[Antithrombotiques oraux et pronostic après un an des patients atteints de fibrillation auriculaire dans un milieu à ressources limitées]. / Oral antithrombotic therapy and one-year clinical outcomes among patients with atrial fibrillation in resource-limited settings.

BACKGROUND: Atrial fibrillation is associated with increased risk of morbidity and mortality. There's limited data on the outcomes of atrial fibrillation patients in Africa. We aimed at evaluating the clinical outcomes and their associated factors in patients with atrial fibrillation on antithrombotic therapy in Douala. METHODS: The Douala atrial fibrillation registry is a prospective, observational cohort study of patients with atrial fibrillation followed by cardiovascular specialists in 3 specialized care centres. From January to April 2018, all patients with electrocardiographic diagnosis of atrial fibrillation, aged 21 years or older, were included in the registry provided their consent. The composite endpoint of heart failure, stroke, major bleeding, hospitalisation and mortality as well as their individual occurrence were assessed at 12 months. RESULTS: Of 113 participants that were included, 6(5.3%) were lost to follow-up. The mean age was 70 ± 12 years, with a female predominance (68%). After a mean follow-up time of 12.2 ± 0.7 months, 51 patients (47.7%) had at least one outcome. Hospitalisation, all-cause mortality, heart failure, stroke and major bleeding rates were 33.3%, 16.8%, 15.2%, 4.8% and 2.9% respectively. There was no significant difference in the composite outcome and mortality according to the antithrombotic treatment. Previous heart failure [aHR = 3.07, 95% CI (1.48-6.36) p = 0.003], new onset atrial fibrillation [aHR= 4.00, 95% CI (0.96-8.19) p < 0.001] and paroxystic atrial fibrillation [aHR= 3.74, 95% CI (1.33-10.53) p = 0.013] were significant predictors of outcome. CONCLUSION: Half of patients with atrial fibrillation in this registry developed an outcome after one year of follow-up, with heart failure, new onset and paroxystic atrial fibrillation being the main predicting factors. Diagnosing and managing atrial fibrillation in patients with heart disease should therefore be considered as a key priority.

Right Ventricular Function and Pulmonary Coupling in Patients With Heart Failure and Preserved Ejection Fraction.

BACKGROUND: Limited data exist to characterize novel measures of right ventricular (RV) function and the coupling to pulmonary circulation in patients with heart failure and preserved left ventricular ejection fraction (HFpEF). OBJECTIVES: This study sought to assess the clinical implications of RV function, the association with N-terminal pro-B-type natriuretic peptide, and the risk for adverse events among patients with HFpEF. METHODS: This study analyzed measures of RV function by assessing absolute RV free wall longitudinal strain (RVFWLS) and its ratio to estimated pulmonary artery systolic pressure (PASP) (RVFWLS/PASP ratio) in 528 patients (mean age 74 ± 8 years, 56% female) with adequate echocardiographic images quality enrolled in the PARAGON-HF trial. Associations with baseline N-terminal pro-B-type natriuretic peptide and with total HF hospitalizations and cardiovascular death were assessed, after accounting for confounders. RESULTS: Overall, 311 patients (58%) had evidence of RV dysfunction, defined as absolute RVFWLS <20%, and among the 388 patients (73%) with normal tricuspid annular planar systolic excursion and RV fractional area change, more than one-half showed impaired RV function. Lower values of RVFWLS and RVFWLS/PASP ratios were significantly associated with higher circulating N-terminal pro-B-type natriuretic peptide. With a median follow-up of 2.8 years, there were 277 total HF hospitalizations and cardiovascular deaths. Both absolute RVFWLS (HR: 1.39; 95% CI: 1.05-1.83; P = 0.018) and RVFWLS/PASP ratio (HR: 1.43; 95% CI: 1.13-1.80; P = 0.002) were significantly associated with the composite outcome. Treatment effect of sacubitril/valsartan was not modified by measures of RV function. CONCLUSIONS: Worsening RV function and its ratio to pulmonary pressure is common and significantly associated with an increased risk of HF hospitalizations and cardiovascular death in patients with HFpEF. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).

Noncommunicable Disease (NCD) strategic plans in low- and lower-middle income Sub-Saharan Africa: framing and policy response.

