Benjamin Jelle Visser

Medical apps for smartphones: lack of evidence undermines quality and safety

Increasing numbers of healthcare professionals are using smartphones and their associated applications (apps) in daily clinical care. While these medical apps hold great potential for improving clinical practice, little is known about the possible dangers associated with their use. Breaches of patient confidentiality, conflicts of interests and malfunctioning clinical decision-making apps could all negatively impact on patient care. We propose several strategies to enhance the development of evidence-based medical apps while retaining their open nature. The increasing use of medical apps calls for broader discussion across medicines organising and accrediting bodies. The field of medical apps is currently one of the most dynamic in medicine, with real potential to change the way evidence-based healthcare is delivered in the future. Establishing appropriate regulatory procedures will enable this potential to be fulfilled, while at all times ensuring the safety of the patient.

Malaria: an update on current chemotherapy

Introduction: Chemotherapy of malaria has become a rapidly changing field. Less than two decades ago, treatment regimens were increasingly bound to fail due to emerging drug resistance against 4-aminoquinolines and sulfa compounds. By now, artemisinin-based combination therapies (ACTs) constitute the standard of care for uncomplicated falciparum malaria and are increasingly also taken into consideration for the treatment of non-falciparum malaria. Areas covered: This narrative review provides an overview of the state-of-art antimalarial drug therapy, highlights the global portfolio of current Phase III/IV clinical trials and summarizes current developments. Expert opinion: Malaria chemotherapy remains a dynamic field, with novel drugs and drug combinations continuing to emerge in order to outpace the development of large-scale drug resistance against the currently most important drug class, the artemisinin derivatives. More randomized controlled studies are urgently needed especially for the treatment of malaria in first trimester pregnant women. ACTs should be used for the treatment of imported malaria more consequently. Gaining sufficient efficacy and safety information on ACT use for non-falciparum species including Plasmodium ovale and malariae should be a research priority. Continuous investment into malaria drug development is a vital factor to combat artemisinin resistance and successfully improve malaria control toward the ultimate goal of elimination.

Leptospirosis in Sub-Saharan Africa: a systematic review

BACKGROUND Leptospirosis is an emerging zoonotic infection worldwide, possibly due to climate change and demographic shifts. It is regarded as endemic in Sub-Saharan Africa; however, for most countries scarce epidemiological data, if any, exist. The primary objectives were to describe the prevalence of leptospirosis in countries in Sub-Saharan Africa, and to develop options for prevention and control in the future. METHODS A systematic review was conducted to determine the prevalence of leptospirosis in Sub-Saharan Africa; the PRISMA guidelines were followed. Medline/PubMed, Embase, The Cochrane Library, Web of Science, BIOSIS Previews, the African Index Medicus, AJOL, and Google Scholar were searched. RESULTS Information about the prevalence and incidence of leptospirosis in humans is available, but remains scarce for many countries. Data are unavailable or outdated for many countries, particularly those in Central Africa. Most data are available from animals, probably due to the economic losses caused by leptospirosis in livestock. In humans, leptospirosis is an important cause of febrile illness in Sub-Saharan Africa. It concerns numerous serogroups, harboured by many different animal carriers. DISCUSSION A wide variety of data was identified. Prevalence rates vary throughout the continent and more research, especially in humans, is needed to reliably gauge the extent of the problem. Preventive measures need to be reconsidered to control outbreaks in the future.

Effectiveness of interventions for diagnosis and treatment of tuberculosis in hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review

Tuberculosis is over-represented in hard-to-reach (underserved) populations in high-income countries of low tuberculosis incidence. The mainstay of tuberculosis care is early detection of active tuberculosis (case finding), contact tracing, and treatment completion. We did a systematic review with a scoping component of relevant studies published between 1990 and 2015 to update and extend previous National Institute for Health and Care Excellence (NICE) reviews on the effectiveness of interventions for identifying and managing tuberculosis in hard-to-reach populations. The analyses showed that tuberculosis screening by (mobile) chest radiography improved screening coverage and tuberculosis identification, reduced diagnostic delay, and was cost-effective among several hard-to-reach populations. Sputum culture for pre-migration screening and active referral to a tuberculosis clinic improved identification. Furthermore, monetary incentives improved tuberculosis identification and management among drug users and homeless people. Enhanced case management, good cooperation between services, and directly observed therapy improved treatment outcome and compliance. Strong conclusions cannot be drawn because of the heterogeneity of evidence with regard to study population, methodology, and quality.

Barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by hard-to-reach populations in countries of low and medium tuberculosis incidence: a systematic review of qualitative literature

Tuberculosis disproportionately affects hard-to-reach populations, such as homeless people, migrants, refugees, prisoners, or drug users. These people often face challenges in accessing quality health care. We did a systematic review of the qualitative literature to identify barriers and facilitators to the uptake of tuberculosis diagnostic and treatment services by people from hard-to-reach populations in all European Union (EU), European Economic Area, EU candidate, and Organisation for Economic Co-operation and Development countries. The 12 studies included in this review mainly focused on migrants. Views on perceived susceptibility to and severity of tuberculosis varied widely and included many misconceptions. Stigma and challenges regarding access to health care were identified as barriers to tuberculosis diagnosis and treatment uptake, whereas support from nurses, family, and friends was a facilitator for treatment adherence. Further studies are required to identify barriers and facilitators to the improved identification and management of tuberculosis in hard-to-reach populations to inform recommendations for more effective tuberculosis control programmes.

Reviewing the evidence on nodding syndrome, a mysterious tropical disorder

OBJECTIVES To review the literature on the prevalence, clinical manifestations, pathogenesis, treatment, and implications of nodding syndrome (NS). METHODS This is a narrative review. RESULTS NS is a mysterious tropical disorder that is emerging in South Sudan, southern Tanzania, and northern Uganda. Over the past decade, thousands of children have become affected, but the prevalence is unknown. NS is characterized by an occasional nodding of the head, which is considered as a form of epilepsy. After symptoms appear, the patients health rapidly deteriorates. Seizures, stunted growth, and mental retardation may appear. In endemic areas, NS is increasingly becoming a public health problem with high morbidity and mortality, and severe social, psychological, and economic implications. However, the pathogenesis is unknown. Evidence suggests a role for Onchocerca volvulus, the parasitic filarial worm responsible for river blindness, which is highly endemic in these areas. There is no cure for NS, and treatment is symptomatic with common anticonvulsants to improve the quality of life. CONCLUSIONS NS seems to be a rapidly growing problem in several eastern African countries. Although it is starting to receive more and more attention in the scientific literature, little is known about NS. A better understanding of the pathogenesis may lead to prevention and treatment opportunities.

The influence of pregnancy on the pharmacokinetic properties of artemisinin combination therapy (ACT): a systematic review.

AbstractBackgroundPregnancy has been reported to alter the pharmacokinetic properties of anti-malarial drugs, including the different components of artemisinin-based combination therapy (ACT). However, small sample sizes make it difficult to draw strong conclusions based on individual pharmacokinetic studies. The aim of this review is to summarize the evidence of the influence of pregnancy on the pharmacokinetic properties of different artemisinin-based combinations.MethodsA PROSPERO-registered systematic review to identify clinical trials that investigated the influence of pregnancy on the pharmacokinetic properties of different forms of ACT was conducted, following PRISMA guidelines. Without language restrictions, Medline/PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, Biosis Previews and the African Index Medicus were searched for studies published up to November 2015. The following components of ACT that are currently recommend by the World Health Organization as first-line treatment of malaria in pregnancy were reviewed: artemisinin, artesunate, dihydroartemisinin, lumefantrine, amodiaquine, mefloquine, sulfadoxine, pyrimethamine, piperaquine, atovaquone and proguanil.ResultsThe literature search identified 121 reports, 27 original studies were included. 829 pregnant women were included in the analysis. Comparison of the available studies showed lower maximum concentrations (Cmax) and exposure (AUC) of dihydroartemisinin, the active metabolite of all artemisinin derivatives, after oral administration of artemether, artesunate and dihydroartemisinin in pregnant women. Low day 7 concentrations were commonly seen in lumefantrine studies, indicating a low exposure and possibly reduced efficacy. The influence of pregnancy on amodiaquine and piperaquine seemed not to be clinically relevant. Sulfadoxine plasma concentration was significantly reduced and clearance rates were higher in pregnancy, while pyrimethamine and mefloquine need more research as no general conclusion can be drawn based on the available evidence. For atovaquone, the available data showed a lower maximum concentration and exposure. Finally, the maximum concentration of cycloguanil, the active metabolite of proguanil, was significantly lower, possibly compromising the efficacy.ConclusionThese findings suggest that reassessment of the dose of the artemisinin derivate and some components of ACT are necessary to ensure the highest possible efficacy of malaria treatment in pregnant women. However, for most components of ACT, data were insufficient and extensive research with larger sample sizes will be necessary to identify the exact influences of pregnancy on the pharmacokinetic properties of different artemisinin-based combinations. In addition, different clinical studies used diverse study designs with various reported relevant outcomes. Future pharmacokinetic studies could benefit from more uniform designs, in order to increase quality, robustness and effectiveness. Study registration: CRD42015023756 (PROSPERO)

