Barriers to and enablers of uptake of antiretroviral therapy in integrated HIV and tuberculosis treatment programmes in sub-Saharan Africa: a systematic review and meta-analysis.

INTRODUCTION: Programmes that merge management of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) aim to improve HIV/TB co-infected patients' access to comprehensive treatment. However, several reports from sub-Saharan Africa (SSA) indicate suboptimal uptake of antiretroviral therapy (ART) even after integration of HIV and TB treatment. This study assessed ART uptake, its barriers and enablers in programmes integrating TB and HIV treatment in SSA. METHOD: A systematic review was performed. Seven databases were searched for eligible quantitative, qualitative and mixed-methods studies published from March 2004 through July 2019. Random-effects meta-analysis was used to obtain pooled estimates of ART uptake. A thematic approach was used to analyse and synthesise data on barriers and enablers. RESULTS: Of 5139 references identified, 27 were included in the review: 23/27 estimated ART uptake and 10/27 assessed barriers to and/or enablers of ART uptake. The pooled ART uptake was 53% (95% CI: 42, 63%) and between-study heterogeneity was high (I2 = 99.71%, p < 0.001). WHO guideline on collaborative TB/HIV activities and sample size were associated with heterogeneity. There were statistically significant subgroup effects with high heterogeneity after subgroup analyses by region, guideline on collaborative TB/HIV activities, study design, and sample size. The most frequently described socioeconomic and individual level barriers to ART uptake were stigma, low income, and younger age group. The most frequently reported health system-related barriers were limited staff capacity, shortages in medical supplies, lack of infrastructure, and poor adherence to or lack of treatment guidelines. Clinical barriers included intolerance to anti-TB drugs, fear of drug toxicity, and contraindications to antiretrovirals. Health system enablers included good management of the procurement, supply, and dispensation chain; convenience and accessibility of treatment services; and strong staff capacity. Availability of psychosocial support was the most frequently reported enabler of uptake at the community level. CONCLUSIONS: In SSA, programmes integrating treatment of TB and HIV do not, in general, achieve high ART uptake but we observe a net improvement in uptake after WHO issued the 2012 guidelines on collaborative TB/HIV activities. The recurrence of specific modifiable system-level and patient-level factors in the literature reveals key intervention points to improve ART uptake in these programmes. Systematic review registration: CRD42019131933.

Evaluation of the accuracy of two point-of-care haemoglobin meters used in sub-Saharan African population: a cross-sectional study.

BACKGROUND: Point-of-care haemoglobin meters are attractive solutions to improve timely diagnosis of anaemia in resource-limited settings. However, concerns regarding the accuracy of these meters may affect their adoption. The accuracy of two hand-held point-of-care haemoglobin meters was evaluated against reference full blood count analyser. METHODS: This was a hospital-based cross-sectional study conducted at the Douala General hospital, Cameroon. Two handheld haemoglobin meters were assessed: Urit12® (URIT Medical Electronics Co.,Ltd. Guangxi, China) and MissionHb®(ACON Laboratories, Inc., San Diego, USA); against a reference standard CELL-DYN RUBY® (ABBOTT DIAGNOSTICS, Illinois, USA). The Pearson's correlation and Bland-Altman agreement were used to assess the technical accuracy of the meters. Clinical accuracy was evaluated using total error allowable and area under the Receiver Operating Curve. Finally, their agreement with the reference in diagnosing anaemia was assessed using the kappa statistic. RESULTS: A total of 228 participants were included in the study. The mean haemoglobin values of both haemoglobin meters (MissionHb®: 11.6 ± 2.5 g/dl; Urit12®: 10.9 ± 2.7 g/dl) were significantly higher than the reference value (10.5 ± 2.5 g/dl), p < 0.001 for both meters. Both haemoglobin meters had good correlation with the reference analyser (r = 0.89 and r = 0.90 for Urit12® and MissionHb® respectively) and good agreement on the Bland-Altman plots. However, the MissionHb® meter did not meet the clinical accuracy requirements (p < 0.001). Even though both meters were excellent at identifying the presence of anemia (MissionHb® - AUC = 0.9161, Urit 12® - AUC = 0.9009), they, however, both had weak agreement with the reference analyser in diagnosing the severity of anaemia (K = 0.39 for MissionHb®, p < 0.001 and K = 0.54 for Urit12®, p < 0.001). CONCLUSION: Although both devices showed technical accuracy with a positive correlation with the reference analyser and were able to accurately diagnose the presence of anemia, both meters however, had sub-optimal agreement with the reference analyser in diagnosing the degree of severity of anaemia among our participants.

Evaluation of emergency obstetric and neonatal care services in Kumba Health District, Southwest region, Cameroon (2011-2014): a before-after study.

