District-Level Forecast of Achieving Trachoma Elimination as a Public Health Problem By 2030: An Ensemble Modelling Approach.

Assessing the feasibility of 2030 as a target date for global elimination of trachoma, and identification of districts that may require enhanced treatment to meet World Health Organization (WHO) elimination criteria by this date are key challenges in operational planning for trachoma programmes. Here we address these challenges by prospectively evaluating forecasting models of trachomatous inflammation-follicular (TF) prevalence, leveraging ensemble-based approaches. Seven candidate probabilistic models were developed to forecast district-wise TF prevalence in 11 760 districts, trained using district-level data on the population prevalence of TF in children aged 1-9 years from 2004 to 2022. Geographical location, history of mass drug administration treatment, and previously measured prevalence data were included in these models as key predictors. The best-performing models were included in an ensemble, using weights derived from their relative likelihood scores. To incorporate the inherent stochasticity of disease transmission and challenges of population-level surveillance, we forecasted probability distributions for the TF prevalence in each geographic district, rather than predicting a single value. Based on our probabilistic forecasts, 1.46% (95% confidence interval [CI]: 1.43-1.48%) of all districts in trachoma-endemic countries, equivalent to 172 districts, will exceed the 5% TF control threshold in 2030 with the current interventions. Global elimination of trachoma as a public health problem by 2030 may require enhanced intervention and/or surveillance of high-risk districts.

Gender differences in the surgical management of trachomatous trichiasis: an exploratory analysis of global trachoma survey data, 2015-2019.

BACKGROUND: Trachomatous trichiasis (TT) is a painful, potentially blinding eye condition that can be managed through epilation or surgery. Women are affected by TT approximately twice as often as men and are believed to face gendered barriers to receiving surgical care to prevent vision loss. METHODS: We used data from 817 cross-sectional surveys conducted during 2015-2019 in 20 African countries to estimate the prevalence difference (PD) between female and male eyes for four outcomes potentially indicating gender-related differences in TT management: (1) received surgery and developed postoperative TT (PTT), (2) never offered surgery, (3) offered surgery but declined it, and (4) offered epilation but never offered surgery. RESULTS: The prevalence was modestly elevated among female eyes compared with male eyes for having PTT (PD:1.8 [95% confidence limits (CL): 0.6, 3.0]) and having declined surgery for the eye (PD: 6.2 [95% CL: 1.8, 10.7]). The proportion offered epilation was similar by gender (PD:0.5 [95% CL: -0.4, 1.3]), while never having been offered surgery was somewhat more prevalent among male eyes (PD: -2.1 [95% CL: -3.5, -0.7]). CONCLUSIONS: Our results suggest potential gender differences in TT management. More research is needed to determine the causes and implications of the observed differences.

An Integrated Care Platform System (C3-Cloud) for Care Planning, Decision Support, and Empowerment of Patients With Multimorbidity: Protocol for a Technology Trial.