A social media self-evaluation checklist for medical practitioners.

Increasing numbers of medical practitioners and medical students are using online social and business-related networking websites such as Facebook, Doc2doc and LinkedIn. These rapidly evolving and growing social media have potential to promote public health by providing powerful instruments for communication and education. However, evidence is emerging from studies, legal cases, and media reports that the use of these new technologies is creating several ethical problems for medical practitioners as well as medical students. Improper online activities may harm not only individual reputations and careers, but also the medical profession as a whole, for example by breach of patient confidentiality, defamation of colleagues and employers, undisclosed conflict of interests that bias the medical practitioners medical advice, posting of advice/information without an evidence base, and infringement of copyright. We developed a self-evaluation checklist for medical practitioners using social media. The checklist addresses three key elements in the use of social media: personal information and accessibility, connections, and postings. It contains questions specifically formulated to evaluate a medical practitioners social media profile, to prevent unintended, improper online activities and to promote professional online behaviour.

A 24-year-old Ethiopian Farmer with Burning Feet

Podoconiosis is a non-infectious tropical disease caused by exposure of bare feet to irritant alkalic clay soils. This causes an asymmetrical swelling of the feet and lower limbs due to lymphoedema. This swelling is called “elephantiasis” and may lead to severe disability of the patient. It is found in areas of tropical Africa, Central and South America and north-west India, where such soils coexist with high altitude, high seasonal rainfall and low income. Social stigmatization of people with the disease is widespread and economic losses are enormous. Podoconiosis is unique in being an entirely preventable non-communicable tropical disease. However, so far it has received little attention from health care policy makers.

Travel-related leptospirosis in the Netherlands 2009-2016: An epidemiological report and case series.

BACKGROUND Leptospirosis is a potentially fatal zoonotic disease that is prevalent in travellers. Here, we describe epidemiological and diagnostic characteristics of all returning travellers diagnosed with leptospirosis in the Netherlands between 2009 and 2016. Furthermore, we present a detailed clinical case series of all travellers with leptospirosis who presented at the Academic Medical Center (AMC) in the same period. METHOD We extracted data from the records of the Dutch Leptospirosis Reference Center (NRL) of all cases of leptospirosis in travellers in the Netherlands from 2009 to 2016. Patients who presented at the AMC were identified and clinical data were extracted from the hospital records. RESULTS 224 cases of travel-related leptospirosis were included. An increase of cases was observed from 2014 onwards. The majority of cases were male (78.1%), and had travelled to South-East Asia (62.1%). Of 41 AMC cases, 53.7% were hospitalised, but most patients had a relatively mild disease course, with no fatalities. A longer delay in diagnosis and treatment initiation existed in hospitalised compared to non-hospitalised patients, suggesting a benefit of early recognition and treatment. CONCLUSIONS Leptospirosis was increasingly observed in returning travellers in the Netherlands, and is a diagnosis that should be considered in any returning febrile traveller.