Association of insulin treatment versus oral hypoglycaemic agents with diabetic retinopathy and its severity in type 2 diabetes patients in Cameroon, sub-Saharan Africa.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a chronic metabolic disease associated with multiple macro and microvascular complications, diabetic retinopathy (DR) being the commonest one. Recent literature has reported an increased risk of DR with insulin use. METHODS: We carried out a cross-sectional study at the Ophthalmology Department of the Douala General Hospital (DGH) during a 2-year period to explore the association between insulin treatment and both DR and its severity as compared with oral hypoglycemic agents (OHAs) in Cameroonian T2DM patients aged ≥35 years, and who were all screened for DR through eye examination including exhaustive retinal evaluation. RESULTS: In total, medical files of 134 T2DM patients were analyzed. The frequency of DR was 54.1% among patients on OHA and 73.9% among those on insulin treatment, giving an overall frequency of 57.5%. There were significantly more OHA treated patients than insulin treated patients (82.8% vs. 17.2%, P<0.001). As expected, both the OHA and insulin groups were comparable by age, sex, duration of diabetes, past history of hypertension, alcohol misuse, and current tobacco smoking. DR was almost significantly more frequent in T2DM patients under insulin regimen than in patients under OHA [73.9% vs. 54.1%; odds ratio (OR) 2.4; 95% confidence interval (CI), 0.9-6.6; P=0.06]. Proliferative diabetic retinopathy (PDR) was significantly more observed in insulin treated patients than in OHA treated patients (34.8% vs. 15.3%; OR 2.95; 95% CI, 1.1-8; P=0.035). Irrespective of staging, the frequency of diabetic macular edema (DME) was significantly higher in the insulin group than in the OHA group (43.5% vs. 19.8%; OR 3.1; 95% CI, 1.2-8; P=0.019). CONCLUSIONS: Compared with OHA, insulin therapy may be associated with DR, DR severity and DME in these T2DM sub-Saharan African patients.

Patterns and trends in mortality among HIV-infected and HIV-uninfected patients in a major Internal Medicine Unit in Yaoundé, Cameroon: a retrospective cohort study.

OBJECTIVE: To describe the trends in mortality and the spectrum of disease in HIV-infected and -uninfected inpatients in a population in Yaoundé. DESIGN: A retrospective study. SETTING: Internal Medicine Unit, University Hospital Centre, Yaoundé, Cameroon. PARTICIPANTS: All deaths registered between January 2000 and May 2007 in the unit. MAIN OUTCOMES MEASURES: Sociodemographic characteristics, clinical features and results of all investigations done, cause of death. RESULTS: During the study period, 362 deaths were registered, consisting of 281 (77.6%) in HIV-infected patients, 54.4% of which were women. HIV-infected patients were younger (mean age: 40.2 (SD: 11.6) vs. 55.5 (SD: 18.3) years, p < 0.001) and economically active (60.3% vs. 24.4%, p < 0.001). Most HIV-infected patients (77.6%) were classified as WHO stage IV, with the rest being WHO stage III. Most HIV-infected patients (87.8%) had evidence of profound immunosuppression (CD4 < 200 cells/mm(3)). The mortality trend appeared to be declining with appropriate interventions. The most frequent causes of death in HIV-infected patients were pleural/pulmonary tuberculosis (34.2%), undefined meningoencephalitis (20.3%), other pneumonias (18.2%), toxoplasmosis (16.4%), cryptococcal meningitis (14.2%) and Kaposi sarcoma (15.7%). HIV-uninfected patients died mostly as a result of chronic diseases including liver diseases (17.3%), kidney failure (13.6%), congestive heart failure (11.1%) and stroke (9.9%). CONCLUSION: There was a declining mortality due to HIV with appropriate interventions such as subsidised tests for HIV-infected patients, increased availability of HAART and other medications for prevention and treatment of opportunistic infections. The spectrum of HIV disease was wide and preventable.