BACKGROUND: There is uncertainty regarding the status of emergency obstetric and neonatal care (EmONC) in the Cameroonian context where maternal and neonatal mortality are persistently high. This study sought to evaluate the coverage, functionality and quality of EmONC services in Kumba health district (KHD), the largest health district in Southwest Cameroon.. METHODS: A retrospective study of routine EmONC data for the periods 1 January 2011 to 31 December 2012 (when EmONC was being introduced) and 1 January 2013 to 31 December 2014 (when EmONC was fully instituted) was conducted. Coverage, functionality and quality of EmONC services were graded as per United Nations (UN) standards. Data was analysed using Epi-Info version 7 statistical software. RESULTS: Among the 31 health facilities in KHD, 12 (39%) had been delivering EmONC services. Three (25%) of these were geographically inaccessible Among the 9 facilities that were assessed, 4 facilities (44%) performed designated signal functions, with 2 being comprehensive (CEmONC) and 2 basic (BEmONC). These exceeded the required minimum of 2.8 EmONC facilities/500000, 0.6 CEmONC facilities/500000 and 2.2 BEmONC facilities/500000, with reference to an estimated KHD population of 265,071. The signal functions that were least likely to be performed were neonatal resuscitation, manual evacuation of retained products and use of anticonvulsants. In 2011-2012, the facilities performed 35% of expected deliveries. This dropped to 28% in 2013-2014. Caesarean sections as a proportion of expected deliveries remained very low: 1.5% in 2010-2011 and 3.6% in 2013-2014. In 2011-2012, met needs were 6.8% and increased to 7.3% in 2013-2014. Direct obstetric fatality rates increased from 8 to 11% (p = 0.64). Intrapartum and very early neonatal deaths increased from 4.% to 7 (p = 0.89). CONCLUSION: Major gaps were observed in the performance of signal functions as well as the quality and utilization of EmONC. While the results of this study seem to indicate the need to sustainably scale up the utilization of quality EmONC, the interpretations of our findings require consideration of improvements in reporting of mortality data associated with the introduction of EmONC as well as dynamics in country-specific maternal health policies and the potential influence of these policies on EmONC indicators.

Evolutionary aspects of non-metastatic breast cancer after primary treatment in a sub-Saharan African setting: a 16-year retrospective review at the Douala general hospital, Cameroon.

BACKGROUND: Breast cancer has a high case fatality rate in sub-Saharan Africa, and this is chiefly because of late detection and inadequate treatment resources. Progressive renovations in diagnostic and management modalities of non-metastatic breast cancer (NMBC) have been noted in the region but there is paucity of data describing the clinical progress of patients with NMBC. This study sought to determine the rates of local relapse, distant metastasis and sequelae and the time span from initial treatment to the occurrence of these adverse events among patients with NMBC. METHODS: This was a retrospective review of medical records of patients with histologically confirmed NMBC at the department of radiation therapy and oncology of the Douala General Hospital in Cameroon from the January 1997 to December 2012 period. Clinicopathological and treatment characteristics as well as occurrences of adverse events were studied. RESULTS: A total of 260 cases were reviewed of which 224/260 (86.2%) had invasive ductal carcinoma. Surgery was performed on 258/260 cases (99.2%) with 187/258 (72.5%) being modified radical mastectomies. Various treatment combinations were used in up to 228/260 patients (87.5%) while surgery alone was the treatment in the remaining 32 cases (12.5%). Metastasis occurred in 142/260 cases (54.6%) of which 68/142 (26.2%) were local relapses and 74/142 (28.5%) were distant metastases. Among the cases of distant metastasis, 9.2% were bone, 8.5% lungs, 6.9% nodal, and 5.4% brain. Metastasis to multiple organs was noted in 4.7% of these cases. The median periods of occurrence of local relapse and distant metastases were 13 and 12 months respectively. Sequelae occurred in 26/260 cases (10%) and were noted after an average of 30 months. The main sequelae were lymphoedema (6.5%) and lung fibrosis (1.5%). At the end of the period under review, 118/260 patients (45.4%) were alive and disease-free with a median follow up time of 24 months. CONCLUSIONS: Adverse events were frequent among patients who received primary treatment for NMBC. Available cancer therapeutic modalities ought to be supplemented with efficient strategies of follow-up and monitoring so as to optimize the care provided to these patients and improve on their survival.

Prevalence and factors associated with depression among medical students in Cameroon: a cross-sectional study.