BACKGROUND: Global efforts to address NCDs focus primarily on 4-by-4 interventions - interventions to prevent and treat four groups of conditions affecting mainly older adults (some cardiovascular disease and cancers, type 2 diabetes, chronic respiratory disease) and four associated risk factors (alcohol, tobacco, poor diets, and physical inactivity). However, the NCD burden in Sub-Saharan Africa (SSA) is composed of a more diverse set of conditions, driven by a more complex group of risks, and impacting all segments of the population. OBJECTIVE: To document the NCD priorities identified by NCD strategic plans, to characterize the proposed policy response, and to assess the alignment between the two. METHODS: Using a two-part conceptual framework, we undertook a descriptive study to characterize the framing and overall policy response of strategic plans from 24 low- and lower-middle-income countries across SSA. RESULTS: The national situation assessments that ground strategic plans emphasize a diversity of conditions that range in terms of severity and frequency. These assessments also highlight a wide diversity of factors that shape this burden. Most include discussions of a broad range of behavioral, structural, genetic, and infectious risk factors. Plans endorse a more narrow response to this diverse burden, with a focus on primary and secondary prevention that is generally convergent with the objectives established in global policy documents. CONCLUSIONS: Broadly, we observe that plans developed by countries in SSA recognize the heterogeneity of the NCD burden in this region. However, they emphasize interventions that are consistent with global strategies focused on preventing a narrower set of cardiometabolic risk factors and their associated diseases. In comparison, relatively few countries detail plans to prevent, treat, and palliate the full scope of the needs they identify. There is a need for increased support for bottom-up planning efforts to address local priorities.

Availability, cost and affordability of essential cardiovascular disease medicines in the south west region of Cameroon: Preliminary findings from the Cameroon science for disease study.

BACKGROUND: More than 80% of premature deaths due to cardiovascular disease (CVD) occur in low- and middle-income countries. However, access to, and affordability of medications remain a challenge in these countries. OBJECTIVE: To assess the availability, cost and affordability of essential cardiovascular medicines in the South West region of Cameroon. METHODS: In an audit of 63 medicine outlets, twenty-six essential medicines were surveyed using the World Health Organisation (WHO) /Health Action International methodology. Availability, costs and the ratio of the median price to the international reference price were evaluated in public, confessional, private facility medicine outlets, and community pharmacies. Affordability was assessed by calculating the number of days' wages it will cost the lowest-paid unskilled government worker to purchase a month worth of chronic treatment. FINDINGS: Availability ranged from 25.3% (public facility outlets) to 49.2% (community pharmacies) for all medicines. This was higher in urban and semi-urban compared to rural outlets. Cost of medicines was highest in community pharmacies and lowest in public facility outlets. Aspirin, digoxin, furosemide, hydrochlorothiazide and nifedipine were affordable (cost a day's wage or less). Medicines for heart failure and dyslipidaemia (beta blockers, angiotensin converting enzyme inhibitors and statins) required 2-5 days and 6-13 days wages respectively for one month of chronic treatment. CONCLUSION: Overall availability of CVD essential medicines was lower than WHO recommendations, and medicines were largely unaffordable. While primary prevention is pivotal, improving availability and affordability of medicines especially for public facilities would provide additional benefit in curbing the CVD burden.

Echocardiographic left atrial remodelling and determinants of left atrial size in the early phase of high blood pressure: a comparative cross-sectional study in Douala, Cameroon.

