Peter Awuah - Academia.edu (original) (raw)
Papers by Peter Awuah
<p>A. The percentage of B cells (CD19+) is unchanged. (ns p = 0.18). B. The percentage of G... more <p>A. The percentage of B cells (CD19+) is unchanged. (ns p = 0.18). B. The percentage of GC B cells (CD10+) is significantly elevated in the malaria tonsils (*** p<0.001). C. The frequency of GC B cells latently infected with EBV is dramatically increased in the malaria tonsils (*** p = 0.001). For details see <a href="http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1004170#ppat-1004170-t001" target="_blank">Table 1</a>. D. The level of EBV infected GC B cells and AID expression do not directly correlate.</p
The Lancet, 2010
Background Surgical debridement was the standard treatment for Mycobacterium ulcerans infection (... more Background Surgical debridement was the standard treatment for Mycobacterium ulcerans infection (Buruli ulcer disease) until WHO issued provisional guidelines in 2004 recommending treatment with antimicrobial drugs (streptomycin and rifampicin) in addition to surgery. These recommendations were based on observational studies and a small pilot study with microbiological endpoints. We investigated the effi cacy of two regimens of antimicrobial treatment in early-stage M ulcerans infection. Methods In this parallel, open-label, randomised trial undertaken in two sites in Ghana, patients were eligible for enrolment if they were aged 5 years or older and had early (duration <6 months), limited (cross-sectional diameter <10 cm), M ulcerans infection confi rmed by dry-reagent-based PCR. Eligible patients were randomly assigned to receive intramuscular streptomycin (15 mg/kg once daily) and oral rifampicin (10 mg/kg once daily) for 8 weeks (8-week streptomycin group; n=76) or streptomycin and rifampicin for 4 weeks followed by rifampicin and clarithromycin (7•5 mg/kg once daily), both orally, for 4 weeks (4-week streptomycin plus 4-week clarithromycin group; n=75). Randomisation was done by computer-generated minimisation for study site and type of lesion (ulceration or no ulceration). The randomly assigned allocation was sent from a central site by cell-phone text message to the study coordinator. The primary endpoint was lesion healing at 1 year after the start of treatment without lesion recurrence or extensive surgical debridement. Analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00321178. Findings Four patients were lost to follow-up (8-week streptomycin, one; 4-week streptomycin plus 4-week clarithromycin, three). Since these four participants had healed lesions at their last assessment, they were included in the analysis for the primary endpoint. 73 (96%) participants in the 8-week streptomycin group and 68 (91%) in the 4-week streptomycin plus 4-week clarithromycin group had healed lesions at 1 year (odds ratio 2•49, 95% CI 0•66 to infi nity; p=0•16, one-sided Fisher's exact test). No participants had lesion recurrence at 1 year. Three participants had vestibulotoxic events (8-week streptomycin, one; 4-week streptomycin plus 4-week clarithromycin, two). One participant developed an injection abscess and two participants developed an abscess close to the initial lesion, which was incised and drained (all three participants were in the 4-week streptomycin plus 4-week clarithromycin group). Interpretation Antimycobacterial treatment for M ulcerans infection is eff ective in early, limited disease. 4 weeks of streptomycin and rifampicin followed by 4 weeks of rifampicin and clarithromycin has similar effi cacy to 8 weeks of streptomycin and rifampicin; however, the number of injections of streptomycin can be reduced by switching to oral clarithromycin after 4 weeks. Funding European Union (EU FP6 2003-INCO-Dev2-015476) and Buruli Ulcer Groningen Foundation.
Journal of Biology Agriculture and Healthcare, 2012
A study to determine the prevalence of subjective tinnitus was carried out at the Kumasi Hearing ... more A study to determine the prevalence of subjective tinnitus was carried out at the Kumasi Hearing Assessment Centre in central Ghana. A total of two thousand two hundred and seven (2,207) outpatients aged between 6->65 years, who complained of hearing problems or tinnitus either in isolation or in association with hearing loss, were seen from January 1995 to December 1998. The procedure adopted included a detailed case history and a study of the patients medical notes, otoscopy and audiometric evaluation. Out of the 2,207 patients seen, 384 (19.3%) complained of tinnitus. 87 (22.5) of the e84 patients suffering from tinnitus had normal hearing. In addition patients with mild hearing loss had more tinnitus than other degrees of hearing loss. There was a relationship between tinnitus and associated symptoms. Tinnitus was described as intermittent and constant and increased with advancing age; it also had varied degrees of annoyance effect.