The highly neglected burden of resistant hypertension in Africa: a systematic review and meta-analysis.

OBJECTIVE: The hypertension epidemic in Africa collectively with very low rates of blood pressure control may predict an incremented prevalence of resistant hypertension (RH) across the continent. The aim of this study was to determine the prevalence of RH and associated risk factors in Africa. DATA SOURCES: We conducted a comprehensive search of electronic databases (PubMed, EMBASE, Africa Wide Information and Africa Index Medicus) completed by manual search of articles, regardless of language or publication date. METHODS: We included studies which have reported the prevalence and/or risk factors for RH in Africa from inception to 19 May 2016. Forest plots were drawn to visualise the combined prevalence of RH and extent of statistical heterogeneity between studies. RESULTS: Out of 259 retrieved studies, only 5 from Cameroon, Nigeria, Burkina Faso, Lesotho and Algeria with a total population of 4 068 patients were finally included in this review. There was no study from the Eastern part of Africa. Though the definition of RH was not similar across studies, its prevalence was respectively 11.7%, 4.9%, 14.6%, 14.3% and 19.0%, with an overall pooled prevalence of 12.1% (95% CI 8.0% to 17.7%). Potential risk factors were: non-compliance to treatment, ageing, male sex, dyslipidaemia, metabolic syndrome, previous cardiovascular events, physical inactivity and stress, but not excessive salt intake, alcohol and coffee ingestions. Moreover, diabetes, smoking, obesity and renal insufficiency yielded discrepant results. CONCLUSIONS: There is a huge dearth of research on the epidemiology of RH in Africa. Thereby, an extensive study of RH prevalence and risk factors is still largely warranted to curtail the high and continuously increasing burden of hypertension across Africa.

Maternal hyperglycemia during labor and related immediate post-partum maternal and perinatal outcomes at the Yaoundé Central Hospital, Cameroon.

BACKGROUND: Data on the prevalence and complications of gestational diabetes are very scarce in Cameroon. The aim of this study was to evaluate the uptake of screening for gestational diabetes and assess the immediate post-partum outcome of hyperglycemic parturient mothers and perinatal outcome of their babies. METHODS: A prospective cohort study was held at the Maternity of the Yaoundé Central Hospital from March to June 2013. One hundred volunteer women in labor without overt diabetes mellitus and having fasted for 8 to 12 h were recruited. No intervention was given. A clinical examination was done and capillary glucose recorded. Parturient women were categorized into two groups (hyperglycemic and non-hyperglycemic subjects) based on glycemia results interpreted according to the International Association of Diabetes and Pregnancy Study Groups. Mothers' clinical examination was repeated and neonates examined immediately after delivery. Perinatal outcomes associated with maternal hyperglycemia during labor were assessed using relative risks. A p value <0.05 was considered statistically significant. RESULTS: One hundred women with a mean age of 27 (SD 6) years were recruited. Of them, 22 (22 %) had already been screened for gestational diabetes at baseline. Thirty-one (31 %) were diagnosed with hyperglycemia during labor, and this condition was highly associated with macrosomia in neonates (RR = 8.9, 95 % CI 2.70-29.32; p < 0.001). Other complications associated with maternal hyperglycemia during labor were perineal tears, cesarean section, and intrauterine fetal death, though the association was not statistically significant. CONCLUSIONS: The main finding of this study is that maternal hyperglycemia during labor is highly associated with macrosomia in neonates. About a third of mothers were concerned with hyperglycemia during labor, and gestational diabetes was insufficiently screened in this series.

Is air pollution a risk factor for rheumatoid arthritis?