BACKGROUND: Left atrial remodelling (LAR) has been described in Western populations with chronic hypertension and is associated with a higher risk of adverse cardiovascular events. Although hypertension tends to occur earlier and is more severe in sub-Saharan Africa than in more developed nations, LAR and its associated factors in these African hypertensive subjects have been poorly elucidated. OBJECTIVES: To assess left atrial structural remodelling in black hypertensive patients and determine factors associated with left atrial size. METHODS: This was a cross-sectional, comparative study carried out in two tertiary hospitals in Douala, Cameroon over a period of three months. Fifty-two patients, either newly diagnosed with hypertension or known hypertensives treated for less than a year, were consecutively recruited. These patients were matched (unpaired matching) for age and gender to 40 randomly selected healthy subjects. The posterior-anterior diameter indexed to body surface area (BSA), volume indexed to BSA, and longitudinal and transverse diameters of the left atrium (LA) were measured using transthoracic echocardiography, in accordance with the American Society of Echocardiography guidelines. LAR was defined as increase in LA size, characterised by LA volume ≥ 34 ml/m2. Early morning urine was analysed for microalbuminuria using urine strips to obtain spot albumin/creatinine ratio. Data were analysed using SPSS version 23 and statistical significance was set at p < 0.05. RESULTS: The gender distribution and mean age were similar between the two groups. Hypertensive patients had significantly higher mean body mass index, left ventricular mass and an altered diastolic function. They also had significantly higher LA longitudinal diameter (50.0 vs 47.4 mm; p = 0.045), surface area (17.9 vs 15.5 cm2; p = 0.003) and volume (52.4 vs 43.8 ml; p = 0.002) compared to the non-hypertensive counterparts. Fourteen patients (26.9%) had LA enlargement compared to one (2.5%) in the non-hypertensive group (odds ratio = 9.78, CI: 2.67-35.8, p < 0.0001). Diastolic dysfunction (p = 0.008) was the only independent predictor of LA size in the hypertensive subjects. Microalbuminuria did not significantly correlate with LA size. CONCLUSIONS: Our study shows evidence of LAR in newly diagnosed black African patients with hypertension, characterised by an increase in the LA length, surface area and volume. Future studies are warranted to better elucidate the biological mechanisms underlying the link between the early phase of hypertension and LAR, as well as its prognostic implications in our population.

Occurrence and challenges in the management of severe chronic plaque type psoriasis in a limited resourced setting: a case report.

Plaque-type psoriasis is a major dermatosis with significant effects on quality of life. Case complexity is often high in low-resourced settings such as in Africa where the incidence has been on the rise. Despite major advancements and newer therapeutic modalities over the last decade, an insight into the real-life, day to day challenges in low resourced settings reveal an interplay between the difficulty in obtaining these drugs and use of alternative traditional indigenous agents. We report the case of a 50 year old immunocompetent male who presented with chronic and extensive well demarcated plaques covered with silver-white scales occupying about 61% of his body surface area. Patient was however lost to follow up for about 8 months during which time, the lesions responded to some unknown homemade indigenous medications which was preferred to a systemic medication. Paramount importance on proper counselling and the need to retain patients in care is warranted by physicians and allied health personnel. Also, incentives aimed at subsidizing the newer systemic agents for patients in low resourced cohorts will go a long way to combat this multi-faceted disorder which is often unrecognized and under diagnosed.

A diagnostic algorithm for pulmonary hypertension due to left heart disease in resource-limited settings: can busy clinicians adopt a simple, practical approach?

Pulmonary hypertension (PH) has progressively moved from an orphan disease to a significant global health problem with a major disease burden in limited7hyphen;resource countries, where over 97% of patients live. The aetiologies of PH differ between high- and low-income nations, but PH due to left heart disease is credited to be the most frequent contemporary form. Although a straightforward diagnosis of PH requires the use of right heart catheterisation (RHC), access to equipment for RHC is a deterrent. Furthermore, the risk associated with RHC limits its uptake to a selection of specialised centres. Moreover, the rigour and clinical reasoning for diagnosis in clinical medicine is rapidly changing and revealing that PH can complicate a diverse range of medical conditions needing other explorations. In this article, we provide for the busy clinician, a simplified diagnostic algorithm for PH that is relevant for making a correct early diagnosis and limiting the impact of PH.

Effects of phloroglucinol on the active phase of labour (EPAL trial): a single blinded randomised controlled trial in a tertiary hospital in sub-Sahara Africa.