Journal of the Ghana Science Association, 2003
Journal of Science and Technology (Ghana), 2012
The objective of this paper is to describe the shortcomings of the standard technique for treatme... more The objective of this paper is to describe the shortcomings of the standard technique for treatment of preauricular sinus (PAS) and to emphasize on an alternative modification of the standard surgical technique. PAS is a common congenital abnormality. Usually these lesions are asymptomatic. However, some patients complain of discharge and/or recurrent infections, requiring excision of the PAS. Surgical treatment of PAS is characterized by high recurrence rates. This paper describes our surgical experience in the treatment of PAS.
Journal of Science and Technology (Ghana), 2012
The study was a prospective, cross-sectional type conducted at the Ear, Nose and Throat Departmen... more The study was a prospective, cross-sectional type conducted at the Ear, Nose and Throat Department of Komfo Anokye Teaching Hospital (KATH) over a six month period from 1 st August 2005 to 31 st January 2006. Fifty one patients involving 69 ears (few with bilateral and majority with unilateral hearing loss) were interviewed followed by otoscopic ear examination, pure tone audiometry using AC 30 audiometer and tympanometric test. The hearing loss of participants was thus determined before and after treatment to establish the change in hearing over the period. The results showed that hearing loss occurs in majority of sufferers of acute otitis media. The prevalence of acute otitis media (AOM) is low in adults, but it is quite high in children (91.3%) of reported cases.
Journal of Science and Technology (Ghana), 2012
Epistaxis is defined as bleeding from the nasal cavity. It is a very common Otorhinolaryngologica... more Epistaxis is defined as bleeding from the nasal cavity. It is a very common Otorhinolaryngological problem that often presents as an emergency to the outpatient departments of most hospitals worldwide. Its true incidence is often very difficult to assess. This study was aimed at analyzing aetiology, treatment and management outcome of patients who presented with epistaxis at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. This is a three year retrospective study (Jan2007-Dec 2010). All cases of epistaxis that presented at the Ear, Nose and Throat (ENT) clinic at KATH) or referred from the polyclinics and the district hospitals were included. A total number of 96 cases were seen with epistaxis over a period of three years. There were 63 (66%) males and 33 (34%) females. Their ages ranged from 1-80 years. The commonest cause of epistaxis was idiopathic with 51 (53%) cases followed by nasal trauma with 11 (11.5%) cases and nasopharyngeal carcinoma 8 (8.3).This study supports the clinical usefulness of conservative management in the treatment of patients with epistaxis.
Molecular Cancer Therapeutics, 2015
SS1P is a recombinant immunotoxin (RIT) that targets mesothelin. It consists of an antimesothelin... more SS1P is a recombinant immunotoxin (RIT) that targets mesothelin. It consists of an antimesothelin Fv fused to a portion of Pseudomonas exotoxin A. In clinical studies, it has produced dramatic responses in patients with advanced mesothelioma, when combined with immunosuppressive therapy so that several treatment cycles could be given. Otherwise its activity is limited by its immunogenicity. In this work, we describe the development and characterization of LMB-T20, a highly potent RIT targeted at mesothelin-expressing cancers with low immunogenicity due to removal of its eight T-cell epitopes. LMB-T20 was more active than SS1P when tested on four different mesothelin-expressing cell lines as well as on cells obtained from patients with mesothelioma. It also has potent antitumor activity in mice, and has reduced immunogenicity as measured by cytokine secretion assays. In conclusion, LMB-T20 is a favorable candidate for evaluation in clinical trials due to its reduced immunogenicity and excellent activity. Mol Cancer Ther; 14(12); 2789-96. Ó2015 AACR.