BACKGROUND: Depression is an important contributor to the global burden disease that affects people of communities all over the world. With high level of demands in academics and psychosocial pressure, medical students during their course of training tend to become depressed, leading to problems later in professional life and compromising patient care. In Cameroon, there is lack of data on the prevalence of depression and its impact on medical students. To determine the prevalence and predisposing factors associated with depression among medical students in Cameroon (preclinical and clinical). We also evaluated the impact of depression on self-reported academic performance. METHODS: A cross sectional study was carried out in all 4 state medical schools in 4 different regions from December 2015 to January 2016. Diagnosis of depression, major depression and its associated factors were assessed using the 9-Item-Patient Health Questionnaire (PHQ-9) and a structured questionnaire respectively. We included 618 medical students (response rate: 90.4%). RESULTS: About a third of them (30.6%, 95% CI: 22.8-36.7) were found to have major depressive disorder (PHQ Score ≥ 10). With regards to the severity of depression, 214 (34.6%), 163 (26.4%), 21 (3.4%), and 5 (0.80%) students were classified as having mild, moderate, moderately severe and severe depression respectively. The presence of a chronic disease (OR: 3.70, 95% CI: 1.72-7.94, p = 0.001), major life events (OR: 2.17, 95%CI: 1.32-3.58, P = 0.002), female gender (OR: 1.59, 95% CI: 1.06-2.37, p = 0.024) and being a student at the clinical level (OR: 4.26, 95% CI: 2.71-6.71, p < 0.001) were independently associated with depression. There was no association between depression and self-reported academic performance, (OR: 1.2, 95% CI: 0.9-1.7, p = 0.080). CONCLUSION: The prevalence of major depressive disorders among medical students in Cameroon is high and is associated with the presence chronic disease, major life events, female gender and being a student at the clinical level. So we recommend clinicians attending to medical students with demographic features suggestive of greater risk of depression, to make an in depth investigation on the possible presence of depression. Despite this high prevalence of major depression among medical students, it was not associated with self-reported academic performance.

A prospective analysis of pinch grafting of chronic leg ulcers in a series of elderly patients in rural Cameroon.

BACKGROUND: Chronic leg ulcers (CLUs) pose serious public health concerns worldwide. They mainly affect the elderly population. Pinch grafting (PG) could be used to treat a variety of CLUs. However, in Cameroon, there is scarce data on the outcome of PG of CLUs in elderly patients in rural hospitals where most of these patients seek for medical attention and where clinicians rely on unconventional wound dressing methods to treat CLUs. Our objective was to describe the outcome of PG of CLUs in elderly patients in rural Cameroon. METHODS: This was a prospective study conducted in a rural hospital of North West Cameroon. From February 2015 to January 2016, comprehensive historical and clinical data were collected per elderly patient who presented with a chronic leg ulcer necessitating PG. PG was done using a simple procedure and each patient followed up for 8 months. Outcome was described in terms of ulcer healing and pain and donor site complications. RESULTS: Our series included 13 patients: 8 males (61.54%; 95% CI: 31.58-86.14) and 5 females (38.46%; 95% CI: 13.86-68.42) aged from 69 to 88 years (mean: 77.54 ± 5.70 years). Three patients (23.08%; 95% CI: 5.04-53.81) had associated co-morbidities. All the ulcers were unilateral with durations ranging from 7 to 41 months (mean: 19.46 ± 11.03 months). The ulcers ranged in size from 9.0 to 38.1 cm2 (mean: 17.66 ± 8.35 cm 2). We registered one (7.69%; 95% CI: 0.19-36.03) graft rejection. Concerning the other ulcers, ten (83.33%; 95% CI: 51.59-97.91) had healed after 12 postoperative weeks while 2 (16.67%; 95% CI: 2.09%-48.41) had healed after 14 postoperative weeks and the mean healing time was 12.33 ± 0.78 weeks. Patients with healed ulcers had reduced ulcer site pain from the immediate postoperative period but there was no significant difference in the mean pain scores before and after graft (6.77 against 4.23, p = 0.13). These ulcers remained healed after 8 postoperative months. Each donor site had healed 2 weeks after PG. Donor site problems were minimal and included hypopigmentation. CONCLUSION: The outcome of PG of CLUs in our series of older patients was satisfactory. This finding does not discount the role of conservative therapy, but we encourage clinicians in rural Cameroon to consider PG over long-term unconventional conservative therapy in the elderly.

Electrocardiographic abnormalities in patients with metabolic dysfunction-associated steatotic liver disease: A systematic review and meta-analysis.

