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Patients' preferences of cutaneous leishmaniasis treatment outcomes: Findings from an international qualitative study
Astrid C. Erber ,
Roles Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Writing – original draft, Writing – review & editing
* E-mail: astrid.erber@ndm.ox.ac.uk
Affiliations Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom, Department of Epidemiology, Center for Public Health, Medical University of Vienna, Vienna, Austria
Byron Arana,
Roles Conceptualization, Methodology, Validation, Writing – review & editing
Affiliation Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
Afif Ben Salah,
Roles Investigation, Methodology, Validation, Writing – review & editing
Affiliations Institut Pasteur de Tunis, Tunis, Tunisia, Department of Family and Community Medicine, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
Issam Bennis,
Affiliations National School of Public Health, Rabat, Morocco, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
Aicha Boukthir,
Affiliation Institut Pasteur de Tunis, Tunis, Tunisia
María del Mar Castro Noriega,
Affiliations Centro Internacional de Entrenamiento de Investigaciones Médicas (CIDEIM), Cali, Colombia, Universidad Icesi, Cali, Colombia
Mamoudou Cissé,
Affiliation Centre MURAZ, Bobo-Dioulasso, Burkina Faso
Gláucia Fernandes Cota,
Affiliation Instituto René Rachou (IRR), Fundação Oswaldo Cruz (FIOCRUZ), Minas Gerais, Brazil
Farhad Handjani,
Affiliation Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
Liliana López-Carvajal,
Roles Conceptualization, Investigation, Methodology, Validation, Writing – review & editing
Affiliation Programa de Estudio y Control de Enfermedades Tropicales (PECET), Universidad de Antioquia, Medellín, Colombia
Kevin Marsh,
Roles Supervision, Writing – review & editing
Affiliation Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
Dalila Martínez Medina,
Affiliations Facultad de Medicina "Alberto Hurtado", Universidad Peruana Cayetano Heredia, Lima, Perú, Departamento de Enfermedades Infecciosas, Dermatológicas y Tropicales, Hospital Cayetano Heredia, Lima, Perú
Emma Plugge,
Roles Conceptualization, Formal analysis, Methodology, Supervision, Writing – review & editing
Affiliations Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom, UK Collaborating Centre for the WHO Health in Prisons Programme, Public Health England, Reading, United Kingdom
Trudie Lang ,
Contributed equally to this work with: Trudie Lang, Piero Olliaro
Piero Olliaro
Roles Conceptualization, Methodology, Project administration, Supervision, Validation, Writing – review & editing
Affiliations Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom, Special Programme for Research & Training in Tropical Diseases (WHO/TDR), Geneva, Switzerland
Astrid C. Erber,
Liliana López-Carvajal
Version 2 Version 1 Uncorrected Proof
Astrid C. Erber Byron Arana ... Piero Olliaro
Cutaneous leishmaniasis (CL) is a disease that often affects exposed skin areas and may heal leaving lifelong scars. Patients' expectations from treatment are rarely considered in drug development for CL. An initiative aiming to address shortcomings in clinical trial design and conduct for CL treatments involving the researchers' community is on-going. This manuscript presents patient-preferred outcomes for CL and an assessment on how to consider these in the conduct of future trials.
Methodology/Principal findings
We report preferred treatment outcomes by 74 patients with confirmed CL in endemic regions of Brazil, Burkina Faso, Colombia, Iran, Morocco, Peru and Tunisia during individual in-depth interviews. Beyond outcomes customarily considered in trials (such as lesion appearance and adverse events), patients talked about a large number of outcomes related to quality of life, such as pain, scar formation, and others affecting their work and daily activities. They also reported fears around getting rid of the parasite, disease recurrence, and possible sequelae.
Conclusions/Significance
The study results provide a rich insight into important outcomes for CL treatments, as well as related topics, from the perspective of a diverse patient population. Among the outcomes identified, we argue that those related to quality of life as well as recurrence should be included to a greater extent for assessment in clinical trials, and discuss the suitability of measurement instruments such as the Dermatology Quality of Life Index (DLQI). Interviews also point out the potential need to address concerns related to parasitological cure or scar formation, such as social stigmatization and disability. In addition, patients should be given information in order to clarify reported misconceptions. This study therefore suggests a methodology for consulting CL patients on outcomes as elements of clinical trial design, and how to incorporate these outcomes in trials. It also discusses how reported outcomes could be addressed in clinical care.
Author summary
Cutaneous Leishmaniasis (CL) is a parasitic disease transmitted by sand fly vectors causing lesions and potentially life-long scars. Trials for CL treatments so far have not included patients' input, such as their preferences on outcomes. This study reports treatment outcomes seen as important by patients that were explored through semi-structured interviews conducted in CL-endemic regions in Brazil, Burkina Faso, Colombia, Iran, Morocco, Peru and Tunisia. In addition to outcomes mostly considered in trials centered on lesion evolution and adverse events, patients reported a wide range of further outcomes and concerns. These are related to their quality of life, but also parasitological cure, potential for recurrence and sequelae of the disease. We suggest possibilities on how to include and measure a number of these patient-preferred outcomes into trials, and discuss ways of considering others in the context of treatment and clinical trials, e.g. via information provided to patients.
Citation: Erber AC, Arana B, Ben Salah A, Bennis I, Boukthir A, Castro Noriega MdM, et al. (2020) Patients' preferences of cutaneous leishmaniasis treatment outcomes: Findings from an international qualitative study. PLoS Negl Trop Dis 14(2): e0007996. https://doi.org/10.1371/journal.pntd.0007996
Editor: Charles John Lacey, University of York, UNITED KINGDOM
Received: July 2, 2019; Accepted: December 15, 2019; Published: February 24, 2020
Copyright: © 2020 Erber et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work was supported by grants from the Special Programme for Research and Training in Tropical Diseases (TDR) (www.who.int/tdr/en/) to ABS, MMCN, MC, GFC, FH and DMM and a grant from the Drugs for Neglected Diseases initiative (DNDi) (www.dndi.org/) to LLC. ACE is a recipient of a DOC-fFORTE fellowship of the Austrian Academy of Sciences (www.oeaw.ac.at/en/) at the Nuffield Department of Medicine, University of Oxford. TDR had the dual role of being the funder and having an active role in the planning, execution and interpretation of the research as well as in strengthening the researchers' capacity in qualitative research, in line with its mission to support research and capacity for research.
Cutaneous leishmaniasis (CL) is the most frequent form of leishmaniasis, one of the Neglected Tropical Diseases (NTD) [1]. CL occurs across tropical, subtropical and temperate regions and is broadly divided in old-world and the new-world forms (OWCL and NWCL), which are caused by different species and cause a range of clinical manifestations [2]. It causes visible lesions on exposed parts of the body, which can be distressing, discomforting and potentially leave life-long scars, although not life-threatening. At present, there is no treatment which is effective, safe and easy to administer against all clinical forms of the disease. This is largely due to the lack of investments in drug development for a disease that affects essentially impoverished populations, it is also contributed to by weaknesses in the design and conduct of clinical trials for CL interventions which render meta-analysis of results and evidence-based recommendations difficult [2–9].
Progress has been made in addressing these shortcomings through reaching consensus across the OWCL and NWCL researchers' community on critical aspects of clinical trial methodologies for CL [10,11], however, patients' views have not yet been genuinely considered, especially regarding treatment outcomes. Trials conducted so far emphasize clinical and parasitological endpoints, but rarely report outcomes affecting patients' quality of life (QoL), or factor in patients' needs in the design phase: A recent systematic review on outcomes included in trials for CL interventions [7] found that nearly all (100% and 86.35% of the studies which included initial and definitive cure, respectively) used complete re-epithelisation of the ulcer as the definition of 'cure'. Additional criteria that were variably present included: absence of active lesion, no relapse, negative parasitological test, clinical improvement, no appearance of new lesions, and/or reversible hypopigmentation. Additional information can be derived from previous systematic reviews: of the 48 studies included in systematic reviews of trials conducted on NWCL, seven did not report adverse events, and none measured the degree of functional and aesthetic impairment, prevention of scarring, or QoL [3,8]. Among 89 trials considered in a Cochrane Collaboration systematic review for OWCL, prevention of scarring was measured in eight studies, and adverse events in all but eight; no study was found to measure the degree of functional or aesthetic impairment, or QoL [6].