Clinical and vaccine …, 2006
Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts... more Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts of the tropics. We have investigated cytokine secretion after stimulation of whole blood from Buruli ulcer (BU) patients in a region of endemicity in Ghana with M. ulcerans sonicate or culture filtrate antigens to investigate the development of the response over time and its specificity by comparison with the response to Mycobacterium tuberculosis sonicate in human immunodeficiency virus-negative tuberculosis patients. Significant gamma interferon (IFN-␥) production in response to whole-blood stimulation with M. ulcerans sonicate was detected in patients with ulcers, which was higher than that in patients with nodules but similar to subjects with healed BU. The mean IFN-␥ response in household contacts of BU patients was not significantly different from that in healthy control subjects from an area of nonendemicity. Results in patients with untreated, smear-positive pulmonary tuberculosis and tuberculosis patients on treatment for more than 2 weeks showed that BU patients responded better to M. ulcerans antigens than tuberculosis patients. In contrast, interleukin-10 results were higher in patients with active M. ulcerans disease than in those with healed lesions, but the pattern of response was similar to that seen in tuberculosis. A similar pattern of cytokine secretion was found using M. tuberculosis sonicate as an antigen. Neither of the two culture filtrate antigens of M. ulcerans appeared to be more specific than M. ulcerans sonicate. In the early stages of M. ulcerans disease there was a mixed Th1 and Th2 cytokine response, but the Th1 response emerged as the dominant type.
Clinical and vaccine …, 2006
Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts... more Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts of the tropics. We have investigated cytokine secretion after stimulation of whole blood from Buruli ulcer (BU) patients in a region of endemicity in Ghana with M. ulcerans sonicate or culture filtrate antigens to investigate the development of the response over time and its specificity by comparison with the response to Mycobacterium tuberculosis sonicate in human immunodeficiency virus-negative tuberculosis patients. Significant gamma interferon (IFN-␥) production in response to whole-blood stimulation with M. ulcerans sonicate was detected in patients with ulcers, which was higher than that in patients with nodules but similar to subjects with healed BU. The mean IFN-␥ response in household contacts of BU patients was not significantly different from that in healthy control subjects from an area of nonendemicity. Results in patients with untreated, smear-positive pulmonary tuberculosis and tuberculosis patients on treatment for more than 2 weeks showed that BU patients responded better to M. ulcerans antigens than tuberculosis patients. In contrast, interleukin-10 results were higher in patients with active M. ulcerans disease than in those with healed lesions, but the pattern of response was similar to that seen in tuberculosis. A similar pattern of cytokine secretion was found using M. tuberculosis sonicate as an antigen. Neither of the two culture filtrate antigens of M. ulcerans appeared to be more specific than M. ulcerans sonicate. In the early stages of M. ulcerans disease there was a mixed Th1 and Th2 cytokine response, but the Th1 response emerged as the dominant type.
Antimicrobial Agents and Chemotherapy, 2005
Mycobacterium ulcerans disease is common in some humid tropical areas, particularly in parts of W... more Mycobacterium ulcerans disease is common in some humid tropical areas, particularly in parts of West Africa, and current management is by surgical excision of skin lesions ranging from early nodules to extensive ulcers (Buruli ulcer). Antibiotic therapy would be more accessible to patients in areas of Buruli ulcer endemicity. We report a study of the efficacy of antibiotics in converting early lesions (nodules and plaques) from culture positive to culture negative. Lesions were excised either immediately or after treatment with rifampin orally at 10 mg/kg of body weight and streptomycin intramuscularly at 15 mg/kg of body weight daily for 2, 4, 8, or 12 weeks and examined by quantitative bacterial culture, PCR, and histopathology for M. ulcerans. Lesions were measured during treatment. Five lesions excised without antibiotic treatment and five lesions treated with antibiotics for 2 weeks were culture positive, whereas three lesions treated for 4 weeks, five treated for 8 weeks, and three treated for 12 weeks were culture negative. No lesions became enlarged during antibiotic treatment, and most became smaller. Treatment with rifampin and streptomycin for 4 weeks or more inhibited growth of M. ulcerans in human tissue, and it provides a basis for proceeding to a trial of antibiotic therapy as an alternative to surgery for early M. ulcerans disease.
