Antifungal Combinations for Treatment of Cryptococcal Meningitis in Africa.

BACKGROUND: Cryptococcal meningitis accounts for more than 100,000 human immunodeficiency virus (HIV)-related deaths per year. We tested two treatment strategies that could be more sustainable in Africa than the standard of 2 weeks of amphotericin B plus flucytosine and more effective than the widely used fluconazole monotherapy. METHODS: We randomly assigned HIV-infected adults with cryptococcal meningitis to receive an oral regimen (fluconazole [1200 mg per day] plus flucytosine [100 mg per kilogram of body weight per day] for 2 weeks), 1 week of amphotericin B (1 mg per kilogram per day), or 2 weeks of amphotericin B (1 mg per kilogram per day). Each patient assigned to receive amphotericin B was also randomly assigned to receive fluconazole or flucytosine as a partner drug. After induction treatment, all the patients received fluconazole consolidation therapy and were followed to 10 weeks. RESULTS: A total of 721 patients underwent randomization. Mortality in the oral-regimen, 1-week amphotericin B, and 2-week amphotericin B groups was 18.2% (41 of 225), 21.9% (49 of 224), and 21.4% (49 of 229), respectively, at 2 weeks and was 35.1% (79 of 225), 36.2% (81 of 224), and 39.7% (91 of 229), respectively, at 10 weeks. The upper limit of the one-sided 97.5% confidence interval for the difference in 2-week mortality was 4.2 percentage points for the oral-regimen group versus the 2-week amphotericin B groups and 8.1 percentage points for the 1-week amphotericin B groups versus the 2-week amphotericin B groups, both of which were below the predefined 10-percentage-point noninferiority margin. As a partner drug with amphotericin B, flucytosine was superior to fluconazole (71 deaths [31.1%] vs. 101 deaths [45.0%]; hazard ratio for death at 10 weeks, 0.62; 95% confidence interval [CI], 0.45 to 0.84; P=0.002). One week of amphotericin B plus flucytosine was associated with the lowest 10-week mortality (24.2%; 95% CI, 16.2 to 32.1). Side effects, such as severe anemia, were more frequent with 2 weeks than with 1 week of amphotericin B or with the oral regimen. CONCLUSIONS: One week of amphotericin B plus flucytosine and 2 weeks of fluconazole plus flucytosine were effective as induction therapy for cryptococcal meningitis in resource-limited settings. (ACTA Current Controlled Trials number, ISRCTN45035509 .).

Estimation and determinants of direct medical costs of ischaemic heart disease, stroke and hypertensive heart disease: evidence from two major hospitals in Cameroon.

BACKGROUND: Cardiovascular disease (CVD) is the largest contributor to the non-communicable diseases (NCD) burden in Cameroon, but data on its economic burden is lacking. METHODS: A prevalence-based cost-of-illness study was conducted from a healthcare provider perspective and enrolled patients with ischaemic heart disease (IHD), ischaemic stroke, haemorrhagic stroke and hypertensive heart disease (HHD) from two major hospitals between 2013 and 2017. Determinants of cost were explored using multivariate generalized linear models. RESULTS: Overall, data from 850 patients: IHD (n = 92, 10.8%), ischaemic stroke (n = 317, 37.3%), haemorrhagic stroke (n = 193, 22.7%) and HHD (n = 248, 29.2%) were analysed. The total cost for these CVDs was XAF 676,694,000 (~US$ 1,224,918). The average annual direct medical costs of care per patient were XAF 1,395,200 (US$ 2400) for IHD, XAF 932,700 (US$ 1600) for ischaemic stroke, XAF 815,400 (US$ 1400) for haemorrhagic stroke, and XAF 384,300 (US$ 700) for HHD. In the fully adjusted models, apart from history of CVD event (ß = - 0.429; 95% confidence interval - 0.705, - 0.153) that predicted lower costs in patients with IHD, having of diabetes mellitus predicted higher costs in patients with IHD (ß = 0.435; 0.098, 0.772), ischaemic stroke (ß = 0.188; 0.052, 0.324) and HHD (ß = 0.229; 0.080, 0.378). CONCLUSIONS: This study reveals substantial economic burden due to CVD in Cameroon. Diabetes mellitus was a consistent driver of elevated costs across the CVDs. There is urgent need to invest in cost-effective primary prevention strategies in order to reduce the incidence of CVD and consequent economic burden on a health system already laden with the impact of communicable diseases.