BACKGROUND: There is an increasing need to organize the care around the patient and not the disease, while considering the complex realities of multiple physical and psychosocial conditions, and polypharmacy. Integrated patient-centered care delivery platforms have been developed for both patients and clinicians. These platforms could provide a promising way to achieve a collaborative environment that improves the provision of integrated care for patients via enhanced information and communication technology solutions for semiautomated clinical decision support. OBJECTIVE: The Collaborative Care and Cure Cloud project (C3-Cloud) has developed 2 collaborative computer platforms for patients and members of the multidisciplinary team (MDT) and deployed these in 3 different European settings. The objective of this study is to pilot test the platforms and evaluate their impact on patients with 2 or more chronic conditions (diabetes mellitus type 2, heart failure, kidney failure, depression), their informal caregivers, health care professionals, and, to some extent, health care systems. METHODS: This paper describes the protocol for conducting an evaluation of user experience, acceptability, and usefulness of the platforms. For this, 2 "testing and evaluation" phases have been defined, involving multiple qualitative methods (focus groups and surveys) and advanced impact modeling (predictive modeling and cost-benefit analysis). Patients and health care professionals were identified and recruited from 3 partnering regions in Spain, Sweden, and the United Kingdom via electronic health record screening. RESULTS: The technology trial in this 4-year funded project (2016-2020) concluded in April 2020. The pilot technology trial for evaluation phases 3 and 4 was launched in November 2019 and carried out until April 2020. Data collection for these phases is completed with promising results on platform acceptance and socioeconomic impact. We believe that the phased, iterative approach taken is useful as it involves relevant stakeholders at crucial stages in the platform development and allows for a sound user acceptance assessment of the final product. CONCLUSIONS: Patients with multiple chronic conditions often experience shortcomings in the care they receive. It is hoped that personalized care plan platforms for patients and collaboration platforms for members of MDTs can help tackle the specific challenges of clinical guideline reconciliation for patients with multimorbidity and improve the management of polypharmacy. The initial evaluative phases have indicated promising results of platform usability. Results of phases 3 and 4 were methodologically useful, yet limited due to the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov NCT03834207; https://clinicaltrials.gov/ct2/show/NCT03834207. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/21994.

Trachoma.

Trachoma is a neglected tropical disease caused by infection with conjunctival strains of Chlamydia trachomatis. It can result in blindness. Pathophysiologically, trachoma is a disease complex composed of two linked chronic processes: a recurrent, generally subclinical infectious-inflammatory disease that mostly affects children, and a non-communicable, cicatricial and, owing to trichiasis, eventually blinding disease that supervenes in some individuals later in life. At least 150 infection episodes over an individual's lifetime are needed to precipitate trichiasis; thus, opportunity exists for a just global health system to intervene to prevent trachomatous blindness. Trachoma is found at highest prevalence in the poorest communities of low-income countries, particularly in sub-Saharan Africa; in June 2021, 1.8 million people worldwide were going blind from the disease. Blindness attributable to trachoma can appear in communities many years after conjunctival C. trachomatis transmission has waned or ceased; therefore, the two linked disease processes require distinct clinical and public health responses. Surgery is offered to individuals with trichiasis and antibiotic mass drug administration and interventions to stimulate facial cleanliness and environmental improvement are designed to reduce infection prevalence and transmission. Together, these interventions comprise the SAFE strategy, which is achieving considerable success. Although much work remains, a continuing public health problem from trachoma in the year 2030 will be difficult for the world to excuse.

Global progress toward the elimination of active trachoma: an analysis of 38 countries.

BACKGROUND: Global elimination of trachoma as a public health problem was targeted for 2020. We reviewed progress towards the elimination of active trachoma by country and geographical group. METHODS: In this retrospective analysis of national survey and implementation data, all countries ever known to be endemic for trachoma that had either implemented at least one trachoma impact survey shown in the publicly available Trachoma Atlas, or are in Africa were invited to participate in this study. Scale-up was described according to the number of known endemic implementation units and mass drug administration implementation over time. The prevalence of active trachoma-follicular among children aged 1-9 years (TF1-9) from baseline, impact, and surveillance surveys was categorised and used to show programme progress towards reaching the elimination threshold (TF1-9 <5%) using dot maps, spaghetti plots, and boxplots. FINDINGS: We included data until Nov 10, 2021, for 38 countries, representing 2097 ever-endemic implementation units. Of these, 1923 (91·7%) have had mass drug administration. Of 1731 implementation units with a trachoma impact survey, the prevalence of TF1-9 had reduced by at least 50% in 1465 (84·6%) implementation units and 1182 (56·4%) of 2097 ever-endemic implementation units had reached the elimination threshold. 2 years after reaching a TF1-9 prevalence below 5%, most implementation units sustained this target; however, 58 (56·3%) of 103 implementation units in Ethiopia showed recrudescence. INTERPRETATION: Global elimination of trachoma as a public health problem by 2020 was not possible, but this finding masks the great progress achieved. Implementation units in high baseline categories and recrudescent TF1-9 might prolong the attainment of elimination of active trachoma. Elimination is delayed but, with an understanding of the patterns and timelines to reaching elimination targets and a commitment toward meeting future targets, global elimination can still be achieved by 2030. FUNDING: None.