<p>A. The percentage of B cells (CD19+) is unchanged. (ns p = 0.18). B. The percentage of G... more <p>A. The percentage of B cells (CD19+) is unchanged. (ns p = 0.18). B. The percentage of GC B cells (CD10+) is significantly elevated in the malaria tonsils (*** p<0.001). C. The frequency of GC B cells latently infected with EBV is dramatically increased in the malaria tonsils (*** p = 0.001). For details see <a href="http://www.plospathogens.org/article/info:doi/10.1371/journal.ppat.1004170#ppat-1004170-t001" target="_blank">Table 1</a>. D. The level of EBV infected GC B cells and AID expression do not directly correlate.</p
The Lancet, 2010
Background Surgical debridement was the standard treatment for Mycobacterium ulcerans infection (... more Background Surgical debridement was the standard treatment for Mycobacterium ulcerans infection (Buruli ulcer disease) until WHO issued provisional guidelines in 2004 recommending treatment with antimicrobial drugs (streptomycin and rifampicin) in addition to surgery. These recommendations were based on observational studies and a small pilot study with microbiological endpoints. We investigated the effi cacy of two regimens of antimicrobial treatment in early-stage M ulcerans infection. Methods In this parallel, open-label, randomised trial undertaken in two sites in Ghana, patients were eligible for enrolment if they were aged 5 years or older and had early (duration <6 months), limited (cross-sectional diameter <10 cm), M ulcerans infection confi rmed by dry-reagent-based PCR. Eligible patients were randomly assigned to receive intramuscular streptomycin (15 mg/kg once daily) and oral rifampicin (10 mg/kg once daily) for 8 weeks (8-week streptomycin group; n=76) or streptomycin and rifampicin for 4 weeks followed by rifampicin and clarithromycin (7•5 mg/kg once daily), both orally, for 4 weeks (4-week streptomycin plus 4-week clarithromycin group; n=75). Randomisation was done by computer-generated minimisation for study site and type of lesion (ulceration or no ulceration). The randomly assigned allocation was sent from a central site by cell-phone text message to the study coordinator. The primary endpoint was lesion healing at 1 year after the start of treatment without lesion recurrence or extensive surgical debridement. Analysis was by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT00321178. Findings Four patients were lost to follow-up (8-week streptomycin, one; 4-week streptomycin plus 4-week clarithromycin, three). Since these four participants had healed lesions at their last assessment, they were included in the analysis for the primary endpoint. 73 (96%) participants in the 8-week streptomycin group and 68 (91%) in the 4-week streptomycin plus 4-week clarithromycin group had healed lesions at 1 year (odds ratio 2•49, 95% CI 0•66 to infi nity; p=0•16, one-sided Fisher's exact test). No participants had lesion recurrence at 1 year. Three participants had vestibulotoxic events (8-week streptomycin, one; 4-week streptomycin plus 4-week clarithromycin, two). One participant developed an injection abscess and two participants developed an abscess close to the initial lesion, which was incised and drained (all three participants were in the 4-week streptomycin plus 4-week clarithromycin group). Interpretation Antimycobacterial treatment for M ulcerans infection is eff ective in early, limited disease. 4 weeks of streptomycin and rifampicin followed by 4 weeks of rifampicin and clarithromycin has similar effi cacy to 8 weeks of streptomycin and rifampicin; however, the number of injections of streptomycin can be reduced by switching to oral clarithromycin after 4 weeks. Funding European Union (EU FP6 2003-INCO-Dev2-015476) and Buruli Ulcer Groningen Foundation.
Journal of Biology Agriculture and Healthcare, 2012
A study to determine the prevalence of subjective tinnitus was carried out at the Kumasi Hearing ... more A study to determine the prevalence of subjective tinnitus was carried out at the Kumasi Hearing Assessment Centre in central Ghana. A total of two thousand two hundred and seven (2,207) outpatients aged between 6->65 years, who complained of hearing problems or tinnitus either in isolation or in association with hearing loss, were seen from January 1995 to December 1998. The procedure adopted included a detailed case history and a study of the patients medical notes, otoscopy and audiometric evaluation. Out of the 2,207 patients seen, 384 (19.3%) complained of tinnitus. 87 (22.5) of the e84 patients suffering from tinnitus had normal hearing. In addition patients with mild hearing loss had more tinnitus than other degrees of hearing loss. There was a relationship between tinnitus and associated symptoms. Tinnitus was described as intermittent and constant and increased with advancing age; it also had varied degrees of annoyance effect.