INTRODUCTION: This study review aimed to consolidate current knowledge on the electrocardiographic abnormalities observed in patients with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD), formerly known as Non-Alcoholic Fatty Liver Disease (NAFLD). METHODS: This was a systematic review of studies on the association between MASLD and electrocardiographic abnormalities, published between January 1, 1946, and October 31, 2023. Data from eligible studies were extracted, analyzed, synthesized, and summarized. RESULTS: We evaluated a total of 27 studies with 8,607,500 participants overall and 1,005,101 participants with MASLD. There was a statistically significant association between MASLD and prevalent atrial fibrillation (pooled OR: 1.34 95 % CI: 1.20-1.49, p < 0.001, n = 12), shorter QRS duration (pooled SMD: -0.073, 95 % CI: -0.144 - -0.001, n = 2, p = 0.048, n = 2), QTc prolongation (p < 0.001, n = 2), LVH (pooled OR: 1.48, 95 % CI: 1.25-1.75, p < 0.001, n = 3), low voltage (p < 0.001, n = 1), ST changes (OR: 1.41, 95 % CI: 1.04-1.91, p = 0.027, n = 1), T wave inversion (p < 0.001, n = 1), axis deviation (OR: 3.21, 95 % CI: 1.99-5.17, p < 0.001, n = 1), conduction defect (OR: 2.79, 95 % CI: 1.83-4.26, p < 0.001, n = 1) and bundle branch block (OR: 2.90, 95 % CI: 1.82-4.61, p < 0.001, n = 1), any persistent heart block (p < 0.001, n = 1), fragmented QRS (p < 0.001, n = 1), and p wave dispersion (p < 0.001, n = 1) CONCLUSION: MASLD is associated with multiple ECG abnormalities which are potential markers of early cardiac involvement, highlighting the multisystemic nature of MASLD. These specific ECG abnormalities could be used in screening and management algorithms to improve cardiac risk stratification in MASLD patients. PROSPERO REGISTRATION: CRD42023477501.

Usefulness of disease surveillance data in enhanced early warning of the cholera outbreak in Southwest Cameroon, 2018.

INTRODUCTION: This study assessed the timeliness and completeness of disease surveillance data for early warning of the cholera outbreak during the socio-political crisis of Southwest Cameroon in 2018. It determined how routine integrated disease surveillance and response (IDSR) data was used for preventative actions and the challenges faced by key health staff in IDSR based decision-making. METHODS: This was a mixed-methods study conducted from June 1st to September 30th 2021. District Health Information System 2 (DHIS2) data from January 2018 to December 2020 for the Southwest region of Cameroon were analysed using simple linear regression on EPI Info 7.2 to determine a potential association of the sociopolitical crisis with timeliness and completeness of data. Qualitative data generated through in-depth interviews of key informants were coded and analyzed using NVivo 12. RESULTS: During high conflict intensity (2018 and 2019), average data timeliness and completeness were 16.3% and 67.2%, respectively, increasing to 40.7% and 80.2%, respectively, in 2020 when the conflict intensity had reduced. There was a statistically significant weak correlation between reduced conflict intensity and increased data timeliness (R2 = 0.17, p = 0.016) and there was also a weak correlation between reduced conflict intensity and data completeness but this was not statistically significant (R2 = 0.01, p = 0.642). During high conflict intensity, the Kumba and Buea health districts had the highest data timeliness (17.2% and 96.2%, respectively) and data completeness (78.8% and 40.4%, respectively) possibly because of proximity to reporting sites and effective performance based financing. Components of IDSR that should be maintained included the electronic report aspect of the DHIS2 and the supportive supervision conducted during the outbreak. Staff demotivation, the parallel multiplicity of data entry tools, poor communication, shortage of staff and the non-usability of data generated by the DHIS2 were systemic challenges to the early alert dimension of the IDSR system. Non-systemic challenges included high levels of insecurity, far to reach outbreak sites and health personnel being targeted during the conflict. CONCLUSION: In general, routine IDSR data was not a reliable way of providing early warning of the 2018 cholera outbreak because of incomplete and late reports. Nonetheless, reduced conflict intensity correlated with increased timeliness and completeness of data reporting. The IDSR was substantially challenged during the crisis, and erroneous data generated by the DHIS 2 significantly undermined the efforts and resources invested to control the outbreak. The Ministry of Public Health should reinforce efforts to build a reporting system that produces people-centered actionable data that engages health risk management during socio-political crises.

Emergence of universal antiretroviral therapy coverage in South Africa: applying the advocacy coalition framework to refine the narratives and inform epidemic responses.