Serum Uric Acid Is Associated with Poor Outcome in Black Africans in the Acute Phase of Stroke.

BACKGROUND: Prognostic significance of serum uric acid (SUA) in acute stroke still remains controversial. OBJECTIVES: To determine the prevalence of hyperuricemia and its association with outcome of stroke patients in the Douala General Hospital (DGH). METHODS: This was a hospital based prospective cohort study which included acute stroke patients with baseline SUA levels and 3-month poststroke follow-up data. Associations between high SUA levels and stroke outcomes were analyzed using multiple logistic regression and survival analysis (Cox regression and Kaplan-Meier). RESULTS: A total of 701 acute stroke patients were included and the prevalence of hyperuricemia was 46.6% with a mean SUA level of 68.625 ± 24 mg/l. Elevated SUA after stroke was associated with death (OR = 2.067; 95% CI: 1.449-2.950; p < 0.001) but did not predict this issue. However, an independent association between increasing SUA concentration and mortality was noted in a Cox proportional hazards regression model (adjusted HR = 1.740; 95% CI: 1.305-2.320; p < 0.001). Furthermore, hyperuricemia was an independent predictor of poor functional outcome within 3 months after stroke (OR = 2.482; 95% CI: 1.399-4.404; p = 0.002). CONCLUSION: The prevalence of hyperuricemia in black African stroke patients is quite high and still remains a predictor of poor outcome.

Cross-sectional assessment of three commonly used measures of adherence to combination antiviral therapy in a resource limited setting.

Nowadays, global coverage of combination antiretroviral therapy (cART) has increased due to a continuous process to scale up access. This increase has potentially transformed HIV-infection from a fatal to a chronic disease: a transformation only possible if the prescribed medications are taken accordingly. We therefore evaluated optimal adherence to cART by three commonly used methods: visual analogue scale (VAS), four days recall (FDR) and clinic attendance (CA) for the last six months in 301 HIV-infected patients on cART for at least six months at the Douala General Hospital, Cameroon. Optimal adherence was defined to be greater than or equal to the 95th percentile estimate of each method. We found that 70.8% of our study population was female. The mean age was 40.8 years (SD 10.5) and 85% were on first line cART. Median CD4 count was 397 cells/ml (252-559). Optimal adherence by VAS, FDR and CA, was 68.1%, 83.4%, and 73.4%, respectively. VAS and FDR inter-correlated strongly (Pearson's Chi square coefficient, r = 0.58, p < 0.001). Higher CD4 count above 200 cells/ml was associated with optimal adherence by CA (Adjusted Odds Ratio [AOR]:2.6 (95% CI: 1.2-5.3, p < 0.001)). As high optimal adherence to cART is associated with good clinical outcome in HIV patients, simple methods such as the VAS for evaluating adherence, should be integrated to the HIV clinic of the Douala General Hospital.

Overweight and obesity in children aged 3-13 years in urban Cameroon: a cross-sectional study of prevalence and association with socio-economic status.

BACKGROUND: Childhood overweight/obesity is increasing rapidly in developing countries. There is a need to provide more evidence on its burden in sub-Saharan Africa, and to identify associated factors in order to set preventive measures. We aimed to determine the prevalence of overweight/obesity and assess its association with the socioeconomic status in nursery and primary school children in urban Cameroon. METHODS: In this cross-sectional study, we included by multi-staged cluster random sampling 1343 children from high (HSES, n = 673) and low (LSES, n = 670) socioeconomic status schools in Douala. Parent/child demographic data were collected, and children's anthropometric parameters were measured using validated methods. The World Health Organization body mass index-for-age reference curves were used. RESULTS: The prevalence of overweight/obesity was 12.5% (13.2% in girls, 11.8% in boys). The risk of overweight/obesity was 2.40 (95% CI 1.70, 3.40) higher in HSES children compared to LSES after adjusting for age and gender. However this association was attenuated to 1.18 (95% CI 0.59, 2.35) once adjustment had been made for a range of potential confounders. CONCLUSIONS: Overweight/obesity is relatively common in sub-Saharan African children and prevalence is associated with HSES. However, this association may be mediated by sweet drink consumption, passive means of travel to school and not doing sport at school. We suggest that these potentially modifiable behaviors may be effective targets for obesity prevention. Further studies should specifically focus on unhealthy behaviors that mediate overweight/obesity as well as other non communicable diseases in children.