Journal of the Ghana Science Association, 2003
Journal of Science and Technology (Ghana), 2012
The objective of this paper is to describe the shortcomings of the standard technique for treatme... more The objective of this paper is to describe the shortcomings of the standard technique for treatment of preauricular sinus (PAS) and to emphasize on an alternative modification of the standard surgical technique. PAS is a common congenital abnormality. Usually these lesions are asymptomatic. However, some patients complain of discharge and/or recurrent infections, requiring excision of the PAS. Surgical treatment of PAS is characterized by high recurrence rates. This paper describes our surgical experience in the treatment of PAS.
Journal of Science and Technology (Ghana), 2012
The study was a prospective, cross-sectional type conducted at the Ear, Nose and Throat Departmen... more The study was a prospective, cross-sectional type conducted at the Ear, Nose and Throat Department of Komfo Anokye Teaching Hospital (KATH) over a six month period from 1 st August 2005 to 31 st January 2006. Fifty one patients involving 69 ears (few with bilateral and majority with unilateral hearing loss) were interviewed followed by otoscopic ear examination, pure tone audiometry using AC 30 audiometer and tympanometric test. The hearing loss of participants was thus determined before and after treatment to establish the change in hearing over the period. The results showed that hearing loss occurs in majority of sufferers of acute otitis media. The prevalence of acute otitis media (AOM) is low in adults, but it is quite high in children (91.3%) of reported cases.
Journal of Science and Technology (Ghana), 2012
Epistaxis is defined as bleeding from the nasal cavity. It is a very common Otorhinolaryngologica... more Epistaxis is defined as bleeding from the nasal cavity. It is a very common Otorhinolaryngological problem that often presents as an emergency to the outpatient departments of most hospitals worldwide. Its true incidence is often very difficult to assess. This study was aimed at analyzing aetiology, treatment and management outcome of patients who presented with epistaxis at Komfo Anokye Teaching Hospital (KATH), Kumasi, Ghana. This is a three year retrospective study (Jan2007-Dec 2010). All cases of epistaxis that presented at the Ear, Nose and Throat (ENT) clinic at KATH) or referred from the polyclinics and the district hospitals were included. A total number of 96 cases were seen with epistaxis over a period of three years. There were 63 (66%) males and 33 (34%) females. Their ages ranged from 1-80 years. The commonest cause of epistaxis was idiopathic with 51 (53%) cases followed by nasal trauma with 11 (11.5%) cases and nasopharyngeal carcinoma 8 (8.3).This study supports the clinical usefulness of conservative management in the treatment of patients with epistaxis.
Molecular Cancer Therapeutics, 2015
SS1P is a recombinant immunotoxin (RIT) that targets mesothelin. It consists of an antimesothelin... more SS1P is a recombinant immunotoxin (RIT) that targets mesothelin. It consists of an antimesothelin Fv fused to a portion of Pseudomonas exotoxin A. In clinical studies, it has produced dramatic responses in patients with advanced mesothelioma, when combined with immunosuppressive therapy so that several treatment cycles could be given. Otherwise its activity is limited by its immunogenicity. In this work, we describe the development and characterization of LMB-T20, a highly potent RIT targeted at mesothelin-expressing cancers with low immunogenicity due to removal of its eight T-cell epitopes. LMB-T20 was more active than SS1P when tested on four different mesothelin-expressing cell lines as well as on cells obtained from patients with mesothelioma. It also has potent antitumor activity in mice, and has reduced immunogenicity as measured by cytokine secretion assays. In conclusion, LMB-T20 is a favorable candidate for evaluation in clinical trials due to its reduced immunogenicity and excellent activity. Mol Cancer Ther; 14(12); 2789-96. Ó2015 AACR.