South Africa possesses the largest anti-retroviral therapy (ART) program in the world, but the path to this record was dramatic. There is scarce literature employing a comprehensive framework to explain this achievement and inform epidemic responses. This paper applies the Advocacy Coalition Framework (ACF) to analyse the interactions among diverse actors, institutions and networks that were associated with the AIDS policy change in South Africa. Post-apartheid, HIV/AIDS and AIDS-related mortality were serious public health problems. At the time, the discernible coalitions in the HIV/AIDS policy subsystem were the pro-science coalition and AIDS dissidents. In view of the availability of compelling scientific evidence on the pathogenesis of HIV/AIDS, the clinical usefulness of ART, the availability of funding for national ART roll-out, strong global advocacy to reduce the cost of ART, all of these in an era when access to adequate HIV treatment/care was increasingly considered a human right, the environment to establish an appropriate HIV/AIDS policy for the country was conducive. However, AIDS dissidents dominated the policy agenda via their control over key institutions, the use of various dimensions of power, biasing evidence to inform policy, and promoting the activities of strong interest groups that were not in support of ART. National ART roll-out finally emerged as a political priority because of external shocks (on the AIDS policy subsystem) which disfavoured the dominant coalition. As in this important experience in the history of HIV treatment, stakeholders involved in epidemic response tend to engage in intense ideological conflicts. An adequate appraisal of the outcomes of these conflicts in terms of population health gains and adopted public health and social measures to control epidemics would require the supplementation of complex system thinking with relevant public policy concepts, notably power dimensions, governance, emergence of global health networks and evidence use in policy.

A systematic review and meta-analysis on the association between ambient air pollution and pulmonary tuberculosis.

There is inconclusive evidence on the association between ambient air pollution and pulmonary tuberculosis (PTB) incidence, tuberculosis-related hospital admission and mortality. This review aimed to assess the extent to which selected air pollutants are associated to PTB incidence, hospital admissions and mortality. This was a systematic review of studies published in English from January 1st, 1946, through May 31st, 2022, that quantitatively assessed the association between PM2.5, PM10, NO2, SO2, CO, O3 and the incidence of, hospital admission or death from PTB. Medline, Embase, Scopus and The Cochrane Library were searched. Extracted data from eligible studies were analysed using STATA software. Random-effect meta-analysis was used to derive pooled adjusted risk and odds ratios. A total of 24 studies (10 time-series, 5 ecologic, 5 cohort, 2 case-control, 1 case cross-over, 1 cross-sectional) mainly from Asian countries were eligible and involved a total of 437,255 tuberculosis cases. For every 10 µg/m3 increment in air pollutant concentration, there was a significant association between exposure to PM2.5 (pooled aRR = 1.12, 95% CI: 1.06-1.19, p < 0.001, N = 6); PM10 (pooled aRR = 1.06, 95% CI: 1.01-1.12, p = 0.022, N = 8); SO2 (pooled aRR = 1.08, 95% CI: 1.04-1.12, p < 0.001, N = 9); and the incidence of PTB. There was no association between exposure to CO (pooled aRR = 1.04, 95% CI: 0.98-1.11, p = 0.211, N = 4); NO2 (pooled aRR = 1.08, 95% CI: 0.99-1.17, p = 0.057, N = 7); O3 (pooled aRR = 1.00, 95% CI: 0.99-1.02, p = 0.910, N = 6) and the incidence of PTB. There was no association between the investigated air pollutants and mortality or hospital admissions due to PTB. Overall quality of evidence was graded as low (GRADE approach). Exposure to PM2.5, PM10 and SO2 air pollutants was found to be associated with an increased incidence of PTB, while exposure to CO, NO2 and O3 was not. There was no observed association between exposure to these air pollutants and hospital admission or mortality due to PTB. The quality of the evidence generated, however, remains low. Addressing the tuberculosis epidemic by 2030 as per the 4th Sustainable Development Goal may require a more rigorous exploration of this association.

A 73-Year-Old Man with an Incidental Diagnosis of Deltoid Intramuscular Myxoma Following a History of Trauma.

BACKGROUND Intramuscular myxomas are rare and benign soft-tissue tumors of uncertain differentiation. Predisposing or precipitating factors have not yet been reported. Activating mutation in GNAS (exons 8 and 9) is detected in >90% of sporadic cases. The role of chronic myopathy, tendinopathy, or trauma to muscles in the etiology of these neoplasms is not known. We report an unusual case of a deltoid mass found following longstanding rotator cuff tendinopathy and a recent fall, later confirmed to be an intramuscular myxoma on biopsy. CASE REPORT A 73-year-old man with a 5-year history of left shoulder pain and rotator cuff tear presented with intractable pain in his left shoulder after a recent fall at home. Physical examination was suggestive of a rotator cuff injury and magnetic resonance imaging (MRI) of the left shoulder revealed a 2.7×2.5×3.7cm T1 hypo- and T2 hyperintense oblong mass-like signal abnormality with heterogeneous, predominantly peripheral enhancement within the deltoid muscle concerning for a malignant mass. Surgical resection was carried out along with left reverse total shoulder replacement, and histopathology revealed findings consistent with an intramuscular myxoma. CONCLUSIONS Intramuscular myxomas are rare, benign tumors. This case report presents one such myxoma incidentally found in a patient with longstanding rotator cuff tendinopathy and a recent fall. Although this co-occurrence is likely incidental, further research and case series review of similar presentations may influence postulations of the pathophysiology of myxomas.