Orbital migration of schistosome eggs: a case report.

BACKGROUND: Ocular damage, including damage to the conjunctiva, lacrimal gland, eyelids, and orbit, caused by Schistosoma haematobium is sporadic. We report a clinical case of orbital migration of schistosome eggs. CASE PRESENTATION: A 14-year-old boy of Malian nationality presented with a painless swelling of the upper right eyelid, which had been gradually increasing for approximately 3 months. Visual acuity was logMAR 0.10 and 0.00 in the right and left eye, respectively. External examination revealed a right palpebral mass, pushing the globe slightly downward and inward. Computed tomography revealed a mass of the right lacrimal gland. Total excision of the mass was performed by transpalpebral orbitotomy. Pathological examination revealed an inflammatory granulomatous infiltrate of the lacrimal gland consisting of lymphocytes, eosinophils, giant cells, epithelioid cell, histiocytes and calcified Schistosoma eggs with terminal spine. Urine examination revealed eggs of S. haematobium. Praziquantel 40 mg/kg was administered to the patient. The hematuria stopped after 1 week. After 3 years of follow-up, no recurrence was noted. CONCLUSIONS: The bilharzian granuloma of the lacrimal gland is an ectopic site of the parasite. In this case, the granuloma was cured by surgical excision followed by a course of Praziquantel.

Localisation, Personalisation and Delivery of Best Practice Guidelines on an Integrated Care and Cure Cloud Architecture: The C3-Cloud Approach to Managing Multimorbidity.

BACKGROUND: C3-Cloud is an integrated care ICT infrastructure offering seamless patient-centered approach to managing multimorbidity, deployed in three European pilot sites. Challenge: The digital delivery of best practice guidelines unified for multimorbidity, customized to local practice, offering the capability to improve patient personalization and benefit. METHOD: C3-Cloud has adopted a co-production approach to developing unified multimorbidity guidelines, by collating and reconciling best practice guidelines for each condition. Clinical and technical teams at pilot sites and the C3-Cloud consortium worked in tandem to create the specification and technical implementation. RESULTS: C3-Cloud offers CDSS for diabetes, renal failure, depression and congenital heart failure, with over 300 rules and checks that deliver four best practice guidelines in parallel, customized for each pilot site. CONCLUSIONS: The process provided a traceable, maintainable and audited digitally delivered collated and reconciled guidelines.

User-Centered Design of the C3-Cloud Platform for Elderly with Multiple Diseases - Functional Requirements and Application Testing.

The number of patients with multimorbidity has been steadily increasing in the modern aging societies. The European C3-Cloud project provides a multidisciplinary and patient-centered "Collaborative Care and Cure-system" for the management of elderly with multimorbidity, enabling continuous coordination of care activities between multidisciplinary care teams (MDTs), patients and informal caregivers (ICG). In this study various components of the infrastructure were tested to fulfill the functional requirements and the entire system was subjected to an early application testing involving different groups of end-users. MDTs from participating European regions were involved in requirement elicitation and test formulation, resulting in 57 questions, distributed via an internet platform to 48 test participants (22 MDTs, 26 patients) from three pilot sites. The results indicate a high level of satisfaction with all components. Early testing also provided feedback for technical improvement of the entire system, and the paper points out useful evaluation methods.

A Collaborative Platform for Management of Chronic Diseases via Guideline-Driven Individualized Care Plans.