INTRODUCTION: One of the most recognized factors of maternal and neonatal outcome pertaining to the peripartum period is the duration of labour. Finding a drug that will decrease the duration of labour with no effects on mother and foetus will be welcomed. Thereby in this study we aimed to evaluate the effects of phloroglucinol on the duration of the active phase of labour. METHODS: We did a single blinded placebo controlled randomised 1:1 parallel designed superiority trial between January and June 2017 in Douala general hospital. Participants greater than 18 years with singleton uncomplicated pregnancy who consented following randomisation, were administered either 80mg/8ml intravenous phloroglucinol or 8ml of sterile water when in active labour. The primary outcome was the duration of labour. Modified intention to treat analysis was done with the level of significance set at a p value of 0.05. RESULTS: 122 participants received the intervention. The mean total duration labour in the treatment and placebo group were 216.8 ± 38.7 and 358.5 ± 65.8 respectively (p value = 0.243). The mean duration of the active phase of labour in the treatment and placebo group were 183.0±35.6 and 316.0±52.2 respectively (p value = 0.046). The mean rate of cervical dilatation in the treatment and placebo group were 2.1 ± 0.4 and 1.3 ± 0.4 respectively (p value = 0.322). There was no difference in maternal and foetal outcomes between the two groups. CONCLUSION: Phloroglucinol shortens the duration of active phase of labour by about 2 hours (42%). It is safe to mother and baby and does not cause adverse foetal or maternal outcomes.

Ivermectin-induced fixed drug eruption in an elderly Cameroonian: a case report.

BACKGROUND: Cutaneous adverse reactions to medications are extremely common and display characteristic clinical morphology. A fixed drug eruption is a cutaneous adverse drug reaction due to type IV or delayed cell-mediated hypersensitivity. Ivermectin, a broad-spectrum anti-parasitic compound, has been an essential component of public health campaigns targeting the control of two devastating neglected tropical diseases: onchocerciasis (river blindness) and lymphatic filariasis. CASE PRESENTATION: We report the case of a 75-year-old Cameroonian man of the Bamileke ancestry who developed multiple fixed drug eruptions a few hours following ivermectin intake that worsened with repeated drug consumption. Discontinuation of the drug, counselling, systemic steroids, and orally administered antihistamines were the treatment modalities employed. Marked regression of the lesions ensued with residual hyperpigmentation and dyschromia. CONCLUSION: Keen observation on the part of physicians is mandatory during the administration of ivermectin for quick recognition and prevention of this adverse drug reaction.

Pulmonary hypertension as seen in a rural area in sub-Saharan Africa: high prevalence, late clinical presentation and a high short-term mortality rate during follow up.

INTRODUCTION: The epidemiology of pulmonary hypertension (PH) in low- to middle-income countries is poorly characterised. We assessed the prevalence, baseline characteristics and mortality rate in patients with echocardiographically diagnosed PH at a rural cardiac centre in Cameroon. METHODS: We conducted a prospective cohort study in a subsample of 150 participants, aged 18 years and older, diagnosed with PH [defined as right ventricular systolic pressure (RVSP) ≥ 35 mmHg in the absence of pulmonary stenosis and right heart failure]. PH was classified as mild (RVSP: 35-50 mmHg), moderate (RVSP: 51-60 mmHg) and severe (RVSP: > 60 mmHg). RESULTS: Of 2 194 patients screened via echocardiograms, 343 (crude prevalence 15.6%) had PH. The sub-sample of 150 patients followed up (54.7% women, mean age of 62.7 ± 18.7 years) had a mean RVSP of 68.6 mmHg. They included 7.3% mild, 29.3% moderate and 63.4% severe PH cases. Co-morbidities included log smoke (80.7%), hypertension (52.0%), family history of cardiovascular disease (50.0%), diabetes (31.3%), alcohol abuse (21.3%) and HIV infection (8.7%). Main clinical features were dyspnoea (78.7%), fatigue (76.7%), palpitations (57.3%), cough (56.7%), jugular venous distension (68%) and peripheral oedema (66.7%). Overall, 70% presented in World Health Organisation functional class III/IV. PH due to left heart disease (PHLHD) was the commonest (64.7%), and rheumatic valvular disease accounted for 36.1%. The six-month mortality rate was 28%. CONCLUSION: PH, dominated by PHLHD, was common among adults attending this rural centre and was associated with a high mortality rate. Related co-morbidities and late clinical presentation reflect the poor socio-economic context. Improved awareness of PH among physicians could promote early diagnosis and management.

Agreement between home and ambulatory blood pressure measurement in non-dialysed chronic kidney disease patients in Cameroon.