There is increasing consensus that patients' involvement in health research can lead to higher rates of enrolment and retention, and improve its translation into clinical practice [12]; it meets also an ethical mandate towards 'democratizing' the research process [13]. Involving patients in the definition of treatment outcomes is recommended, though not frequent practice yet [14–16], but has proved useful in identifying outcomes not previously brought up by other stakeholders [17,18]. The COMET (Core Outcomes Measures in Effectiveness Trials) initiative [19] is committed to the development of Core Outcome Sets (COS), actively involving patients in their development. A COS, consisting of Core Outcomes or Core Outcome Measures (COMs), is an agreed minimum set of outcomes that should be measured and reported in clinical trials of a specific disease or trial population [14,17,18,20].
The purpose of this study is to present findings relating to OWCL and NWCL patients' expectations on desired treatment outcomes as part of a large multi-centre qualitative study exploring patients' perceptions and understanding of CL. This will complement the consensus reached among the clinical research communities [10,11]. Together, these comprehensive approaches are intended to improve the design of interventions and the way these are assessed, so as to achieve better care for neglected populations affected by CL.
We conducted 74 individual, semi-structured in-depth interviews with CL patients at sites in seven endemic countries (Brazil, Burkina Faso, two regions in Colombia, Iran, Morocco, Peru, and Tunisia), as described in the protocol [21]. These countries were chosen due to their CL disease burden, prevalent Leishmania species, and accessibility for research. Interviews were conducted by the local principal investigators (PIs) in the endemic regions, who are researchers or health care professionals (HCPs) working with CL patients.
All sites used collaboratively-developed, equivalent protocols and interview topic guides ([21], supplementary file 1), with minor adaptations depending on the country specific ethics committees' requirements. For this study, a two-step sampling approach was used. Maximum variation was sought within a defined patient spectrum along characteristics such as patients' gender, age, treatment status (before, during, after treatment), clinical lesion presentation and causative Leishmania species, under the assumption that this would cover the range of patients'/disease profiles. The background parameters informing the sampling strategy, including CL epidemiology at each site, can be found in [21], supplementary file 2.
The interviews lasted about one hour, were conducted in the patient's mother tongue and audio recorded; interviewers took notes before, during and after the interviews. Each recording was transcribed verbatim into the language in which the interview was conducted and then translated into English for analysis, either by the PIs or a dedicated person. Translated transcripts were verified and if necessary back-translated by the PIs who conducted the interviews, in order to confirm the accuracy of translation, before they were forwarded for analysis. Detailed in-text notes, e.g. explaining regional dialect or colloquial expressions, and communication in person to clarify any misunderstandings helped with analysis and interpretation.
Thematic content analysis with a coding framework following the six distinct steps described by Braun and Clarke [22] was used. The coding framework was developed collaboratively during a face-to-face meeting of investigators after familiarization with the data, based on three initial interview transcripts from Morocco. Transcripts were read twice, and sections organized under different, suitable headings. Headings were grouped into seven broader domains (nodes): Costs, Symptoms, Impact on daily life, Relationship with health system, Treatment, Knowledge and understanding of disease, and Diagnosis (in no particular order), as well as suitable sub-nodes. Consensus was achieved through discussion among the investigators.
For identifying outcomes, data in all transcripts were coded to a subset of nodes including Outcomes, Expectations and Preferences (in the category Treatment), as well as Scar (in the category Symptoms), Medical and Self-treatment as well as Adverse events. This allowed us to capture contextual information) using NVivo 11. During analysis, the coding framework was subject to continuous updating, with the final framework shown in Fig 1, reflecting the rich information found in the interviews.
Fig 1. NVivo coding framework for interview transcripts.
This framework was established for coding interviews. Nodes are depicted in dark blue, sub-nodes in blue.
https://doi.org/10.1371/journal.pntd.0007996.g001
Themes were then identified using pen-and-paper due to the high volume of data: Transcript sections that had been coded to relevant nodes were printed from NVivo and manually arranged into key themes (corresponding to outcome domains) and subthemes (corresponding to outcomes). Examples for themes emerging include social stigmatization, or fear of sequelae. Themes are concepts or propositions that describe, help to interpret and explain aspects of the data. They were articulated and developed by comparison between and within interviews by two researchers (ACE and EP), specifically looking for emerging patterns, similarities and differences [23].
Subsequently, all outcomes reported as relevant by patients were assessed for possible inclusion into clinical trials based on (a) whether they were clinically meaningful and measurable by the research group, based on published literature, and (b) whether they could be addressed by additional or alternative measures. Outcomes were grouped over several steps by exclusion: (1) Outcomes that were found to be already incorporated and reported in clinical trials. (2) Outcomes based on unfounded fears or misconceptions related to CL. (3) Outcomes that were considered meaningful and measureable and could be included in clinical trials. (4) Outcomes with a longer-term impact, those that were experienced due to comorbidities, and outcomes having gender-specific and cultural connotations surrounding the broader psychological and social impact of scar formation.
Ethical clearance of the protocol was obtained from the following institutional review boards (IRBs) and ethics committees (ECs) responsible for the entire study, and the respective sites: World Health Organization Research Ethics Review Committee (WHO ERC), Geneva, Switzerland, Comité d'éthique de la Faculté de Médecine et du CHU Hassan II Fes, Fez, Morocco. Comité d'éthique Biomédicale de l'Institut Pasteur de Tunis, Institut Pasteur de Tunis, Tunis, Tunisia. Comité Institucional de Ética de Investigación en Humanos (CIEIH), Centro Internacional de Entrenamiento e Investigaciones Médicas (CIDEIM), Cali, Colombia. Comité d'éthique institutionnel du Centre MURAZ, Bobo-Dioulasso, Burkina Faso. Instituto Rachou (IRR), Fundação Oswaldo Cruz (FIOCRUZ), Minas Gerais, Brazil, and Comissão Nacional de Ética em Pesquisa—CONEP, Brazilia, Brazil. Shiraz University of Medical Sciences (SUMS) Ethics in Research Committee, Shiraz, Iran. Comité de Bioética de Investigación en Humanos, Sede de Investigación Universitaria (CBEIH-SIU) of the University of Antioquia, Medellin, Colombia. Comité Institucional de Etica para Humanos, Universidad Peruana Cayetano Heredia (CIEH—UPCH), Lima, Perú. Oxford Tropical Research Committee (OxTREC), University of Oxford, Oxford, UK.
Only patients above the age of consent were interviewed. Participants gave their consent by signature, or an appropriate alternative as specified by the relevant IRBs, to the interviewer or a designated person using an informed consent declaration. To obtain consent from participants who were unable to sign, at least one literate witness was chosen, whenever possible by the participants themselves, from outside the research team.
Ethical procedures at each site observed the respective IRB guidance, and are further detailed in the study protocol [21].
Patients' characteristics
The characteristics of the interviewed patients are listed in S 1 File. Sixty-two percent (n = 46) of participants were male (reflecting an estimated distribution of 60% men and 40% women overall at the sites [21]). At each site, the distribution was also in line with previous estimates of gender distribution among patients in the study area [21]. The median age of patients was 35 years (range 18–73 years). There were equal numbers of OWCL and NWCL patients. Patients live in areas where the predominant Leishmania species are L. (Viannia) braziliensis, peruviana, and panamensis for NWCL and L. major and L. tropica for OWCL. On average, patients had 3.4 (SD = 6.6, median = 2) lesions, with considerable variation in total (Q1 = 1, Q3 = 3.75, IQR = 2.75) and across sites, with the median numbers ranging from 1 to 6. Five percent of patients have had CL diagnosed but not started treatment, 47% were under treatment, 46% had completed their treatment and 1% had remained untreated; those receiving only symptomatic (medical) treatment were also considered as being treated.
Outcomes relevant for patients
Eight broad themes related to outcomes, corresponding to what patients would like to see or expect from treatment, and what they would not like to experience, emerged from the data. These were: Sequelae, Pain, Scar formation, Daily activities, Lesion appearance, Getting rid of parasites, Relapse and reinfection and Side effects (Fig 2). These domains are comprised of subthemes which correspond to individual outcomes. The wording corresponds to medical terminology in line with researchers' background and the study aims, and importantly, facilitating comparison with the literature and integration into an outcomes classification [19]. We avoided prioritizing certain outcomes over others; therefore we did not conduct frequency analysis and avoided to present them in a particular order, in line with the exploratory nature of the study.
