patients defaulted from ART treatment. ART clinics should ensure that patients' addresses are correct and complete. Programmatic and counseling efforts to decrease ART defaulting should address illicit drug and excessive alcohol use, decentralise ART services, institute home-based treatment options for seriously ill and bedridden patients, and address patients concerns.