Rheumatoid arthritis is a chronic inflammatory debilitating disease triggered by a complex interaction involving genetic and environmental factors. Active smoking and occupational exposures such as silica increase its risk, suggesting that initial inflammation and generation of rheumatoid arthritis-related autoantibodies in the lungs may precede the clinical disease. This hypothesis paved the way to epidemiological studies investigating air pollution as a potential determinant of rheumatoid arthritis. Studies designed for epidemiology of rheumatoid arthritis found a link between traffic, a surrogate of air pollution, and this disease. Furthermore, a small case-control study recently found an association between wood smoke exposure and anticyclic citrullinated protein/peptide antibody in sera of patients presenting wood-smoke-related chronic obstructive pulmonary disease. However, reports addressing impact of specific pollutants on rheumatoid arthritis incidence and severity across populations are somewhat conflicting. In addition to the link reported between other systemic autoimmune rheumatic diseases and particulate matters/gaseous pollutants, experimental observation of exacerbated rheumatoid arthritis incidence and severity in mice models of collagen-induced arthritis after diesel exhaust particles exposure as well as hypovitaminosis D-related autoimmunity can help understand the role of air pollution in rheumatoid arthritis. All these considerations highlight the necessity to extend high quality epidemiological researches investigating different sources of atmospheric pollution across populations and particularly in low-and-middle countries, in order to further explore the biological plausibility of air pollution's effect in the pathogenesis of rheumatoid arthritis. This should be attempted to better inform policies aiming to reduce the burden of rheumatoid arthritis.

Osteoprotegerin in relation to insulin resistance and blood lipids in sub-Saharan African women with and without abdominal obesity.

BACKGROUND: Osteoprotegerin (OPG), a soluble member of the tumor necrosis factor receptor superfamily that inhibits bone resorption, has been suggested as a potential marker of cardiovascular risk. This study aimed to assess the relationship between insulin resistance, lipid profile and OPG levels in obese and non-obese sub-Saharan African women. METHODS: Sixty obese (44) and non-obese (16) volunteer women aged 18 to 40 years were recruited in this cross-sectional study. Their clinical (age, height, weight, waist circumference, systolic and diastolic blood pressures) and biochemical parameters (fasting blood glucose, total cholesterol, high density lipoprotein-cholesterol (HDL-C)) were measured using standard methods. Insulin levels were measured using an electrochemiluminescence immunoassay, while OPG levels were measured using the ELISA technique. Low density lipoprotein-cholesterol (LDL-C), body mass index (BMI) and Homeostasis Model Assessment of Insulin Resistance (HOMA-IR) were calculated using standard methods. Abdominal obesity was defined as a waist circumference ≥ 80 cm. RESULTS: OPG levels were higher in obese than in normal subjects, though the difference was not significant (p = 0.9). BMI, waist circumference, percent body fat and systolic blood pressure were significantly higher in obese than in non-obese subjects (p < 0.05). In these subjects, only age significantly correlated with OPG levels (r = 0.831, p = 0.003), while none of the anthropometric nor metabolic parameter did, even after adjustment for age. In obese subjects, OPG levels fairly correlated with HDL-C (r = 0.298, p = 0.058), and significantly correlated with HOMA-IR (r = -0.438, p = 0.018). After adjustment for age, OPG levels remained negatively correlated to HOMA-IR (r = -0.516, p = 0.020) and LDL-C (r = -0.535, p = 0.015) and positively correlated to HDL-C (r = 0.615, p = 0.004). In multiple linear regression analysis, age was a main determinant of OPG levels in non-obese (ß = 0.647, p = 0.006) and obese (ß = 0.356, p = 0.044) women. HDL-C was also associated to OPG levels in obese women (ß = 0.535, p = 0.009). CONCLUSION: The positive correlation of OPG with HDL-C and HOMA-IR, and its negative correlation with LDL-C suggest that it may be a marker of insulin sensitivity/resistance and atherogenic risk in obese African women.

Effect of HIV Infection and Highly Active Antiretroviral Therapy on Hearing Function: A Prospective Case-Control Study From Cameroon.