Fig 2. Key themes and subthemes of outcomes relevant for patients.
Patients' unique identifiers contain a two-letter code corresponding to the site where they were interviewed (BR-Brazil, BF-Burkina Faso, CC-Colombia/CIDEIM, CP-Colombia/PECET, IR-Iran, MO-Morocco, PE-Peru, TU-Tunisia). For two quotes, interviewer's questions (I) were left in as they were deemed necessary for comprehension of the patients' responses (R).
Patients saw successful treatment as avoiding sequelae such as large lesions leading to amputation of limbs, disease progression to affect internal organs, cancer and even death. If not successfully treated, several patients feared amputation of limbs as potential complication, such as this young man from Brazil:
[…] For me it is a bad bug starving, it keeps eating, eating and eating. […] The injury will go deeper and it can take a nerve, one may lose the movement and may need to have to amputate a limb!
(BR05)
For a diabetic young woman from Tunisia, her fear of amputation of a leg due to CL was so strong that she reported suicidal thoughts:
A catastrophe […] in my life named leishmaniasis, I swear. I can't talk. I'm thinking how my leg could be amputated. How my life will look like after amputating my leg, I think about suicide, at the same time I think about my daughter how she will calm down after my death. I can't live without my leg.
(TU04)
Several patients mentioned the possibility of the disease affecting internal organs and cancer as a sequel of CL.
I think that cure would be the decontamination of the infection. The most important thing is the elimination of the risk of compromising the internal organs.
(…) It will change to a cancer that what he [someone at the health centre] said. […] He said to me it is possible to change […] with the years and he said I had a lucky chance to not get the disease inside me. This form of disease is the most dangerous one.
(MO08)
Several patients feared death as a potential consequence of CL; a female patient from Burkina Faso was afraid that CL could kill her—a CL outbreak erupted there in 2013. The patient came from a previously unaffected area where the population was unaware of the disease.
A number of male patients in Colombia being treated with pentavalent antimonials and pentamidine isethionate as first- or second-line treatment, respectively, talked about their fears that CL treatment could leave them sterile, that is, unable to father children. Patients referred to rumours they have heard, or someone telling them about it.
Many people say you cannot have children. So that could be it. […] Those are comments you hear. From that to reality, I'd say there is a 20% chance of that to happen. So that doesn't affect me at all. […] Friends always say that: You have children already? No. Oh boy, you lost your chance now. [laughs] I don't pay attention to them though.
(CP10)
Pain and unpleasant sensations
Itching, stinging or tickling sensations or unspecified pain was mentioned by patients as symptoms. Unspecified, very strong pain was mentioned several times, and most notably by the majority of patients in Burkina Faso. Patients described it differently: One male patient compared it to chili pepper being put onto the lesion, or a female patient experienced the pain associated with her CL lesions as 'being burnt by fire', rendering her unable to work.
I went to the health centre and they told me that there is no treatment for this disease. Lesions became painful and I went to health centre again and they told me that there is no treatment for this disease. Lesions were painful and itching. […] I didn't work in my farm because of the pain that is like being burnt by fire. I didn't get anything in that year from my farm.
(BF02)
In contrast, other patients emphasized that CL itself was painless. By them, pain was experienced as treatment side effect:
[…] Because as I'd told you, the illness does not cause any pain, but the treatment itself does.
(CC01)
Patients mentioned that being cured for them means being able to perform work, to have a normal social life without their family being affected, and a good fitness level. Being able to go back to work, either paid or by supporting family, was seen as associated with being healthy again. This male patient in Burkina Faso reported being unable to work while sick, thereby decreasing his income to an extent that he was unable to provide for his family:
[Healing] means that you got a good recovery and your family is no longer suffering and your kids too.
For several patients, to be able to go out and have a normal social life, free from stigmatization, was a very important component of being healed.
In the future I hope I will have a happy life, to be an active person, to go out and to communicate with others.
Lesion appearance
Different components of the lesion appearance were considered as important outcomes of treatment, mostly whether the lesion was closed, its dryness, its size, and its colour, and often a combination of these elements. A closed lesion corresponds to re-epithelialization in medical terms, that is, the wound being covered with an intact tissue.
[Healing means] let the wound close, heal. […] Covered, that's what I imagine.
(PE05)
For several patients, a dried wound and a reduction in wound size indicated cure. Others expected treatment to remove the discoloration.
[After treatment I expect the lesions] at least to return to the same skin colour, right? Because I see it all bruised.
Often, patients mentioned 'normal skin' as an outcome, but did not specify it further.
I guess it will disappear totally. I will not see any knob on it and my skin will return to normal.
Getting rid of the parasite
The absence of the pathogen, and, importantly, confirmation by a HCP were seen as a relevant outcome by many patients. The pathogen was in many cases specified as a parasite.
Cured, well, to know that the parasite is eliminated from the body a hundred percent, basically. Regardless of the scars left. That is the least of my worries. That will be something one can handle as time goes by. [So my main concern is] that there aren't any creatures in my body.
Fear of recurrence, that is, relapse and reinfection, was an issue for many patients. In most cases patients were clearly able to distinguish between relapse, with the lesions occurring in the same skin area, and reinfection by a sand fly, in particular if they went back to the endemic areas.
This patient from Burkina Faso, talks about his concerns on the community level as well as on an individual level. He is afraid that his scars could turn into active lesions again:
Oh! I pray [to] God so that this disease never comes [back again]. […] This disease has appeared suddenly and has disappeared now. It could come back again. […] I want God to eradicate definitely this disease here [in this village] so that people can be in good health and then this disease can't come back again. […] I can say that it is not still present. My lesions have been healed but I am afraid that the scars become lesions.
Patients felt very concerned and uncertain about a relapse. Some specifically mentioned that they did not feel cured as long as there was this possibility.
I consider it [late complications and relapse] and it makes me very worried. […] According to the search I performed, future lesions can appear and mucosal lesions as well. My biggest concern is that today: the disease relapse. It is very important. […] and, about the risk of future lesions, we can't even know. […] I have no idea whether I'm cured or not.
Often, patients were aware that they could be reinfected despite a successful treatment, and were afraid of it happening. In particular the soldiers interviewed in Colombia were well informed about the danger of reinfection if they went back to the endemic regions, and often mention having seen colleagues in the army getting infected multiple times.
An elderly male patient from Iran discusses possible immunity to reinfection after having healed by itself, after around one year. This is also reflected in the traditional name Salak (in Persian Sal means year) given to CL:
Well according to experiences, the reason that they named it Salak that it lasts one year and then it will get healed. […] It will get healed and then one's body is immune to CL. […] As I said, I heard this from people.
(IR03)
Scar formation
Scars were important and the absence of a scar was seen as a sign of being healed (as a proxy for cure). If in visible areas, many patients expressed their fear of social stigmatization. Many reported being affected by social stigmatization with a visible scar, ranging from embarrassment about others asking about its origin, to being ridiculed. Others reported fears of not finding employment or a suitable partner with a visible scar. Several participants emphasized gender-specific aspects, for example the problems a visible scar in the face could pose for unmarried women.
This Brazilian woman mentions and reiterates that a visible scar might indicate that she is not yet fully cured:
I think that if this scar disappeared, then I would have the notion that it is healed. The scar being here makes me remember of this disease. […] I think when you see the wound, when you see the scar, you're remembering. Sometimes, this question arises… Will it be gone? It is insecure.
Some patients, predominantly men, did not see their scars as problematic.
I don't care much [about the remaining scars]. I have already some. Look at this. […] One day I put a cup of gunpowder in the fire and it exploded in my hand. I'm not worried about scars. There is a good cream for scars anyways.
No, they are completely healed but the scar remained. The most important thing that it is over, I don't care about the scar. I'll marry another woman! I'll undress my shoulders, I don't care.
In some regions patients freely talk about the availability of scar treatments, for example in Iran and Tunisia, where cosmetic surgery seems to be common as it is mentioned frequently in the interviews. However, whereas CL treatment is free, the costs for scar treatment are not covered by insurance, and pose a financial problem to many patients. Several patients pointed out how a scar affects girls or women more than men, specifically if the scars are located on their face or other visible areas and if the girl is still unmarried.
This young man from Morocco talks about the problem that scars pose for young women. He points out psychological problems due to deformations, and compares the CL scar to deformed teeth:
She will have a serious problem which can lead to psychological complexes in her life. […] She can become psychologically sick because of the scar, I know people who have a problem by The Will of God. For example, a girl with deformed teeth and defected look, it makes her psychically sick, although for the teeth there is a solution because the medical science became now more developed.