Clinical and vaccine …, 2006
Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts... more Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts of the tropics. We have investigated cytokine secretion after stimulation of whole blood from Buruli ulcer (BU) patients in a region of endemicity in Ghana with M. ulcerans sonicate or culture filtrate antigens to investigate the development of the response over time and its specificity by comparison with the response to Mycobacterium tuberculosis sonicate in human immunodeficiency virus-negative tuberculosis patients. Significant gamma interferon (IFN-␥) production in response to whole-blood stimulation with M. ulcerans sonicate was detected in patients with ulcers, which was higher than that in patients with nodules but similar to subjects with healed BU. The mean IFN-␥ response in household contacts of BU patients was not significantly different from that in healthy control subjects from an area of nonendemicity. Results in patients with untreated, smear-positive pulmonary tuberculosis and tuberculosis patients on treatment for more than 2 weeks showed that BU patients responded better to M. ulcerans antigens than tuberculosis patients. In contrast, interleukin-10 results were higher in patients with active M. ulcerans disease than in those with healed lesions, but the pattern of response was similar to that seen in tuberculosis. A similar pattern of cytokine secretion was found using M. tuberculosis sonicate as an antigen. Neither of the two culture filtrate antigens of M. ulcerans appeared to be more specific than M. ulcerans sonicate. In the early stages of M. ulcerans disease there was a mixed Th1 and Th2 cytokine response, but the Th1 response emerged as the dominant type.
Clinical and vaccine …, 2006
Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts... more Mycobacterium ulcerans disease (Buruli ulcer) is a skin-ulcerating infection common in some parts of the tropics. We have investigated cytokine secretion after stimulation of whole blood from Buruli ulcer (BU) patients in a region of endemicity in Ghana with M. ulcerans sonicate or culture filtrate antigens to investigate the development of the response over time and its specificity by comparison with the response to Mycobacterium tuberculosis sonicate in human immunodeficiency virus-negative tuberculosis patients. Significant gamma interferon (IFN-␥) production in response to whole-blood stimulation with M. ulcerans sonicate was detected in patients with ulcers, which was higher than that in patients with nodules but similar to subjects with healed BU. The mean IFN-␥ response in household contacts of BU patients was not significantly different from that in healthy control subjects from an area of nonendemicity. Results in patients with untreated, smear-positive pulmonary tuberculosis and tuberculosis patients on treatment for more than 2 weeks showed that BU patients responded better to M. ulcerans antigens than tuberculosis patients. In contrast, interleukin-10 results were higher in patients with active M. ulcerans disease than in those with healed lesions, but the pattern of response was similar to that seen in tuberculosis. A similar pattern of cytokine secretion was found using M. tuberculosis sonicate as an antigen. Neither of the two culture filtrate antigens of M. ulcerans appeared to be more specific than M. ulcerans sonicate. In the early stages of M. ulcerans disease there was a mixed Th1 and Th2 cytokine response, but the Th1 response emerged as the dominant type.
Antimicrobial Agents and Chemotherapy, 2005
Mycobacterium ulcerans disease is common in some humid tropical areas, particularly in parts of W... more Mycobacterium ulcerans disease is common in some humid tropical areas, particularly in parts of West Africa, and current management is by surgical excision of skin lesions ranging from early nodules to extensive ulcers (Buruli ulcer). Antibiotic therapy would be more accessible to patients in areas of Buruli ulcer endemicity. We report a study of the efficacy of antibiotics in converting early lesions (nodules and plaques) from culture positive to culture negative. Lesions were excised either immediately or after treatment with rifampin orally at 10 mg/kg of body weight and streptomycin intramuscularly at 15 mg/kg of body weight daily for 2, 4, 8, or 12 weeks and examined by quantitative bacterial culture, PCR, and histopathology for M. ulcerans. Lesions were measured during treatment. Five lesions excised without antibiotic treatment and five lesions treated with antibiotics for 2 weeks were culture positive, whereas three lesions treated for 4 weeks, five treated for 8 weeks, and three treated for 12 weeks were culture negative. No lesions became enlarged during antibiotic treatment, and most became smaller. Treatment with rifampin and streptomycin for 4 weeks or more inhibited growth of M. ulcerans in human tissue, and it provides a basis for proceeding to a trial of antibiotic therapy as an alternative to surgery for early M. ulcerans disease.