IMPORTANCE: Human immunodeficiency virus (HIV) infection remains a major cause of morbidity and mortality worldwide. Many studies have found a higher prevalence of hearing impairment among HIV-positive individuals. OBJECTIVE: To investigate the effect of HIV and highly active antiretroviral treatment (HAART) on the hearing function in a Cameroonian population. DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective case-control study from March 1, 2012, through January 31, 2013. The study took place at the National Social Insurance Fund Hospital in Yaoundé, Cameroon, a public health facility. We included 90 HIV-positive case patients and 90 HIV-negative control patients aged 15 to 49 years without any history of hearing loss or treatment with a known ototoxic drug. The case group was further divided into 3 subgroups: 30 HAART-naive patients, 30 patients receiving first-line HAART, and 30 patients receiving second-line HAART. INTERVENTIONS: Hearing function was assessed by pure-tone audiometry and classified according to the criteria of the Bureau International d'Audio-Phonologie. MAIN OUTCOMES AND MEASURES: Hearing loss due to HIV and HAART. RESULTS: The HIV-positive patients had more otologic symptoms (hearing loss, dizziness, tinnitus, and otalgia) than HIV-negative patients (41 vs 13, P = .04). There were 49 cases (27.2%) of hearing loss in the HIV-positive group vs 10 (5.6%) in the HIV-negative group (P = .04). Compared with HIV-negative individuals, the odds of hearing loss were higher among HIV-infected HAART-naive patients (right ear: odds ratio [OR], 6.7; 95% CI, 4.3-9.7; P = .004; left ear: OR, 6.2; 95% CI, 3.5-8.3; P = .006), patients receiving first-line HAART (right ear: OR, 5.6; 95% CI, 1.9-10.5; P = .01; left ear: OR, 12.5; 95% CI, 8.5-15.4; P < .001), and patients receiving second-line HAART (right ear: OR, 6.7; 95% CI, 3.3-9.6; P = .004; left ear: OR, 3.7; 95% CI, 3.0-5.0; P = .08). CONCLUSIONS AND RELEVANCE: Hearing loss is more frequent in HIV-infected patients compared with uninfected patients. Therefore, HIV-infected patients need special audiologic care. Further studies are needed because controversy remains regarding the factors that lead to ear damage.

Determinants of fructosamine levels in a multi-ethnic Sub-Saharan African population.

BACKGROUND AND PURPOSE: Fructosamine provides an estimate of diabetes control over a shorter period than HbA1c, and has been proposed as a suitable parameter to monitor glycemic control in low-income countries. The aim of this study was to investigate determinants of fructosamine levels in an urban non-diabetic population of Cameroon. METHODS: This was a cross-sectional study including 437 healthy adults with no known history of diabetes mellitus, aged 40 years and above, recruited from the ten administrative regions, representing major ethnic groups in the country. Plasma glucose and fructosamine were measured after an overnight fasting. Univariable and multivariable analyses were used to investigate the factors associated with fructosamine measurements. RESULTS: Fructosamine levels ranged from 68.2 to 940.8 µmol/l with a mean (standard deviation) of 294.4 (131.3) µmol/l. These levels varied significantly across regions and were higher in men than in women (p=0.001) and in those with screen-detected diabetes than in those with normoglycemia (p<0.0001). There was a negative correlation between fructosamine and body mass index (r=-0.15, p=0.009), and a positive correlation with fasting plasma glucose (FPG) (r=0.37, p<0.0001) and total bilirubinemia (r=0.21, p<0.0001). In multivariable model, sex, BMI, FPG, total bilirubine and screen-detected diabetes were no longer associated with fructosamine levels. CONCLUSION: Fructosamine was not independently associated with age, sex, ethnicity, and the glycemic status. Further studies need to be carried out to better elucidate all the factors determining the measurement of fructosamine in order to accurately interpret its values in diabetic populations.

What is the best strategy for the prevention of transfusion-transmitted malaria in sub-Saharan African countries where malaria is endemic?