He continues explaining the impact he thinks his scar will have on his own relationships with women, and in his workplace:
[Should I meet a girl], I can convince her by giving details that it is a disease and [that] I followed the treatment prescribed by the doctor, to not be scared any more. […] I: If the scar will remain, you may have any problem in your work? R: I don't understand, do you mean I must keep my basketball cap whole working day to hide the scar? No, I can't do it all day long.
Most notably, a woman from Iran, with three scars on her face and hands, told her story, and how has severely affected her social life and two marriages:
I was 5 years old when I got CL and didn't know what it was. […] All the other children had it on their hands or feet. Me and my sister had it on our face… […] Well I got married at 17 and I got divorced because of this issue. He told me something about my face and I finally got separated when we were engaged. […] I got married again, and my husband's skin is white without any spots. I had to use creams since I was a kid. […] Yeah, I married twice and I didn't have a wedding ceremony both times due to my CL. […] Because they took films at weddings and the camera takes a close shot from your face and I didn't want that… […] As much as I remember, I put on makeup all the time […] It's been 4.5–5 years that I married my current husband… emmm… I think yesterday was the first time that he saw me without makeup [pause] I feel ashamed to look in his face… I looked down. […] I want to go outside but without makeup.
By contrast, this Peruvian patient explains neither being ashamed, nor being afraid to be stigmatized in his social environment:
I: And, do you mind that scar? R: No doctor, normal, [it doesn't matter] in my work. I: And, what about the one on your face? R: The same. I: And is there no problem? R: No, no problem. What can I do doctor? I: Don't you mind? Are you not ashamed? R: No, no. I: Some people feel ashamed; they do not want to go out. R: But, since I was a boy, and after all in my land, all my countrymen know me, and we know each other, what can I do? It will be the same.
Some patients feared that the scar would result in a permanent disability, such as a young male soldier from Colombia who suffered a lot from its location very close to his eye, and was afraid that the complications and pain would continue with a scar resulting from that wound.
For this specific theme, the analysis focusses on fears and conceptions of patients. An overview of the treatments administered can be found in [21], supplementary file 2. Common side effects reported were headaches, local swelling, pain (e.g. back or stomach ache, pain in the joints, muscles, kidneys, legs or the testicles), loss of appetite, fever, tiredness and dizziness. Patients also complained about palpitations, shivers, weakness, weight loss and vomiting to a lesser extent. These adverse events are documented in the literature [3,4,6,24]. In general, people felt informed about adverse events related to the treatment.
I've heard it's to check the organs to see if they are in good shape; because the Glucantime, it's so heavy that it affects the heart, kidneys, liver …It affects pretty much every organ, so you must have them in good shape. […] I've seen partners who have two and three treatments already and it's not the same, doctor. I've seen them having troubles with their kidneys and how that decays their bodies. I've seen people that with the Glucantime only they lose a lot of weight.
Pain was described as a common side effect of treatment, sometimes perceived as unbearable:
Yes, it was very hurtful. When you have already received 5 of the 10 injections, the medicine doesn't go through because the buttocks are so swollen that they are forced to suspend the treatment. You cannot endure the pain. I was one of those. I went to therapy but it wasn't enough. I was all the time lying in bed. I couldn't even walk. Very painful.
Summary of findings
Patients have clear ideas about desired treatment outcomes. These relate to their personal health and wellbeing as well as their social and socioeconomic context, and comprise the domains Lesion appearance, Side effects, Recurrence, Getting rid of the parasite, Scar formation, Daily activities, Pain and Sequelae. Many of the reported outcomes are generally not reflected in trials conducted to date, which focus mostly on outcomes looking at lesion and infection indicators (such as absence of an active lesion, complete re-epithelisation, parasitological cure, no appearance of new lesions and/or reversible hypopigmentation) [3–8].
Patients' fears surrounding persistence of the parasite and disease relapse are supported by available evidence. Several forms of leishmaniasis can occur after healing: Leishmaniasis recidivans is a chronic form of CL due to L. tropica or L. (Viannia) braziliensis occurring 1–2 years after healing of the initial lesion, usually in the face, causing microsatellite and confluent lesions that finally ulcerate at the border of the initial scars. Mucocutaneous leishmaniasis (MCL), caused by L. (Viannia) braziliensis and other NWCL species, affects nasal and oral mucosa, and evolves after cure of CL and a variable period of latency. It potentially leads to disfiguring mutilations due to widespread tissue necrosis. Leishmaniasis is also a common opportunistic infection of HIV, in addition rendering the distinction between viscerotropic species (causing VL) and dermatotropic species (causing CL) less valid [25]. Leishmania DNA has been shown to persist in humans after therapeutically achieved clinical resolution for L. (Viannia) in peripheral blood, lesions, mucosa and scars [26–29] of patients. Several studies provide evidence of the viability and infectivity of the parasite in some specimens isolated after clinical cure: Old world species (L. infantum) (syn. L. chagasi) [30,31]), as well as new world species (L. (Viannia) [26,32]), suggesting that persistence of parasites in both OWCL and NWCL might be common.
Fears surrounding involvement of tissues other than skin might indicate a fear of visceral leishmaniasis (VL), which is co-endemic in some countries such as Brazil, Tunisia and Morocco [33,34]. In addition, the vagueness of their descriptions indicates that there is a lack of knowledge.
Findings from the interviews supported the association of CL with social stigma, anxiety and depression. A Tunisian woman with diabetes who reported suicidal thoughts in case of amputation of her leg because of CL gives a good illustration of this aspect. Epidemiological studies conducted for OWCL have shown that around 50% of CL lesions are located in the face, and the visibility of lesions is considered an important risk factor for depression in dermatological conditions [35,36]. Other studies point out a significant association of CL with anxiety, depression and decreased QoL in patients [37–40]. Of great impact are ulcerative lesions and scarring on the faces of young women, exposing them to stigma and potentially affecting their marriage prospects [3,41,42].
Implications for research practice: Recommendations based on patient-preferred outcomes
Information obtained on preferred outcomes was very rich, and we identified both generally-applicable and context-specific themes.
Outcomes and outcome domains identified (Fig 2) were classified into four groups according to recommendations (Fig 3).
Fig 3. Reported outcome domains and outcomes by recommendations.
Four groups distinguish outcomes according to the recommendations being given, these are discussed in more detail in the text. Green: Outcomes already included in clinical trials. Blue: Additional outcomes to be included in clinical trials. Brown/gold: Outcomes whose considerable psychological impact should be specifically addressed. Red: Outcomes where additional information should be given to patients.
Outcomes already included in clinical trials
The first group contains outcome domains and outcomes depicted in green, mostly concerning Lesion appearance, and also the most common Side effects. These are concepts corresponding to the clinical definition of cure with regards to lesion appearance already used and reported in clinical trials for CL interventions, that is, all inflammatory signs having disappeared, and epithelialization of ulcerative lesions.
Additional outcomes to be included in clinical trials
The second group, depicted in blue, contains the domains Daily activities, Pain and Recurrence as well as the outcome Absence as proxy for cure in the domain Scar formation.
Relapse, contained in the domain Recurrence, is addressed in trials, but at varying time points [2–4,6]. In line with Olliaro et al. [11], we would recommend to consistently include six months (180 days) follow up to assess final cure. Taking into consideration potentially increased costs and the probability of loss to follow-up, this would be particularly recommended for phase IV and/or post-licensing surveillance studies.
We would argue that Daily activities, Pain and Scar formation (via its immediate impact on daily life) are Quality of Life (QoL)-related and could be measured, as a secondary outcome, using an appropriate instrument before treatment and at follow-up. The Dermatology Quality of Life Index (DLQI) [43] is an option to assess QoL-related aspects in clinical trials for CL. It contains questions relating to Symptoms, Daily activities, Leisure activities, Work and school and Personal relationships. The DLQI is standardized, used widely and has been translated into more than 90 languages. However, it is not validated for CL, nor consistently used, and does not include economic impact and access to health services, which are strongly related to QoL. A specific and comprehensive Cutaneous Leishmaniasis Impact Questionnaire (CLIQ) for assessment of the impact of CL on patients' QoL was developed more recently by Galvao et al. [44] in Brazil, and has undergone initial validation.