INTRODUCTION: home blood pressure measurement (HBPM) is not entirely capable of replacing ambulatory blood pressure (BP) measurement (ABPM), but is superior to office blood pressure measurement (OBPM). Although availability, cost, energy and lack of training are potential limitations for a wide use of HBPM in Sub-Saharan Africa (SSA), the method may add value for assessing efficacy and compliance in specific populations. We assessed the agreement between HBPM and ABPM in chronic kidney disease (CKD) patients in Douala, Cameroon. METHODS: from March to August 2014, we conducted a cross sectional study in non-dialyzed CKD patients with hypertension. Using the same devices and methods, the mean of nine office and eighteen home (during three consecutive days) blood pressure readings were recorded. Each patient similarly had a 24-hour ABPM. Kappa statistic was used to assess qualitative agreement between measurement techniques. RESULTS: forty-six patients (mean age: 56.2 ± 11.4 years, 28 men) were included. The prevalence of optimal blood pressure control was 26, 28 and 32% for OBPM, HBPM and ABPM respectively. Compared with ABPM, HBPM was more effective than OBPM, for the detection of non-optimal BP control (Kappa statistic: 0.49 (95% CI: 0.36 - 0.62) vs. 0.22 (95%CI: 0.21 - 0.35); sensitivity: 60 vs 40%; specificity: 87 vs. 81%). CONCLUSION: HBPM potentially averts some proportion of BP misclassification in non-dialyzed hypertensive CKD patients in Cameroon.

Challenges in the management of cardiovascular emergencies in Sub-Saharan Africa: a case report of acute heart failure complicating infective endocarditis in a semi-urban setting in Cameroon.

BACKGROUND: Infective endocarditis is a deadly disease if not promptly treated with antibiotics either in association with cardiac surgery or not. Cardiac complications are the most common complications seen in infective endocarditis. Heart failure remains the most common cause of mortality and the most common indication for cardiac surgery in patients with infective endocarditis which is increasingly available in resource limited settings. CASE PRESENTATION: We report a case of native valve infective endocarditis of the aortic valve in a 27-year old female in a semi-urban setting in Cameroon complicated by severe aortic valve regurgitation and heart failure. She presented with a 2 month history of fever and a 2 weeks history of rapidly worsening shortness of breath. Emergency cardiac surgery was indicated which unfortunately could not be performed leading to the death of the patient. CONCLUSIONS: In spite of improvement in availability of diagnostic and therapeutic modalities for cardiovascular emergencies, affordability is still a challenge. Universal health coverage is advocated else the ravages of premature mortality from cardiovascular diseases may continue to remain unchecked in Sub-Saharan Africa.

Risk factors for acute respiratory infections in children under five years attending the Bamenda Regional Hospital in Cameroon.

BACKGROUND: Acute respiratory infections (ARI) are a leading cause of morbidity and mortality in under-five children worldwide. About 6.6 million children less than 5 years of age die every year in the world; 95% of them in low-income countries and one third of the total deaths is due to ARI. This study aimed at determining the proportion of acute respiratory infections and the associated risk factors in children under 5 years visiting the Bamenda Regional Hospital in Cameroon. METHODS: A cross-sectional analytic study involving 512 children under 5 years was carried out from December 2014 to February 2015. Participants were enrolled by a consecutive convenient sampling method. A structured questionnaire was used to collect clinical, socio-demographic and environmental data. Diagnosis of ARI was based on the revised WHO guidelines for diagnosing and management of childhood pneumonia. The data was analyzed using the statistical software EpiInfo™ version 7. RESULTS: The proportion of ARIs was 54.7% (280/512), while that of pneumonia was 22.3% (112/512). Risk factors associated with ARI were: HIV infection ORadj 2.76[1.05-7.25], poor maternal education (None or primary only) ORadj 2.80 [1.85-4.35], exposure to wood smoke ORadj 1.85 [1.22-2.78], passive smoking ORadj 3.58 [1.45-8.84] and contact with someone who has cough ORadj 3.37 [2.21-5.14]. Age, gender, immunization status, breastfeeding, nutritional status, fathers' education, parents' age, school attendance and overcrowding were not significantly associated with ARI. CONCLUSION: The proportion of ARI is high and is associated with HIV infection, poor maternal education, exposure to wood smoke, passive cigarette smoking, and contact with persons having a cough. Control programs should focus on diagnosis, treatment and prevention of ARIs.