The transmission of malaria by blood transfusion was one of the first recorded incidents of transfusion-transmitted infections (TTIs). Although the World Health Organization (WHO) recommends that blood for transfusion should be screened for TTIs, malaria screening is not performed in most malaria-endemic countries in sub-Saharan Africa (SSA). The transfusion of infected red blood cells may lead to severe post-transfusion clinical manifestations of malaria, which could be rapidly fatal. Ensuring that blood supply in endemic countries is free from malaria is highly problematical, as most of the donors may potentially harbour low levels of malaria parasites. Pre-transfusion screening within endemic settings has been identified as a cost-effective option for prevention of transfusion-transmitted malaria (TTM). But currently, there is no screening method that is practical, affordable and suitably sensitive for use by blood banks in SSA. Even if this method was available, rejection of malaria-positive donors would considerably jeopardize the blood supply and increase morbidity and mortality, especially among pregnant women and children who top the scale of blood transfusion users in SSA. In this context, the systematic prophylaxis of recipients with anti-malarials could constitute a good alternative, as it prevents any deferral of donor units as well as the occurrence of TTM. With the on-going programme, namely the Affordable Medicine Facility - Malaria, there is an increase in the availability of low-priced artemisinin-based combination therapy that can be used for systematic prophylaxis. It appears nonetheless an urgent need to conduct cost-benefit studies in order to evaluate each of the TTM preventive methods. This approach could permit the design and implementation of an evidence-based measure of TTM prevention in SSA, advocating thereby its widespread use in the region.

Mother-to-child transmission of HIV: findings from an early infant diagnosis program in Bertoua, Eastern Cameroon.

INTRODUCTION: Early diagnosis of HIV is crucial to ensure early antiretroviral (ARV) treatment which is associated with lower mortality in HIV-infected children. This study reports the prevalence of HIV infection and the factors associated to mother-to-child transmission (MTCT) in an Early Infant Diagnosis (EID) program in Bertoua, Cameroon. METHODS: We reviewed the records of 112 HIV-exposed infants aged six weeks to 18 months who had an HIV-1 DNA PCR test done in 2010. Data included socio-demographic characteristics, clinical manifestations of HIV, ARV prophylaxis, feeding options and results of the PCR tests. RESULTS: The median age at first HIV testing was 4 months (IQR, 2-7). Ninety-one point one percent of infants and 65.2% of mothers did not receive ARV prophylaxis. Fifty infants (44.6%) were exclusively breastfed, 37 (33%) received formula feeding and 25 (22.4%) received mixed feeding. The prevalence of HIV in the infants was 11.6%. MTCT of HIV was significantly associated with mixed feeding (adjusted odds ratio (aOR): 6.7, 95% CI 1.6-28.3; p=0.009) and an age at 1st PCR test greater than 6 months (aOR: 6.5, 95% CI 1.4-29.3; p=0.014). The mothers of 66.1% of the infants tested returned to collect the result. CONCLUSION: There is a high rate of MTCT of HIV in this setting, due to a poor implementation of the PMTCT program. There is a critical need to increase the use of ARV prophylaxis, and to improve rapid first testing and completion of the EID. The infant feeding practices also have to be improved.

Occupational exposure to blood, hepatitis B vaccine knowledge and uptake among medical students in Cameroon.

BACKGROUND: Hepatitis B virus (HBV) is the most contagious blood borne pathogen. The risk of occupational exposure to HBV among health care workers is a major concern, especially medical trainees. In this study we describe the knowledge of risk factors for HBV infection, history of accidental exposure to blood, awareness of HBV vaccine and the vaccination status among medical students in Cameroon. METHODS: In April 2012, a cross-sectional survey was carried out using a pretested self-administered questionnaire among 111 medical students. RESULTS: Sixty-two students (55.9%) had had at least one accidental exposure to blood since the beginning of their medical training, with a median of 2 (IQR, 1-3) exposures. There was a good knowledge of the risk factors for HBV infection and awareness of HBV vaccine among participants. However, only 20 (18%) participants had completed the three doses of primary HBV vaccination. Furthermore, only 2 of the 20 (10%) adequately vaccinated participants had a post-vaccination test to confirm a good immune response and thus an effective protection against HBV infection. The main reason for not being vaccinated was lack of money to pay for the vaccine (45.6%). Forty seven (42.3%) participants had been sensitized by their training institutions about the importance of HBV vaccination. These were more likely to be vaccinated compared to those who had not been sensitized (p<0,001). CONCLUSION: There is a high rate of accidental exposure to blood and a very low HBV vaccination uptake in medical students in Cameroon, leading to a high occupational risk of HBV infection. HBV vaccination should be strongly recommended for medical students and the vaccine made available free of charge at the beginning of their training.