As the absence of scars was considered a surrogate for cure, we would also recommend including outcomes assessing scar formation or prevention of scarring, in addition to its impact of QoL, in clinical trials, using e.g. the Vancouver Scar Scale [45] at six months after the end of treatment [46]. So far, prevention of scarring was only assessed in a small minority of OWCL trials [6].
A summary of recommendations can be found in Table 1.
Table 1. Recommendations for outcomes and outcome measures to be included in clinical trials.
https://doi.org/10.1371/journal.pntd.0007996.t001
Outcomes whose considerable psychological impact should be specifically addressed
The third group, in brown and gold, contains outcomes broadly contained in the outcome domain Scar formation, such as Social stigmatization (and in particular Gender-specific stigmatization towards women) and Disability, as well as Amputation in the outcome domain Sequelae. Amputation is a rare, but possible, sequela in patients with comorbidities such as diabetes, or a sequela in those who develop MCL. Such patients form part of special populations and would not be included in routine trials.
These outcomes may have a considerable psychological impact on patients which should be consistently addressed. The DLQI [43] or the CLIQ [44] are options for assessment, given that they include impact on personal relationships and feelings as well as disabilities to a lesser extent. In addition, we would recommend informing patients, for example about treatment options for scars after the follow-up time, and if necessary, provide psychological support, in line with the considerable association of CL with anxiety and depression as discussed previously. These recommendations become even more important in the context of clinical care.
Outcomes where additional information should be given to patients
The fourth group, in red, contains outcomes patients are afraid of, but which would not be meaningful outcomes for a clinical study. A number are grouped in the domain Sequelae, consisting of fears around Sterility, Death, Cancer and Sequelae affecting internal organs. These could be considered as misconceptions in relation to CL. Getting rid of the parasite, mostly expressed as the absence of parasites in the body, is an outcome patients would like to see. Whereas parasitological confirmation is strongly recommended for inclusion in trials, evidence of parasite persistence after clinical resolution of lesions, as discussed previously, renders parasitological cure most likely not a clinically meaningful outcome and would generate unnecessary concern for patients. Reinfection, in the domain Recurrence, was also found of concern to patients, but was not recommended for inclusion in trials.
We would suggest addressing outcomes in this group carefully by informing patients to clarify these issues and alleviate their fears, for example by inclusion of information in the Patient Information or Informed Consent Declaration for trials, through personal communication, or by using a 'Cutaneous Leishmaniasis Fact Sheet' that could be given to patients at treatment onset in clinical care. Beyond volunteers in clinical trials, these findings demonstrate significant gaps in health education and support the need to account for these dimensions in future public health programs.
In general, reported outcomes were found to be quite uniform across regions. This section focusses on interpretation of two unexpected findings, or discrepant data: The fear of infertility as a potential sequela of CL treatment; and strong pain as a symptom of CL.
In Colombia CL is seen as an occupational disease, that is, a disease related to the military profession (L. López, personal communication). Five out of the six male Colombian patients mentioning fear of infertility were soldiers with the army. Infertility is not among the documented sequelae for either pentavalent antimonials or glucantime which was administered to patients interviewed [24]. This interesting finding could indicate a cultural notion related to a certain profession, or gender. As a significant life event, fathering a child can be integral to the production of a masculine identity [47], and the inability to do so could threaten that identity. The local PI pointed out the importance of the ability to father children in the Colombian context. She noted in addition that, since many of the soldiers were very young and undisciplined, their commanders were struggling to keep them in the military base while on treatment; the commanders therefore told them having sexual relations while on treatment could confer sterility. She concluded that sterility as possible sequel encountered in the interviews could be one of several variations of this rumour (L. López, personal communication). A Colombian anthropologist, working at the same site for her research on armed conflict and CL in Colombia, confirmed these findings (L. Pinto García, personal communication). In summary, the medically unfounded fears surrounding male infertility as possible sequel of CL treatment could be due to interrelated rumours in a very male, and male dominated, culture of machismo in the Colombian army, and there are indications that these rumours might have been produced on purpose.
Typically, CL lesions (nodules and ulcers) are not painful, unless secondary bacterial infection takes place—which is not uncommon, and may lead to pain and disability [3]. When discussing this strong emphasis on pain reported by patients in Burkina Faso with the local PI (M. Cissé), he noted that it occurred before traditional treatments were administered, instead of as a consequence, and saw it as part of the natural evolution of the disease. Results should be interpreted against the background that patients were from an emerging CL focus and have never experienced symptoms before (M. Cissé, personal communication). CL in new foci tends to be more aggressive [10]. This is in line with the high average number of lesions of patients in Burkina Faso (11, as compared to 3.4 of the entire study).
Strengths and limitations of the study
This was a unique study involving partners from a number of different countries affected by CL, and engaging a range of patients whose voices have hitherto been unheard in CL research. It was an exploratory study, aiming to elicit the views of a patient population as large and diverse as possible. As a qualitative study, it is not intended to be representative of a given study population, however most key themes were remarkably consistent across the different countries and patients groups despite cultural and disease heterogeneities.
Interviews were being conducted in a range of local contexts and six different languages (Arabic, Dioula, Farsi, Mooré, Portuguese and Spanish). The analysis of pooled interviews, conducted by two researchers and greatly relying on notes taken during the interviews and discussions with the local PIs was able to ensure consistency and take the cultural context into consideration.
We did not set a maximum time limit between the end of treatment and the time point when interviews would take place, in line with our maximum variation sampling approach. This aspect was considered important in order to allow participants to reflect on a long duration of experiences, such as those related to scars. The topic guide was designed as being as conducive as possible to participants speaking freely, in order to also recall distant memories. At the same time, participants are expected to have had a selective memory recall during the interviews.
By design, there was a focus on implications for clinical trial design; therefore we did not include patients who would not normally be enrolled, e.g. patients with comorbidities or more severe disease manifestations.
Children were also excluded, despite the fact that they form a significant part of the patient population in some countries such as Iran. Interviewing children requires a skillset and precautions that were beyond the resources of our study [48]. Future studies should focus on these important populations because most cases of OWCL are among children in old foci and the co-existence of CL and chronic diseases, such as diabetes among elderly, in emerging foci.
When the study findings are compared to the outcomes traditionally included in trials, we see gaps, which overlap with those already discussed by three Cochrane Collaboration reviews [3,4,6]: outcomes related to the degree of functional and aesthetic impairment (which we suggest correspond to the outcomes contained in the domain Sequels or Disability associated with scars in our study), prevention of scarring (outcomes domain Scar formation) and QoL (outcomes contained in the domains Daily activities or Pain).
Validated measurement instruments for dermatologic conditions would allow for inclusion and measurement of these endpoints in clinical trials. Current limitations of the DLQI can be overcome by development of an instrument validated for NTDs, or specifically for CL, such as the CLIQ. The interviews also pointed out some fears and misconceptions surrounding CL, and a need for better informing and counselling patients.
The next step in our project is now to bring these results to the attention of the broader health provider, drug developer and researcher communities, and specialists in ethics so that they can be taken into account when designing new treatments and clinical trials. We propose a Delphi consensus survey including a large number of HCPs and researchers following the methodology developed by COMET for COS development [19,49]. The survey questionnaire will combine outcomes reported in the literature with outcomes reported during this study and recommended for inclusion in clinical trials. The aim of this study is the development of a COS for CL, consisting of a consensus set of proposed outcomes and their measurement instruments recommended for inclusion in future clinical trials, therefore working towards harmonization of clinical trial methodology and including patients' voices (11).
This study shows how otherwise disempowered patients suffering from a neglected tropical disease can be effectively involved in research, providing valuable insights into desired outcomes, and be given a voice in designing both new medications and treatment approaches and the way these are tested in clinical trials. We believe that combining expert [10,11] and patient consultation, if properly acted upon, can promote better trials and lead to more adapted interventions. With few notable exceptions, such as the OMERACT initiative for rheumatologic conditions [50] these steps as seldom taken, especially when it comes to poverty-related diseases affecting disproportionally disenfranchised populations. The work we did in CL shows that this is possible, and can be seen as an exemplar which can be applied to other similar situations.
The proposed development of a COS for CL would be a further step towards including patients' opinions into the harmonization of clinical trial methodology [11].