Factors associated with measles resurgence in the United States in the post-elimination era.

There have been growing concerns of a potential re-establishment of measles transmission in the United States (US) in the years to come. This study aims to explore potential factors underlying the resurgence of measles in the US by objectively assessing the associations between annual incidence rates (AIR), case importation, vaccination status and disease outbreaks. Data on measles transmission between January 1st, 2001 and December 31st, 2019 were obtained from the national centres for disease control and prevention (CDC) surveillance databases and other published reports. Changes in incidence rates over time were assessed by binomial regression models. Of the 3874 cases of measles in the US over the study period, 3506 (90.5%, 95% CI: 89.5-91.4) occurred in US residents. The AIR per million population in US residents over this period was 0.60 (95% CI: 0.59-0.61), with an overall significant increase over time (p = 0.011). The median percentage of imported and vaccinated cases were 36% [17.9-46.6] and 15% [12.1-23.2] respectively. There was a significant decrease in the percentage of imported cases (p < 0.001) but not of vaccinated cases (p = 0.159) over time. There was a moderate and weak negative correlation between the AIR and the percentage of imported and vaccinated cases respectively (r = -0.59 and r = -0.27 respectively). On multiple linear regression there was a significant linear association between the AIR and the number of outbreaks (p = 0.003) but not with the percentage of imported cases (p = 0.436) and vaccinated cases (p = 0.692), R2 = 0.73. Strong negative and positive correlations were seen between the number of outbreaks and the percentage of imported cases (r = -0.61) and the of number states affected (r = 0.88) respectively. Despite the overall reduction in the percentage of imported cases of measles over the past two decades, pockets of internal transmission of the disease following importation via increasing number of outbreaks in unvaccinated subpopulations, reinforced by vaccine hesitancy, account for the sustained increase in measles incidence rates in the US. Controlling indigenous transmission through efficient vaccination coverage in at-risk subpopulations and among international US travellers, improved disease surveillance and rapid outbreak containment are essential in curbing the measles resurgence.

A Case Report of Steroid-Resistant Cryptogenic Organizing Pneumonia Managed with Intravenous Immunoglobulins.

Fewer than ten reported cases of cryptogenic organizing pneumonia (COP) have been managed with intravenous immunoglobulins (IVIg). We report a case of a 72-year-old man who presented with a worsening cough and diffuse opacities on chest radiograph. Following no improvement with antibiotics and negative complementary investigations for infectious, malignant, and autoimmune etiologies, COP was confirmed on lung biopsy. Due to continued clinical deterioration despite high-dose steroids and new severe steroid-induced hallucinations, the patient was placed on intravenous immunoglobulins (IVIg) and mycophenolate mofetil and made a satisfactory recovery. IVIg should be considered as an important steroid-sparing alternative in patients with COP.

Systematic review of therapeutic outcomes of multidrug resistant tuberculosis and their predictors in adults receiving integrated treatment of tuberculosis and human immuno-deficiency virus in low- and middle-income countries: a study protocol.

BACKGROUND: Programs that integrate tuberculosis (TB) and human immunodeficiency virus (HIV) treatment aim to provide efficient treatment services and maximize successful treatment outcomes through the delivery of both TB and HIV treatment by one provider at the same time and location. However, multi-drug resistant tuberculosis (MDR-TB) is more difficult to treat as compared to drug-sensitive TB, and in low- and middle-income countries (LMICs), the potential of programs integrating TB/HIV treatment to sustain favourable MDR-TB treatment outcomes is poorly elucidated. The objective of this review is to perform a systematic collection, critical appraisal and synthesis of existing evidence on therapeutic outcomes of MDR-TB and their predictors among adults receiving integrated treatment for TB/HIV in LMICs. METHODS: A systematic review of quantitative evidence from observational cohort studies will be performed. MEDLINE, Embase, and Global Health electronic databases will be searched for relevant studies published from March 2004 to December 2019. Two investigators will independently screen the search output, review the eligible studies, and assess the quality of the eligible studies using quality assessment tools of the National Heart Lung and Blood Institute. Random-effects meta-analysis will be used to obtain summary estimates. Heterogeneity across studies will be assessed using the I2 statistic. The confidence in the summary estimates will be rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. The final review will be reported following the guidelines of the Preferred Reporting System for Systematic Reviews and Meta-analysis, presented at scientific conferences and published in a peer-reviewed journal. DISCUSSION: This study is expected to report the performance of integrated TB/HIV treatment programs as regards their potential to uphold successful MDR-TB treatment outcomes in LMICs. Furthermore, the review will indicate patient-related and healthcare-related factors that should be addressed to improve on survival of patients with MDR-TB/HIV co-infection in LMICs. SYSTEMATIC REVIEW REGISTRATION: This review has been registered with the International Prospective Register of Systematic Reviews and the reference ID is CRD42020159745.