Acute type A aortic dissection involving the iliac and left renal arteries, misdiagnosed as myocardial infarction.

Acute aortic dissection is the most frequent and deadly presentation of acute aortic syndromes. Its incidence is estimated at three to four cases per 100 000 persons per year. Its clinical presentation may be misleading, with misdiagnosis ranging between 14.1 and 38% in many series. A late diagnosis or absence of early and appropriate management is associated with mortality rates as high as 50 and 80% by the third day and second week, respectively, especially in proximal lesions. We report on the case of a 53-year-old man who presented with type A aortic dissection, misdiagnosed as acute myocardial infarction, who later died on day 12 of hospitalisation. Although a relatively rare condition, poor awareness in Africa probably accounted for the initial misdiagnosis. Thorough investigation of acute chest pain and initiation of clinical registries are potential avenues to curb related morbidity and mortality.

Building and strengthening capacity for cardiovascular research in Africa through technical training workshops: a report of the joint course on health research methods by the Clinical Research Education Networking and Consultancy and the Ivorian Society of Cardiology.

Africa bears a quarter of the global burden of disease but contributes less than 2% of the global research publications on health, partially due to a lack of expertise and skills to carry out scientific research. We report on a short course on research methods organised by the Clinical Research Education Networking and Consultancy (CRENC) during the third international congress of the Ivorian Cardiac Society (SICARD) in Abidjan, Cote d'Ivoire. Results from the pre- and post-test evaluation during this course showed that African researchers could contribute more to scientific research and publications, provided adequate support and investment is geared towards the identification and training of motivated early-career scientists.

Illuminating the pathway for the next generation of cardiovascular medicine practitioners and researchers: Highlights of the Joint PASCAR-SCC clinical symposium on hypertension and heart failure, Cameroon.

The Pan-African Society of Cardiology roadmap aims to achieve a 25% control of hypertension by the year 2025. Whether this is attainable or not depends largely on the capacity of healthcare providers and policy makers to address the rising prevalence of hypertension and its complications, including heart failure. Task sharing is fundamental in optimising hypertension control. The Clinical Research Education, Networking and Consultancy (CRENC) engaged with the Pan-African Society of Cardiology (PASCAR) and the Cameroon Cardiac Society (SCC) in a joint hypertension and heart failure symposium at the Douala General Hospital in 2016. The primary aims were to foster clinical research in cardiovascular medicine by raising awareness on cardiovascular diseases, to provide evidence-based training of an international standard, to encourage the conduction and dissemination of high-quality research, and to build programmes for continuing medical education. The secondary aim was to potentiate the 2nd Douala Research and Scientific Days. The symposium, which featured didactic lectures interspaced with oral/poster abstract presentations and a clinical visit, culminated in the launching of the book Heart of Africa, and the Young Investigator award. It is hoped that these served to capacitate existing cardiovascular structures, breed the next generation of cardiovascular physicians and researchers, and imprint a trail of clinical research excellence to be emulated in Cameroon and beyond.

Pre- and post-exercise electrocardiogram pattern modifications in apparently healthy school adolescents in Cameroon.

Background Physical Education and Sport (PES) is compulsory in Cameroonian education system. Cardiac accidents and sudden cardiac deaths (SCD) have been reported during PES examinations. This study aimed to contribute in the prevention of these cardiac accidents by studying pre- and post-exercise electrocardiogram (ECG) pattern modifications in apparently healthy school adolescents. Methods One hundred school adolescents without apparent heart disease [aged 18 ± 2 years; body mass index (BMI): 21.9 ± 2.3] were included. Participants performed two intermittent sprint-endurance tests. The test consisted in walking 2000 m as warm-up, followed by sprint and endurance races. A 12-leads ECG was performed before and in 5 min after the tests. ECG patterns changes were studied with particular attention to abnormalities that could be associated with risk of SCD. Results At rest, ECG patterns variants consisted of bradycardia (30%), sinus arrhythmia (9%), posterior hemi post-block (2%), and early repolarization (3%). which disappeared after exercise in all participants. QTc (ms) and heart rate (HR) increased after exercise (p < 0.001); and RR (ms) decreased post-exercise (p < 0.001). Other changes includes the appearance of the T-waves reversed in precordial leads (V2-V4) (p < 0.001), ventricular (6%), atrial and other supraventricular premature beats (2%) in the post-exercise ECG. Left ventricular hypertrophy (2%), right auricular enlargement (2%), short PR (2%) appeared at the end of the tests. Conclusion This study suggests that an intermittent exercise can induce cardiac abnormalities able to provoke cardiac accidents and SCD in apparently healthy school adolescents.