Older age is associated with an increased accumulation of multiple chronic conditions. The clinical management of patients suffering from multiple chronic conditions is very complex, disconnected and time-consuming with the traditional care settings. Integrated care is a means to address the growing demand for improved patient experience and health outcomes of multimorbid and long-term care patients. Care planning is a prevalent approach of integrated care, where the aim is to deliver more personalized and targeted care creating shared care plans by clearly articulating the role of each provider and patient in the care process. In this paper, we present a method and corresponding implementation of a semi-automatic care plan management tool, integrated with clinical decision support services which can seamlessly access and assess the electronic health records (EHRs) of the patient in comparison with evidence based clinical guidelines to suggest personalized recommendations for goals and interventions to be added to the individualized care plans. We also report the results of usability studies carried out in four pilot sites by patients and clinicians.

Prevalence of trachoma in the Kayes region of Mali eight years after stopping mass drug administration.

BACKGROUND: In 2009, three years after stopping mass treatment with azithromycin, a trachoma impact survey in four health districts in the Kayes region of Mali found a prevalence of trachomatous inflammation-follicular (TF) among children aged 1 to 9 years of >5% and a trachomatous trichiasis (TT) prevalence within the general population (≥1-year-old) of <1%. As a result, the government's national trachoma program expanded trichiasis surgery and related activities required to achieve trachoma elimination. METHODOLOGY/PRINCIPAL FINDINGS: In 2015, to assess progress towards elimination, a follow-up impact survey was conducted in the Kayes, Kéniéba, Nioro and Yélimané health districts. The survey used district level two-stage cluster random sampling methodology with 20 clusters of 30 households in each evaluation unit. Subjects were eligible for examination if they were ≥1 year. TF and TT cases were identified and confirmed by experienced ophthalmologists. In total 14,159 people were enumerated and 11,620 (82%) were examined. TF prevalence (95% confidence interval (CI)) was 0.5% (0.3-1%) in Kayes, 0.8% (0.4-1.7%) in Kéniéba, 0.2% (0-0.9%) in Nioro and 0.3% (0.1-1%) in Yélimané. TT prevalence (95% CI) was 0.04% (0-0.25%) in Kayes, 0.29% (0.11-0.6%) in Kéniéba, 0.04% (0-0.25%) in Nioro and 0.07% (0-0.27%) in Yélimané. CONCLUSIONS/SIGNIFICANCE: Eight years after stopping MDA and intensifying trichiasis surgery outreach campaigns, all four districts reached the TF elimination threshold of <5% and three of four districts reached the TT elimination threshold of <0.1%.

Bridging the Semantic Gap Between Diagnostic Histopathology and Image Analysis.

With the wider acceptance of Whole Slide Images (WSI) in histopathology domain, automatic image analysis algorithms represent a very promising solution to support pathologist's laborious tasks during the diagnosis process, to create a quantification-based second opinion and to enhance inter-observer agreement. In this context, reference vocabularies and formalization of the associated knowledge are especially needed to annotate histopathology images with labels complying with semantic standards. In this work, we elaborate a sustainable triptych able to bridge the gap between pathologists and image analysis scientists. The proposed paradigm is structured along three components: i) extracting a relevant semantic repository from the College of American Pathologists (CAP) organ-specific Cancer Checklists and associated Protocols (CC&P); ii) identifying imaging formalized knowledge issued from effective histopathology imaging methods highlighted by recent Digital Pathology (DP) contests and iii) proposing a formal representation of the imaging concepts and functionalities issued from major biomedical imaging software (MATLAB, ITK, ImageJ). Since the first step i) has been the object of a recent publication of our team, this study focuses on the steps ii) and iii). Our hypothesis is that the management of available semantic resources concerning the histopathology imaging tasks associated with effective methods highlighted by the recent DP challenges will facilitate the integration of WSI in clinical routine and support new generation of DP protocols.

[Juvenile retinoschisis and macular hole: a case report]. / Retinoschisis juvenile et trou maculaire: à propos d'un cas.