The association between antiretroviral therapy and selected cardiovascular disease risk factors in sub-Saharan Africa: A systematic review and meta-analysis.

BACKGROUND: With increasing adverse cardiovascular disease (CVD) outcomes in HIV/AIDS patients, the possible contribution of antiretroviral therapy (ART) to the prevailing CVD epidemic in sub-Saharan Africa (SSA) through its effect on CVD risk factors has rather been under investigated. This study aimed to assess the extent to which ART is associated with hypertension, diabetes mellitus (DM) and dyslipidemia in SSA. METHODS: This is a systematic review and meta-analysis of studies from SSA, published between January 1946 and December 2017, from Medline, Embase, Africa-wide Information, the Cochrane library, African Index and Medicus databases. Both observational and interventional studies with comparable ART-treated and ART-naïve populations were selected and data was extracted from eligible studies. Pooled estimates of the effect of ART on the outcomes of interest (hypertension, diabetes and abnormal lipid profiles) were obtained using random effects meta-analysis, and meta-regression analysis was used to explore between-study heterogeneity. RESULTS: Twenty cross-sectional studies were included involving 5386 participants. There was no association between ART use and hypertension (OR: 1.9, 95%CI: 0.96-3.76, n = 8, I2 = 73.8%) and DM (OR: 2.53, 95%CI: 0.87-7.35, n = 8, I2 = 73.8%). ART use was associated with high total cholesterol (OR: 3.85, 95%CI: 2.45-6.07, n = 8, I2 = 67.0%), high triglycerides (OR: 1.46, 95%CI: 1.21-1.75, n = 14, I2 = 10.0%) and high LDL-cholesterol (OR: 2.38, 95%CI: 1.43-3.95, n = 11, I2 = 87.6%). ART was associated with rather lower odds of having low HDL-cholesterol (OR: 0.53, 95%CI: 0.32-0.87, n = 8, I2 = 78.2%). There was evidence of between-study heterogeneity for all outcomes except high triglycerides. CONCLUSIONS: ART appears to be associated with CVD risk in HIV/AIDS patients in SSA only through dyslipidemia but not through hypertension and DM, however, high quality and robust research in SSA is mandated to accurately ascertain the actual contribution of ART to the CVD burden in this part of the world. Nevertheless, HIV/AIDS patients should still benefit from systematic CVD screening alongside their regular care services. TRIAL REGISTRATION: Prospero Registration - CRD42016042306.

Current challenges and proposed solutions to the effective implementation of the RTS, S/AS01 Malaria Vaccine Program in sub-Saharan Africa: A systematic review.

BACKGROUND: The Malaria Vaccine Implementation Program, coordinated by the World Health Organization, intended to initiate the roll-out of the RTS, S/AS01 malaria vaccine in 3 sub-Saharan African countries in 2018. With sub-optimal implementation, the effectiveness of this vaccine in routine clinical use could be significantly lower than its measured efficacy in randomized trials. This study had as objectives to systematically review and summarize published studies addressing the challenges faced during the implementation phase of malaria vaccination programs and randomized trials conducted in sub-Saharan Africa. The review also sought to report proposed solutions to the challenges identified. METHOD: This was a systematic review of studies published between 1947 and 2017. Medline, Embase and the Cochrane library databases were searched. Of the 365 studies retrieved, 8 eligible studies reported on challenges of implementing a malaria vaccine in sub-Saharan Africa and possible solutions to these challenges. Data were abstracted from the eligible studies and a qualitative synthesis was done. RESULTS: The 8 studies included in the review had a total of 6189 participants and used a variety of methodologies (3 qualitative, 1 quantitative, 3 mixed method studies and 1 clinical trial review). There was an overall positive acceptance towards the new malaria vaccine (n = 6/8 studies), with a mean acceptance rate of 86.1% (95% CI: 62.0-110.2, n = 2). The main challenges to vaccine receptivity were: inadequate community engagement due to lack of information about the vaccine (n = 6), fear of the vaccine's side effects (n = 5), inefficient delivery of vaccination services to children (n = 4), and sub-optimal quality of the health services (n = 3). Main themes identified from the proposed solutions consisted of the following: using dynamic communication models and trusted sources for delivering vaccine-related health information to the communities (n = 6), community engagement at both national and district level (n = 6), implementing the new vaccine services alongside the existing health services already delivered (n = 6). CONCLUSION/RECOMMENDATIONS: Effective implementation of the malaria vaccine program requires careful consideration of the socio-cultural context of each community. The RTS, S/AS01 malaria vaccine acceptance and uptake may be significantly enhanced if caregivers' perceptions about vaccines and their importance are adequately fine-tuned. In order to achieve these, community participation and the provision of adequate information in an acceptable form via reliable communication channels seem to be imperative.