S1 File. An overview of study sites and demographic and clinical characteristics of patients enrolled in the study.
https://doi.org/10.1371/journal.pntd.0007996.s001
(DOC)
We would like to thank Dr. Christine Halleux and Mr. Abdul Masoudi for their support with ethics review and administration, respectively, the HERG team at the Nuffield Department of Primary Care Health Sciences at the University of Oxford for the great training in qualitative research during two workshops and L. Pinto García and Genesis Huera-Vera for their support with data analysis and interpretation. We are particularly grateful to all the CL patients who have contributed to the study.
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Is the Subject Area "Lesions" applicable to this article?
Is the Subject Area "Scars" applicable to this article?
Is the Subject Area "Pain" applicable to this article?
Is the Subject Area "Leishmaniasis" applicable to this article?
Is the Subject Area "Clinical trials" applicable to this article?
Parasitic diseases
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text:
Professional Headshots Taken for the Cast of Les Miserables
Lisa Jorgensen, Reporter
The Arrowhead Drama actors got their headshots taken by Abby Tessemier, a college student and aspiring photographer, on Wednesday, December 1st, 2021 at 5 pm. The headshots will be going out in the North Campus Front Foyer display that will be decorated with a Les Miserable theme for the week of the show. The performances for Les Miserables are Feb 2nd through 6th, 2022.
Tessemier is a former Arrowhead student and did headshots for Arrowhead Drama shows while she was at Arrowhead. Tessemier also did the headshots for the 2020 – 2021 Drama shows and is coming back again to do them for Les Miserables.
Maralynn Markano, an English, acting, and advanced speech teacher, drama director, and stage crew advisor at Arrowhead, said, "I love giving former students [the opportunity] especially if they have a keen interest in photography or graphic design or whatever." Markano said that she loves giving former students something to do to help their portfolios for their futures.
The headshots aren't only for the actors though. The production team also had their headshots taken on Wednesday. The current production team includes the director, assistant director, student director, vocal director, costume coordinator, stage manager, and two assistant stage managers. The actors and production team were not required to pay for their headshots.
There was certain attire that everyone had to wear for their photos. The directors requested nicer attire than t-shirts and sweatshirts. The girls were not allowed to wear low neckline shirts or black shirts. The guys were required to wear button up shirts or colored polo shirts that were not black.
Markano said that solid colors or subtle patterns are really the best for the girls and that it looks more professional if they are in a collared shirt with buttons for the guys.
Tessemier set up her equipment while the cast did their last run-throughs of blocking for At The End of the Day that they had been working on.
Headshots were being taken one at a time and Annella Maclean, a junior at Arrowhead, volunteered to go first to help Tessemier get everything right.
Maclean said, "I forgot how to smile."
Tessemier had to do multiple headshots for Maclean since Maclean didn't want to look weird and it was hard to remember how to smile after having to wear a mask last year for the shows.
After everyone got their headshots taken, Markano gathered everyone to give announcements and do a quick round of Dum, Dum, Dada. It is a rhythm game where everyone has to go at one speed and go through 3 different motions starting simple and progressively getting harder.

redpajama_set_name: RedPajamaCommonCrawl


A record of the Royal Shakespeare Company's production of Peter Brook's 'US', a play about the Vietnam war, showing extracts and interviews with writer-director Peter Brook and cast members.
A documentary following US, Peter Brook 's experimental play about the moral issues surrounding the Vietnam War, Benefit of the Doubt is the only known film record of the Royal Shakespeare Company production. It was filmed by Peter Whitehead concurrently with his Tonite Let's All Make Love in London (1967), on the surface a very different film, yet both share a central concern with the war, protest and Britain's political and cultural relationship with America.
Drawing on the improvisational techniques of the influential Polish experimental theatre director Jerzy Grotowski , US explored its theme through painstaking factual research of American cultural and political artefacts (including Whitehead 's own documentary, Wholly Communion (1965), which included an anti-Vietnam War protest poem by the author of the play's 'libretto', Adrian Mitchell ), as well as actual documents from the war itself.
Appropriately for a production so concerned with process, filming took place at a specially performed rehearsal at London's Aldwych Theatre. With no audience present and the actors only partially in makeshift costumes, the film captures the play in an evolving state. It takes on the appearance of a workshop, as though staged only for the benefit of the actors, as collective therapeutic research. Responding to the play's unconventional approach, Whitehead 's camera crosses the threshold of the stage, tracking between the actors as they perform.
Although controversial in the right-wing press, the play was criticised for its ambiguity by many opposed to the war. In interviews throughout the film, Brook is at pains to clarify that his concern was not to provide answers but to interrogate the war's reality and Britain's place in it. Since the only experience of the war available to the British was images filtered via the media (Vietnam was regarded as the world's first 'television war'), it is only through this evidence that judgements could be formed - hence the play's methodology. Interestingly, the film brings the play back within the arena of images, enabling the viewer to respond, in turn, to the play within the film.
Although rarely screened since the time of its initial release, the award-winning film more recently experienced a resurgence of interest when it was shown, alongside Brook 's own film adaptation of the play, Tell Me Lies (1967), at a 2003 meeting exploring similar issues of complicity raised by the invasion of Iraq - a war that would come to define the 2000s as Vietnam defined the 1960s.


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Obama renews push for a public option in unexpected forum
The public option largely disappeared from the policy debate in recent years, but with a new Democratic push, it's back in a big way.
President Barack Obama returns via the Marine One helicopter to the White House in Washington, June 2, 2016.
July 12, 2016, 1:18 PM UTC / Updated July 12, 2016, 1:20 PM UTC
Readers of the Journal of the American Medical Association (or JAMA) probably expect to read articles from medical professionals. As Reuters reported, the new issue includes a piece from a very high-profile author from an entirely different field.
President Barack Obama urged Congress on Monday to reconsider offering a government-run health insurance option alongside private plans on the exchanges created as part of his national healthcare law. In an article published in the online edition of the Journal of the American Medical Association, Obama said the Affordable Care Act had made much progress toward improving access to healthcare and the quality and affordability of care.
The entirety of the article is online here -- Obama is the first sitting president to be published in JAMA -- and it covers quite a bit of ground. The piece touts the ACA's many successes, while also presenting a variety of ideas about possible improvements.
But in terms of basic political salience, Obama's renewed support for a public option is probably the most notable thing in his JAMA piece. "[B]ased on experience with the ACA, I think Congress should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited," the president wrote.
And if you feel like you've been hearing quite a bit more about the public option lately, after years of relative silence, it's not your imagination.
Let's back up for a minute for those who may not remember what this idea is all about. Revisiting our previous coverage, during the fight to pass health care reform in 2009 and 2010, one of the most widely discussed aspects of Obama's plan was something known as the "public option." The idea, which polls showed was quite popular, was to create a public, non-profit health insurer that would compete with private insurance companies for consumers' business, along the lines of the educational model in which public and private universities compete in the same space.
The policy was poised to be part of the Affordable Care Act, but it was ultimately killed by one man, then-Sen. Joe Lieberman, who vowed to join a Republican filibuster and destroy the entire reform effort if the public option was included in the final package. Left with no choice, reform advocates relented.
As it turns out, the measure's demise six years ago wasn't permanent. Hillary Clinton's campaign has voiced support for the measure repeatedly in recent months, and the presumptive Democratic nominee reiterated her position over the weekend to help shore up support from Bernie Sanders.
Obviously, a Republican Congress, which is obsessed with the idea of destroying "Obamacare" and everything in it, will never consider a progressive policy like this one. But this renewed push for a public option serves as a reminder that in Democratic politics, the idea never really went away, and if a President Hillary Clinton has an opportunity to work with a Democratic Congress, this measure -- which is scored by the CBO as a cost-saver, thanks to increased competition -- will be a leading priority.


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Ejike Asiegbu, Paul Obazele, Sonny McDon, other Nollywood actors protest against killings in Nigeria
Nigerian actors have raised their voice against the politically motivated killings in the North as well as other parts of the country.
The actors under the aegis of 'Concerned Actors And Seasoned Nollywoood Stars' at a rally in Lagos, decried the killings, which they described as a 'horror movie'.
The group, led by veteran actor and former president of Actor's Guild of Nigeria, Ejike Asiegbu, berated politicians for turning their back against the people they swore to protect.
"We have watched the horror movie in Zamfara State and concluded that our politicians have thrown the sanctity of human lives to the dogs with the way and manner that they have carried their political activities, which have resulted in the loss of so many lives and destruction of properties," Asiegbu said.
