HIV post-exposure prophylaxis programmes in the developed and developing world: can we learn from each other?

In an audit of HIV post-exposure prophylaxis (PEP) programmes in Blantyre, Malawi, and Liverpool, UK, a striking common deficiency was poor attendance of follow-up visits and of HIV testing to determine efficacy of PEP. Causes of poor follow-up after PEP need to be explored in both settings.     

A new method to estimate quantitatively seminal vesicle and prostate gland contributions to ejaculate

AIMS: We sought to optimize a quantitative noninvasive method to determine the concentration in their glands of origin of biochemical markers of compartments of the male genital tract as the first step towards validation of a novel method for estimation of drug concentrations in these male genital tract compartments. METHODS: Sixty-eight men participated. We compared four collection devices to split ejaculate into fractions. Fractions were assayed for fructose and prostate specific antigen (PSA) as unique markers of the seminal vesicle and prostate, respectively. Seminal vesicle fructose and prostatic PSA were estimated using a linear regression method, based on fructose-PSA axis intercepts, and compared with an older method which solves a simultaneous series of equations. RESULTS: A five-compartment collection device performed best with mean (95% confidence interval) PSA vs. fructose r(2) of 0.84 (0.71, 0.98, P < 0.001). Using resampling simulations, glandular PSA and fructose estimates were highly variable and often implausible when using only two fractions. Using our method, the prostate contributed 37-44% to the whole ejaculate and the seminal vesicle contributed 55-61%. The novel regression method was highly correlated (r(2) > or = 0.98) with older methods. CONCLUSIONS: We developed a noninvasive quantitative method of male genital tract biochemical marker estimation using a five-compartment tray to collect three to five ejaculate fractions. Our novel regression method is quantitative and more fully developed than older methods. This noninvasive method for determining glandular marker concentrations should be useful to provide quantitative estimates of drug concentrations in these glands.     

Do multiple concurrent infections in African children cause irreversible immunological damage?

Much of the developing world, particularly sub-Saharan Africa, has high levels of morbidity and mortality associated with infectious diseases. The greatest risk of invasive disease is in the young, the malnourished and HIV-infected individuals. In many regions in Africa these vulnerable groups and the wider general population are under constant immune pressure from a range of environmental factors, under-nutrition and multiple concurrent infections from birth through to adulthood. Intermittent microbial exposure during childhood is required for the generation of naturally acquired immunity capable of protection against a range of infectious diseases in adult life. However, in the context of a resource-poor setting, the heavy burden of malarial, diarrhoeal and respiratory infections in childhood may subvert or suppress immune responses rather than protect, resulting in sub-optimal immunity. This review will explore how poor maternal health, HIV exposure, socio-economic and seasonal factors conspire to weaken childhood immune defences to disease and discuss the hypothesis that recurrent infections may drive immune dysregulation, leading to relative immune senescence and premature immunological aging.     

“Not just dogs,but rabid dogs”: tensions and conflicts amongst research volunteers in Malawi

Building trust between researchers and communities involved in research is one goal of community engagement. This paper examines the implications of community engagement for trust within communities, including trust among community volunteers who assist with research and between these volunteers and other community members. We describe the experiences of two groups of community volunteers recruited as part of an HIV and TB intervention trial in Malawi: cluster representatives, recruited both to act as key informants for TB suspects and mortality reporting and to identify and report community concerns, and community counsellors, recruited to provide semi-supervised HIV self-testing. We examine tensions experienced due to playing multiple roles, and the implications of volunteer responsibilities for short- and long-term community relationships. Data was collected through a workshop, in-depth interviews and focus group discussions with volunteers and community members. While the volunteer system initially enhanced trust among volunteers and with the community, relationships deteriorated when cluster representatives assumed an additional supervisory role part-way through the trial. Combined with challenging recruitment targets and unequal power relations between volunteers, this new role damaged trust, with implications for volunteer well-being and social relationships. These experiences suggest researchers should consider potential social implications when designing community engagement systems.     

Nerve growth factor and basic fibroblast growth factor promote reinnervation by nerve−muscle−endplate grafting

Introduction: Grip strength (GS) is a common measure of general muscle strength in patients with chronic inflammatory demyelinating polyneuropathy (CIDP). However, it is important to investigate the correlation and responsiveness of GS compared with isokinetic muscle strength (IKS) and function of the lower limbs. Methods: Seventy patients with CIDP were evaluated with GS, IKS, and functional measures of the lower limbs. Reevaluation was performed after 2 and 10/12 weeks. Correlation and response analyses were performed. Results: GS correlated with IKS at the ankle (IKS_ankle; maximum Spearman's rank‐order correlation [R_S] = 0.58) and with walking performance (maximum R_S = ?0.38). IKS_ankle was more responsive to detect change (standardized response mean [SRM] = 0.57) than GS (SRM = 0.27). Discussion: GS does not seem to be an appropriate surrogate measure of IKS and function of the lower limbs in patients with CIDP. Muscle Nerve 58 : 449–452, 2018     

Severe acidosis in patients taking metformin--rapid reversal and survival despite high APACHE score.

BACKGROUND: Metformin has been shown to reduce complications and mortality from Type 2 diabetes mellitus, and is increasingly used to treat this condition. This agent is, however, associated with a rare but serious risk of lactic acidosis. CASE REPORT: We present cases of 10 patients with Type 2 diabetes mellitus who developed acute renal failure and severe lactic acidosis. Despite the severity of their illness, all patients but one survived. CONCLUSIONS: The increasing prevalence of Type 2 diabetes and its treatment with metformin might result in more cases of lactic acidosis. However our case report demonstrates that early and aggressive treatment with haemofiltration can improve outcomes even in the presence of severe acidosis.     

Tuberculosis control in Malawian prisons: from research to policy and practice.

Following an operational research study in Zomba Central Prison, Malawi, in 1996, the National Tuberculosis Control Programme (NTP) and the Prison Medical Services worked together to improve the diagnosis and treatment of tuberculosis (TB) in prisoners. Prisoners are screened for TB on admission and during their prison sentences. A system was established of treating patients, according to NTP guidelines, while in prison and on discharge from prison. Monitoring and evaluation is undertaken using TB officers at district and regional level, and 6-monthly meetings are held with all stakeholders and the central unit to collate data and review prison TB control activities.     

Local perceptions of tuberculosis in a rural district in Malawi.

SETTING: Ntcheu district, Malawi. OBJECTIVE: To determine 1) the number of patients treated by traditional healers, 2) the type of diseases managed by them, 3) the perceived causes of these disease, and 4) how both patients and healers looked at tuberculosis (TB). DESIGN: In-depth interviews and structured questionnaires with traditional healers, and focus group discussions with TB patients and their guardians. RESULTS: Traditional healers recognized four main causes of disease, related to why the patient is sick rather than what the patient is suffering from. Two hundred and seventy-six traditional healers saw approximately 4600 patients a week, managing a variety of diseases, mainly of a chronic nature. Twenty-four per cent of patients seen by traditional healers had a cough, including patients with TB. Traditional healers believe they can cure TB, and have therefore been briefed on the infectious form of TB (smear-positive cases). The possibility of including traditional healers in early diagnosis has been explored. CONCLUSION: There is a need to address local beliefs in health education and possibly find ways of involving healers in supervision of treatment.