The spectrum of cardiac disease in the West Region of Cameroon: a hospital-based cross-sectional study.

BACKGROUND: Cardiovascular disease is a growing public health problem in Africa. The extent of heart disease in Cameroon remains largely unknown. This study aimed at reporting the etiology of cardiac disease in a cardiologic clinic situated in a semi-urban area in the West region of Cameroon. METHODS: This is an analysis of echocardiographic diagnosis of cardiac disease done between July 2008 and October 2010 at the "Centre Medical de la Trinité" in the West region of Cameroon. Data included age, sex and echocardiographic findings. RESULTS: A total of 1252 patients presented with abnormal echocardiograms, 60.4% (n = 756) being female and 85.8% (n = 1074) aged over 50 years. Overall, the most important conditions were hypertensive heart disease (41.5%, n = 520) and cardiomyopathies (30.5%, n = 382). Among patients aged less than 10 years, congenital heart diseases were the most frequent (52.4%, n = 22), and rheumatic heart disease was the most important cardiac condition in patients aged 10 to 19 years (62.1%, n = 18) and those aged 20 to 39 years (53.3%, n = 8). Congenital heart diseases included persistent ductus arteriosus (27.6%, n = 8), tetralogy of Fallot (20.7%, n = 6) and inter-atria/interventricular communication (20.7%, n = 6). CONCLUSION: Hypertension is the leading cause of cardiac disease among the elderly in our setting, emphasizing the necessity to strengthen the preventive strategies against hypertension in Cameroon. Rheumatic heart disease and congenital heart disease frequent in children and youths highlight the need of early detection and treatment of throat infections, and of routine cardiac surgery services in Cameroon.

Prevalence and correlates of depressive symptoms in HIV-positive patients: a cross-sectional study among newly diagnosed patients in Yaoundé, Cameroon.

BACKGROUND: Depression is one of the most common neuropsychiatric complications of HIV disease, and in turn it is associated with worse HIV-related outcomes. Data on depression among HIV-infected patients in Cameroon are scarce. In this study, we report the prevalence and correlates of depressive symptoms among newly diagnosed HIV-infected patients in Yaoundé, Cameroon. METHODS: Interviews were conducted with 100 newly diagnosed HIV-infected patients at three referral hospitals of Yaoundé. Depression was assessed using the nine-item Patient Health Questionnaire (PHQ-9). A positive depression screen was defined as PHQ-9 score greater than 9. RESULTS: The overall prevalence of depressive symptoms was 63% (95% CI: 53.2 to 71.8), the majority having symptoms corresponding to moderate depression. Multiple logistic regression analysis showed that probable depressed patients were more likely than those who were not depressed to have had experience of alcohol abuse (OR: 19.03, 95% CI 3.11-375.85; p = 0.0083), and a 100 CD4 cells/mm3 fewer was associated with a 2.9 times increase of the odds of probable depression (95% CI 1.88-4.84; p < 0.0001). CONCLUSIONS: Our findings indicate a high prevalence of depressive symptoms in newly diagnosed HIV-infected patients in our setting, and their association with alcohol abuse and severe immunosuppression. This study also highlights the necessity to integrate mental health interventions into routine HIV clinical care in Cameroon.