He said actors would no longer fold their hands "and watch politicians continue with their nefarious activities that have brought untold sorrow and blood to numerous families," adding, "the worrisome aspect of the whole issue is the fact that these politicians have been dramatising in public and on pages of newspapers condemning the act, when in truth, the entire world knows they are the ones behind the senseless killing of innocent women and children, because of their vested interest."
Asiegbu berated the political elite for "turning their back against the people" they swore to protect. "We know gold is a precious stone but to make the mistake of equating gold with human life is an anomaly that must be resisted by all and sundry in the interest of peace and tranquility in Northwest Nigeria.
"These gold miners are not spirits, they have names, and they reside among the people, and above all, they have sponsors. But they must realise also that the same people sponsoring them to kill innocent people today can decide to turn against them and order their elimination tomorrow."
While hoping that people behind the Zamfara killings as well as others across the country will see reason and stop it, Asiegbu stated: "The 'Concerned Actors And Seasoned Nollywoood Stars' have reviewed the situation critically and concluded that unless urgent and proactive measures are taken, the killings will not abate, especially with the level of desperation exhibited by the main players behind the carnage."
And this as well is extended to other parts of the country and we state categorically that the gold in Zamfara State is not for a group of individuals or people but belongs to all of us Nigerians just as the oil in the Niger Delta belongs to all Nigerians."
Chair of AGN Lagos chapter, Moji Oyetayo, veteran Nollywood stars such as Paul Obazele, Sonny McDon, Emeka Ossai, Frank Dallas, Uche Anyamele and producers Chico Ejiro, Zeb Ejiro, Wisdom Nwankwo, Tony Ani, Mike Nliam and others were present.
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Posted by Bishop Ikedi at May 15, 2019
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Martha Visser't Hooft
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Painting, oil on canvasSigned at lower right
Martha Visser't Hooft was an artist and teacher in the modernist tradition, best known for her abstract expressionist work, geometric-totemic abstractions, and surrealism. Her career spanned more than 60 years and she garnered critical acclaim with many awards and distinctions during the course of her long art career. She exhibited extensively in Buffalo, New York City and throughout the United States.
Martha for the most part was a self-taught artist. In 1922 she traveled to Europe to study the works of the emerging modernist painters at the Académie Julian, in Paris, as well as the music and avant-garde theater of the day. She moved to New York City three years later to further her studies at the Parson's School of Applied Art, where she practiced set design for the theater there. She taught at the University of Buffalo from 1956-58, in Buffalo, NY. Her sister Mary Hamlin Goodwin, designer and patron of the arts, settled in Taos as a member of the Taos Art Colony. Visser't Hooft visited her often, where she painted the surrounding landscape.
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Transmission (2016)
Video | 147 min | Adult, Drama, Romance
NSA Agent
Stills By Alan
Stills By Alan, Bree Mills (story)
26 January 2017 | lor_
Lexi & Charlotte in the supporting short subject shine, while "Transmission" collapses
Lesbian Cinema's latest money-spinners Mills & Stills play the Film School grad game of jumping from genre to genre, self-indulgence at the viewer's expense. This is their very meager stab at sci-fi (as was A.I. preceding it), packing in a ton of "sounds intelligent" verbal exposition but failing miserably at dramaturgy.
Of course it's great to see icon (from a decade ago) Hillary Scott making a comeback as a MILF type, oddly miscast as an astronomer who makes a crucial discovery, that an intelligence from the M13 cluster in Outer Space has returned Carl Sagan's famous "message to space" broadcast back in 1974. Scott is celebrating the Earth-shaking discovery with her lesbian lover Samantha Rone.
Screenwriter/director Alan seems to have done his Wikipedia-level research as Scott and Rone throw around a ton of credible-sounding dialog, but the joke's on the filmmakers, rather than the viewer, when Scott commits an unpardonable howler early on. Reciting some of the info Sagan packed into his message to convey to aliens particular data about Earth and its inhabitants, she mentions the basic elements of human DNA, including hydrogen, nitrogen and carbon. She goes on to say the message just received back (42 years later) adds "SILICONE" to that list (the aliens' basic elements), meaning to say silicon of course, but a flub left in the final print by Alan -and having rather obvious blow-back on Hillary's fake breast implants for all to see. No, this was not an intentional joke -just watch the movie and see.
After they stop yammering mindlessly, the stars get down to some quality Sapphic humping, but are interrupted, as luck would have it, by the dreaded NSA. Abigail Mac, big up front but rather unconvincing as a mean agent Dick Chaney would be proud of, leads some male armed personnel (so this isn't an all-female cast for a change) to terrorize the young women.
Mac reads Hillary the riot act, and blackmails her into some satisfying three-way lesbian sex, or else! Both Hillary and Sam comply, and subscribers to this Girlsway/Gamma Ent. content are undoubtedly satisfied with the result, storytelling be damned. Punchline is predictable - instead of fulfilling her promise and letting the innocent astronomer off the hook, after sex Mac has her male minions whisk Rone off to captivity in some secret site, to keep the pesky Hillary from further threatening "national security".
At this point Bree and Alan can't leave bad enough alone, so they contrive to have the star character from their "A.I.", Celeste Star, suddenly show up as a deux ex machina, working with Hillary to save the day. Celeste is not a robot (as she insists on reminding the viewer, over and over and even into the BTS "bonus") but rather an artificial intelligence fabricated into a woman's body and capable of near- omniscient feats. Just the ticket for Scott to extricate herself from her mess. Or more importantly to have Hillary tribbed into orgasm, courtesy of the double-jointed lesbian icon Ms. Star.
This three-part saga ends with a title card "The End?", with nothing resolved and promising a sequel, which I dread. But fortunately the DVD concludes with a supporting (and unrelated) program starring Lexi Belle and Charlotte Stokely that saves the day.
Lexi, who's been playing a cute sweet thing for well over a decade already, is radically different here -her body having filled out incredibly, a whole new look. She's cast as a private detective, likely a pilot episode for a potential Stills & Mills series in the future. The great man himself (Alan) cameos ever so subtly as Charlotte's husband - he hires Lexi to put his wife under surveillance and get the goods on her suspected cheating, anent forthcoming divorce proceedings.
Lexi sneaks into Charlotte's home, which just happens to be the "Immoral Proposal" mansion, my favorite porn backdrop already featured in hundreds of adult movies shot over the last five years.
Wonderful cat & mouse visual gags and elegant timing denote Lexi's hiding nearby as Charlotte on the phone speaks potentially incriminating sweet nothings, before she's found. It's some of the best work Stills & Mills have ever done, and the beautiful pair segue to hot lesbian sex before a twist ending. Even the mansion is put to better photographic use than usual in this fabulous, stand-alone vignette.
Is it worth the price of admission, namely to buy the clunker "Transmission" in order to see its short subject? The answer is no of course -the modern audience out there streams and downloads this content and can easily skip "T" and merely watch Lexi & Charlotte instead, but an old sort of Luddite like me is stuck with the whole enchilada on DVD.
When Hillary is explaining the 1974 Arecibo message sent by Carl Sagan to Outer Space in an effort to contact alien civilizations, she mentions it contained a list of the elements in human DNA, including carbon, nitrogen, oxygen and hydrogen, but when she notes the return message received from the M13 cluster, she says the alien's list of elements includes "silicone" (she meant to say silicon), a flub left in the final release print with its obvious unintended relevance re: the cast's breast enlargements.
Adult | Drama | Romance | Sci-Fi


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LENRACH
The Seraph of the Lichdragon
Yashin Live Generation: Gen. 0
Character Name: Lenrach
Nicknames: (Len, Moth, Honeybee (Dasu only)
Title / Classification: Seraph of the Lichdragon/Helix of Desolation/??? (Helix/Seraph/???),
Appearance: A young male with an angelic form, numerous grey wings, a long coat, and sometimes a halo made of wings with a singularity in the centre.