The challenge in the diagnosis and management of an advanced abdominal pregnancy in a resource-low setting: a case report.

BACKGROUND: Abdominal pregnancy is a rare form of ectopic pregnancy that is frequently left undiagnosed by inexperienced obstetricians and radiologists. It is associated with higher risk of maternal hemorrhage at any gestation and more at advanced gestation. CASE PRESENTATION: We present the case of a 22-year-old sub-Saharan African woman, gravida 3 para 0, who was diagnosed with advanced abdominal pregnancy of 25 weeks' gestation by a transvaginal ultrasound after the failure of two medical terminations of pregnancy in the first and second trimesters and a series of repeated obstetric ultrasounds showing intrauterine pregnancy. Laparotomy was done and her recovery was uneventful. CONCLUSIONS: The management of advanced abdominal pregnancy is more challenging as compared to earlier gestation so patients with failed medical termination of pregnancy should be critically analyzed for ectopic pregnancy as early as possible.

Vitamin B12 deficiency neuropathy; a rare diagnosis in young adults: a case report.

BACKGROUND: Vitamin B12 deficiency is a metabolic disorder with many causes. It often presents with megaloblastic anaemia and neurological disorders which entail prompt treatment. The diagnosis of Vitamin B12 deficiency is challenging in resource limited-settings due to limited access to diagnostic tools and unfamiliarity with the disease, owing to its rarity especially in young people. CASE PRESENTATION: A 28 year old female Cameroonian presented with progressive burning painful sensations on the upper trunk, paraesthesia and numbness of the upper and lower limbs for a period of 5 years. Before presenting to us, she had consulted in numerous health institutions for which she had been treated for diverse pathologies with no relieve of symptoms. After clinical and laboratory evaluation, a diagnosis of vitamin B12 deficiency-associated neuropathy was made. She was placed on oral vitamin B12 supplements at 2 mg daily for 3 months. Follow up was marked by good clinical recovery after 1 month of therapy. CONCLUSION: Vitamin B12 deficiency neuropathy is a rare debilitating disease that affects mostly the elderly. However; young adults with neuropathic symptoms warrant a high index of suspicion. Peripheral blood smears and complete blood counts are sufficiently diagnostic in resource-limited settings.

Occurrence of Emery-Dreifuss muscular dystrophy in a rural setting of Cameroon: a case report and review of the literature.

BACKGROUND: Emery-Dreifuss muscular dystrophy is a rare genetic muscular disease, presenting mainly with contractures, weakness and cardiac conduction abnormalities. Its clinical and laboratory similarities to other muscular dystrophies, and rarity poses diagnostic challenges, requiring a high index of suspicion in resource limited settings. CASE PRESENTATION: An 8 year old sub-Saharan male presented with rigidity and deformity of both elbows and ankles, and weakness of the upper limbs and lower limbs for duration of 4 months. This progressed to inability to stand and walk. There was no mental impairment. Physical examination was remarkable for contractures of the elbows and ankles, and wasting of muscles of the limbs and trunk, with a scapulohumeroperoneal pattern, and tachycardia. After laboratory investigations, a diagnosis of Emery-Dreifuss muscular dystrophy was suspected. Physiotherapy was started, wheel chair was prescribed, and referral to a specialist center was done for appropriate management. CONCLUSIONS: Emery-Dreifuss muscular dystrophy is a rare disabling muscular disease which poses a diagnostic challenge. High index of suspicion is paramount for its early diagnoses to prevent orthopedic and cardiac complications. Prompt diagnosis and management is essential to improve on the prognosis of this disease.