An unusual case of extensive truncal cutaneous larva migrans in a Cameroonian baby: a case report.

BACKGROUND: Cutaneous larva migrans is a neglected zoonotic helminthic disease which is paradoxically underreported in low-income and middle-income countries from where a majority of the cases emanate. It presents as migratory, raised, erythematous serpentine lesions, responsive to treatment with antihelminthics. It is common in children, but rare in babies. We report an unusual case of cutaneous larva migrans in a Cameroonian baby. CASE PRESENTATION: We report the case of a 9-month-old Cameroonian baby girl, whose mother had the habit of drying the child's clothes on the grass in her courtyard. The child was brought to our hospital after she developed itchy, snake-like, slowly progressing lesions on her abdomen and chest. An examination revealed multiple raised serpentine and erythematous skin lesions consistent with cutaneous larva migrans which subsided on antihelminthic and antihistaminic therapy. CONCLUSIONS: Cutaneous larva migrans is an endemic disease with predilection for poor and vulnerable persons. Preventive efforts such as wearing of slippers, usage of drying lines, and deworming of pets are crucial in preventing the occurrence of this disease and should be encouraged.

Markers of adiposity in HIV/AIDS patients: Agreement between waist circumference, waist-to-hip ratio, waist-to-height ratio and body mass index.

BACKGROUND: Waist circumference (WC), waist-to-hip ratio (WHR) and waist-to-height ratio (WHtR) are all independent predictors of cardio-metabolic risk and therefore important in HIV/AIDS patients on antiretroviral therapy at risk of increased visceral adiposity. This study aimed to assess the extent of agreement between these parameters and the body mass index (BMI), as anthropometric parameters and in classifying cardio-metabolic risk in HIV/AIDS patients. METHODS: A secondary analysis of data from a cross-sectional study involving 200 HIV/AIDS patients was done. Anthropometric parameters were measured from participants using standard guidelines and central obesity defined according to recommended criteria. Increased cardio-metabolic risk was defined according to the standard cut-off values for all four parameters. Data were analyzed using STATA version 14.1. RESULTS: The prevalence of WC-defined central obesity, WHR-defined central obesity and WHtR > 0.50 were 33.5%, 44.5% and 36.5%, respectively. The prevalence of BMI-defined overweight and obesity was 40.5%. After adjusting for gender and HAART status, there was a significant linear association and correlation between WC and BMI (regression equation: WC (cm) = 37.184 + 1.756 BMI (Kg/m2) + 0.825 Male + 1.002 HAART, (p < 0.001, r = 0.65)), and between WHtR and BMI (regression equation: WHtR = 0.223 + 0.011 BMI (Kg/m2)- 0.0153 Male + 0.003 HAART, (p < 0.001, r = 0.65)), but not between WHR and BMI (p = 0.097, r = 0.13). There was no agreement between the WC, WHtR and BMI, and minimal agreement between the WHR and BMI, in identifying patients with an increased cardio-metabolic risk. CONCLUSION: Despite the observed linear association and correlation between these anthropometric parameters, the routine use of WC, WHR and WHtR as better predictors of cardio-metabolic risk should be encouraged in these patients, due to their minimal agreement with BMI in identifying HIV/AIDS patients with increased cardio-metabolic risk. HAART status does not appear to significantly affect the association between these anthropometric parameters.

Association between CD4 Cell Count and Blood Pressure and Its Variation with Body Mass Index Categories in HIV-Infected Patients.

The aim of this study was to establish whether an independent relationship exists between CD4 count and hypertension and if this relationship is modified or confounded by the body mass index (BMI). Methods. A secondary data analysis of a cross-sectional study on 200 HIV/AIDS patients at a referral hospital in Cameroon was conducted. Linear and logistic regression models were used as appropriate to explore the association between the variables of interest. Results. There was no linear association between log CD4 count and both systolic (p = 0.200; r = 0.12) and diastolic blood pressures (p = 0.123; r = 0.14), respectively. After adjusting for BMI, patients with CD4 count ≥ 350 cells/µl were more likely to have hypertension than those with CD4 count < 350 cells/µl (AOR: 2.50, 95% CI: 1.05-5.93, and p = 0.032). There was no effect modification from BMI (test of homogeneity, p = 0.721). There was no independent relationship between CD4 count and hypertension after controlling for age, sex, family history of hypertension, BMI-defined overweight, HAART use, and duration of HIV infection (AOR: 1.66, 95% CI: 0.48-5.71, and p = 0.419). Conclusion. This study did not identify any independent relationship between CD4 count and hypertension. Large prospective studies are recommended to better explore this relationship between hypertension and CD4 count.