Character Lore:
A grand golden dragon presides over the concepts of creation, molded by the dreaming Nothingness to serve as a hand to awaken its will unto reality. She was the creator of Novum Anua, Her universal reverie in which She watched her children grow and evolve, reaching out towards Her stars. However, She was plagued by doubts of Her role, and by loneliness in the solitude of it all. These gave birth to small seeds within Her mind, rooting themselves within Her doubt and fear. They whispered of generations anew, Her own kind to watch over and defend this cosmic cradle and the creations within. Thus did She birth the first generation of Gods, each seizing a concept to personify as many in place of a singular One. Each concept a rune to conjure the Great Evil that brought their seeds forth, each God to take their place as a catalyst for the Great Evil that harbored the dragons doubts. Once the Gods acquired their concepts, She fell into a great slumber to continue dreaming of Novum Anua, leaving Her vulnerable to their plight. They siphoned her dreams as energy for the ritual, each one a step closer to the birth of a forbidden deity. Slowly Her dreams turned to nightmares, staining Her proud golden scales with sanguine midnight. Sores grew forth, leaking wells of sable that malformed the landscape. Each stuttered breath cursed Her doubts and failures, giving further power to the Evil within Her regrets. By then She was far too weak to awaken, eclipsed unto a shell of Her former splendor. She issued one last command to her familiars; The Penumbra. They will remove Her eyes, and store what was left of Her dreams within them, serving as a phylactery for what remained of the Goddess. One eye shall be used to dream one last child into being, formed of Her own self but with a will of its own, uninfluenced by the Great Evil. He shall not be a god, shackled by the instinct of divinity, but instead as an Angel born of Her blackened blood. The other eye shall be kept safe with them after their birth, so that their mother may always be with them. This child shall be the final bastion of Her fractured reign, the last child faithful to Her. She bestowed on him the final concept she housed; Void, as Her powers of Creation were no more, and the rest were stolen from Her nightmares. As the command was heeded, his name blossomed forth within the depths of his chrysalis.
He shall be named Lenrach.
(Artwork coming soon)
Novum Anua
The first plane of existence created by The All Dreamer. Novum Anua encompasses the main universe of her reign, but is now eclipsed by the dogma and dictatorship of her children: The Pillars. Each hospitable planet corresponds to a Pillar as its anchor of worship, and thus takes on many traits the Pillar may have. Examples include a planet rich with agriculture that answers to a god of fertility and harvest, a planet constantly torn apart by combat under the grip of a violent war god, or a planet which serves as the hub of reincarnation and death rotating to the whispers of a deity overseeing Samsara. Some may be happy and profitable, while others are plagued by crimes and tragedies. All answer to the wishes of their home deity. These planets also serve as a Pillars anchor to Novum Anua itself, so if the planet is destroyed or the faith of their people dies, they will no longer be able to descend into the realm. All planets are overseen by the High Sefirot in tandem; divine beasts born of the gods, serving as protectors of Novum Anua and hands of the Gods.
Oblitus
A ruined plane of existence that defies all known laws of reality. The sky is dull and appears cracked or fractured, like shards from a broken mirror. Strange law defying shapes float throughout this broken horizon. The landscape itself is glitch incarnate, with towering shapes and non Euclidian landmasses spitting in the face of creation. The land is inhabited by damned creatures born of the Gods mistakes; known to mortals only as Qliphoth. Here they dwell in dangerous territories, locked in eternal conflict with the Sephirot. Torrents, hoarfrost, great winds and abundant plague scour the planes, as the land is ravaged by territorial dispute between High Qliphoth and their warriors. One such High Qliphoth is the rampaging black sea serpent Tehom, eclipsing the horizon with its suffocating oceans that covet the land and sky. Very few areas are truly hospitable here, and those that can live will have to survive in a world that denies them, and wishes for them to be forgotten.
What once was, and is no more. Ruined by the bleeding corpse of The All-Dreamer, transformed beyond potential and hope. This is nothing but a nightmare.


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Criminal Justice History
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The study of the history of criminal justice is a challenging one. The truth is that we can never know just how it began, because criminal justice, in some form or another, has been present forever.
The concepts of right and wrong have been around since before humans began recording history.
And since then, people have been occupied with the task of enforcing laws, rules, ordinances, and commandments.
The apprehension, detainment, conviction or release, incarceration, and punishment for law breakers are the facets that make up the foundation of criminal justice and they have been employed for thousands of years.
In the following sections, we'll take a look at the recorded history of criminal justice and its ancient practices around the world.
You'll also learn modern criminal justice history and how it has affected and formed how we go about fighting justice and keeping the peace today.
Here's a glimpse of criminology history as it was used in society in a variety of places across the world.
China - Ancient Chinese criminal justice was carried out by appointed law-keepers called prefects. Prefects had regions of geography throughout the kingdom they were in charge of.
Below the prefects were sub-prefects and various other enforcers to aid in smaller portions of these great regions.
Developed in both the Chu and Jin kingdoms, the prefecture system reported to the magistrate and carried out the local law. Different prefects had different jobs, some acting in more bureaucratic roles, while others worked more as modern day detectives.
Ancient Greece - Unlike the prefecture system in Ancient China, Greece and Rome had very different views on criminal justice than we do today.
Justice and retribution were more private matters than public ones, and it was generally up to the victim's family (especially in the case of murder) to decide the fate of the perpetrator.
Colonial America - While the origins of modern day criminal justice can be found all around the world during the last several thousand years, it was during the Colonial American era that today's law and order system had begun to solidify into something we would carry with us to the present.
They used the common law system to solve disputes, which included a list of rules to follow.
They also were the first to differentiate between two types of crime: felony and misdemeanor.
Modern Day Justice
Today we mostly employ a law and order system that is based on early European and Colonial American legal structures.
We get our police officer system from seventeenth century France, jails and prisons from almost every culture throughout time, and the judiciary from a variety of places but mostly modeled after English culture.
Most of us consider modern criminal justice to be a fairly effectual system, allowing us to punish the criminals and free the innocent.
However, it is anything but a perfect system.
There are raging debates that have been going on for a long time and show no signs of stopping about numerous ethics in criminal justice, such as:
How we treat our prisoners
The effectiveness and inhumane practices of capital punishment
And the future of corrupt judiciary systems.
Will criminal justice history ever become a study of a perfect structure? Probably not.
As long as the people are in charge, there will be some who disagree with how things are done. But, then again, the alternative isn't exactly appetizing.
We make do with what we've got and hope that we are right far more often than we are wrong.
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Good things really do come in three. We're terribly thrilled that three outstanding 3 year-old dressage mares have joined Château de Fontaine's talented string.
2017 Danish Warmblood Mare of the Year Skovens Tzarina and Gold medal Danish Warmblood dressage mare Queensparks Wendy, impressed the judges competing against the very best of Danish sport horse breeding, represented at the 2017 Danish Warmblood Elite Show, Vilhelmsborg, Denmark.
Skovens Tzarina, bred by Kirsten Bjerregaard Hansen and Jens Lund Pedersen, is out of the very successfull combination Blue Hors Zack and Blue Hors Don Schufro. Like Queensparks Wendy, bred by Kurt Gosmer, she was awarded a perfect 10 for her fantastic canter.
Last but not least, is the tall, elegant and very promising Westphalian Edmée who shows great promise, giving us a growing feeling of excitement for the 2018 season.


●New style rotor head sets, CNC cutting with the usual black aluminum plating,the external appearance of texture is greatly enhanced , make the flight stability and the control more excellently.
●This new style rotor set can directly upgrade T-REX 450 PRO Rotor head . It is used along with accessories: metal stability control, metal main rotor holder, Metal CCPM Swashplate, Metal flybar control group.


Perry "Moose" Marshall, 59, of Fostoria passed away June 13, 2018 at Toledo Hospital.
He was born to Dempsey and Norma "Toots" (Day) Marshall on Oct. 17, 1958 in Fostoria.
Surviving are his mother; sisters, Sandra Shackelford, Pat Marshall, both of Fostoria, and Laura Williams-Proffit of Fredericksburg, Maryland; and brothers, Tony, Tracy and Jonah Marshall, all of Fostoria.
Memorial services will be 1 p.m. Monday, June 18, at Harrold-Floriana Funeral Home, Fostoria, with the Rev. Donald Goodwin officiating.
Visitation will be from 11 a.m.-1 p.m. two hours prior to services at the funeral home.


The youngster in your life adores the Philadelphia Eagles and enjoys watching them dominate their opponents. Now you can help illustrate a high level of devotion by getting this Zach Ertz Philadelphia Eagles Game jersey from Nike. It's perfect because it's a replica of the jersey that's worn on game days, all the way down to the stunning Philadelphia Eagles and Zach Ertz graphics. By wearing this jersey, you'll know that your young fan's loyalty will never be questioned.