Juvenile retinoschisis is an inherited macular dystrophy that is transmitted in the chromosome X-linked recessive mode. Clinical signs include a macular star, with or without peripheral retinoschisis, responsible for decreased visual acuity. We report the case of a 12-year-old boy received for a visual acuity decline (VAD). His visual acuity after the best correction is 10/100 on the right and 20/100 on the left. The anterior segment examination shows no peculiarities. In funduscopy, macular striations and macular hole are observed respectivelly on the right and on the left, with inferotemporal schisis in the middle periphery. The electrophysiological assessment shows a major dysfunction of the electroretinogram. The evolution is aggravated by the occurrence of vitreous hemorrhage and retinal detachment.

Le rétinoschisis juvénile est une dystrophie maculaire héréditaire qui se transmet sur le mode récessif lié au chromosome X. Les signes cliniques incluent une étoile maculaire avec ou sans rétinoschisis périphérique responsable de baisse d'acuité visuelle. Nous rapportons le cas d'un garçon de 12 ans reçu pour une baisse d'acuité visuelle (BAV). Son acuité visuelle après la meilleure correction est de 10/100 à droite et 20/100 à gauche. L'examen du segment antérieur est sans particularités. Au fond d'œil on retrouve des stries maculaires à droite et un trou maculaire à gauche, avec un schisis inféro-temporal en moyenne périphérie. Le bilan électrophysiologique montre un dysfonctionnement majeur de l'électrorétinogramme. L'évolution est aggravée par la survenue d'une hémorragie intra vitréenne (HIV) et d'un décollement de rétine (DDR).

Active trachoma among children in Mali: Clustering and environmental risk factors.

BACKGROUND: Active trachoma is not uniformly distributed in endemic areas, and local environmental factors influencing its prevalence are not yet adequately understood. Determining whether clustering is a consistent phenomenon may help predict likely modes of transmission and help to determine the appropriate level at which to target control interventions. The aims of this study were, therefore, to disentangle the relative importance of clustering at different levels and to assess the respective role of individual, socio-demographic, and environmental factors on active trachoma prevalence among children in Mali. METHODOLOGY/PRINCIPAL FINDINGS: We used anonymous data collected during the Mali national trachoma survey (1996-1997) at different levels of the traditional social structure (14,627 children under 10 years of age, 6,251 caretakers, 2,269 households, 203 villages). Besides field-collected data, environmental variables were retrieved later from various databases at the village level. Bayesian hierarchical logistic models were fit to these prevalence and exposure data. Clustering revealed significant results at four hierarchical levels. The higher proportion of the variation in the occurrence of active trachoma was attributable to the village level (36.7%), followed by household (25.3%), and child (24.7%) levels. Beyond some well-established individual risk factors (age between 3 and 5, dirty face, and flies on the face), we showed that caretaker-level (wiping after body washing), household-level (common ownership of radio, and motorbike), and village-level (presence of a women's association, average monthly maximal temperature and sunshine fraction, average annual mean temperature, presence of rainy days) features were associated with reduced active trachoma prevalence. CONCLUSIONS/SIGNIFICANCE: This study clearly indicates the importance of directing control efforts both at children with active trachoma as well as those with close contact, and at communities. The results support facial cleanliness and environmental improvements (the SAFE strategy) as population-health initiatives to combat blinding trachoma.

Mapping xerophthalmia in Mali: results of a national survey on regional distribution and related risk factors.

BACKGROUND: Vitamin A deficiency is recognized to be a severe public health problem in most of the sahelian countries. In Mali, several surveys had been performed at the district or regional level. Unfortunately, they did not cover the entire territory. In the aim of getting a general picture, we collected information on the frequency and presentation of xerophthalmia among the children under 10 years old population recruited in the setting of a national survey planned in 1996 and 1997 to evaluate the prevalence and determinants of trachoma in Mali. METHODS: In each of the seven regions (with the exception of Bamako district), a random sample of thirty villages was taken from the general population. In a subsample of those villages, children under 10 years of age were examined by an ophthalmologist and their related mothers interviewed. Diagnosis of night blindness and Bitot spot occurrence was used for data gathering. Information was collected on village's infrastructures and familial socioeconomic condition. Multiple logistic regression analyses were performed to purpose the best model to describe the relationship between each outcome variable and the various risk factors assessed. RESULTS: The prevalence of night blindness was estimated to be 1.95% (95% Confidence Interval [CI]: 1.58-2.39) and Bitot spots frequency to be 1.10% (95% CI: 0.83-1.45) among children between 2 and 6 years of age. Xerophthalmia prevalence was 2.51% (95% CI: 2.09-3.00) and nearly similar according to gender (2.68% among boys and 2.32% among girls). By region of the country and for the same age group, the prevalence ranged from 0.26% in the Kayes region to 7.02% in the Timbuktu region. In Mali, in four regions out of seven, the WHO thresholds defining a serious public health problem have been exceeded. The higher prevalence rates were found in Timbuktu, Mopti and Segou. After adjustment to season, the main risk factors were latitude, village size and poor sanitary coverage. The main protective determinants were education and rice culture. CONCLUSIONS: This presentation illustrates a public health problem concerning vitamin A deficiency among young children in the general population and allows considering the effectiveness of substitutive intervention with vitamin A capsule distribution along with the improvement of vitamin A rich food production and consumption.

Ocular lesions associated with malaria in children in Mali.

This study sought to estimate the frequency of ocular complications in malaria and its prognostic value in Mali. A total of 140 children (aged 6 months to 9 years) with severe malaria (105 with cerebral malaria, 35 without neurological complications) were compared with 34 children with mild malaria and 82 children with nonmalarial fever. Ocular lesions were rare in the mild malaria group (5.8%). Retinal hemorrhages occurred in 11.8% of the children in the severe noncerebral malaria group. Cerebral malaria was associated with retinal hemorrhages (22.9%) and retinal edema (10.5%). No association was found between ocular signs such as retinal hemorrhages or retinal edema and mortality. Exudates, papilledema, and the presence of cottonwool spots were associated with an increased risk of death. Coma score and convulsions were significantly associated with death but not with ocular signs. The presence of retinal signs in a child in a malaria-endemic area may signal a case of severe malaria.

Prevalence of undernutrition and vitamin A deficiency in the Dogon Region, Mali.

OBJECTIVES: A representative sample of 1510 preschool children living in the Bandiagra circle (Mopti Region, Mali) was examined between March and April 1997 to determine the level of vitamin A deficiency. METHODS: Using a randomized two level cluster sampling, 20 clusters of 75 children aged six months to six years were selected for evaluating xerophthalmia (XN night blindness and/or X1B Bitot spot). Concurrently stature and weight were determined. A semiquantitative seven-day dietary questionnaire was applied to the mothers of 484 infants to assess consumption of vitamin A rich foodstuffs. The prevalence of biochemical deficiency was attested using the Modified Relative Dose Response test (MRDR) on a sub-sample of 192. RESULTS: Of the studied children, 4.3% (95% Confidence interval [CI]: 3.2-5.3) reported night blindness and 2% (95% CI: 1.3-2.7) had Bitot spots. Prevalence of xerophthalmia attested by at least one of these signs was 5.4% (95% CI: 4.2-6.5). The prevalence reached 10.5% at three years of age. The MRDR test proved abnormal in 77.1% of the subjects (95% CI: 70.3-82.7). Serum retinol was lower than 0.35 micro mol/L in 43.8% (95.6% CI: 36.9-51.3) and less than 0.70 micro mol/L in 92.7% of the children (95% CI: 87.8-95.8). Weekly consumption of vitamin A rich food was rare: 75.8% had not eaten any animal vitamin A rich food, and 22.1% had consumed less than seven times a vitamin A rich food of either vegetable or animal origin. CONCLUSIONS: These data define vitamin A deficiency as a severe public health problem in the Bandiagara area of Mali.