[Lipodystrophy and echographic hepatic steatosis in HIV-positive patients under highly active antiretroviral therapy (HAART) in Yaounde (Cameroon)]. / Lipodystrophie et stéatose hépatique échographique chez les patients VIH positifs sous multithérapie antirétrovirale (ARV) à Yaoundé (Cameroun).

The association between sonographic liver steatosis and clinical lipodystrophy in AIDS patients treated by highly active antiretroviral therapy (HAART) has been studied. We conducted a cross-sectional study reviewing medical files of 117 AIDS patients followed up in Yaounde, Cameroon (6.3 F/1 M, mean age = 40 ± 9.4 years), and treated the patients with HAART protocol comprising stavudine or zidovudine for at least six months. All participants underwent abdominal ultrasonography and anthropometric assessment including body mass index (BMI). Data analysis included determining the association between sonographic liver steatosis, clinical lipodystrophy, and other clinical and biological data using the ¢(2) test, and the calculation of odd ratio. Fifty-one patients presented clinical lipodystrophy. The sonographic prevalence of hepatomegaly and splenomegaly was 70.1% and 25.6%, respectively. The overall prevalence of sonographic steatosis was 28.2%; specifically 37.3% among lipodystrophic patients and 21.1% among nonlipodystrophic patients (P = 0.03). According to the type of lipodystrophy, the prevalence was 40.6% among lipohypertrophic patients, 38.5% among lipodystrophic patients, and 16.7% among lipoatrophic patients. Clinical lipohypertrophy was statistically associated with a higher prevalence of sonographic steatosis (odd ratio = 2.5; 95% CI: [1.01-6.39], and P = 0.04). HAART protocol including stavudine was associated with lipodystrophy. The prevalence of sonographic liver steatosis is high among AIDS patients under HAART and is associated with lipohypertrophy.

New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries.

As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions. Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries. The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics. Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished. This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Promouvoir l'Adhésion Universelle aux Mécanismes d'Assurance Maladie au Cameroun / Promoting universal adherence to health insurance mechanisms in Cameroon

La présente note d'information stratégique vise à éclairer les parties concernées par la faible adhésion des citoyens aux divers systèmes d'assurance maladie sur le marché camerounais et propose trois options visant à améliorer l'accès équitable aux services et soins de santé. Le système actuel de paiement direct au point de délivrance des soins et services de santé place ces derniers dans la logique marchande des biens et services courants compromettant ainsi lourdement la prospective d'atteindre les Objectifs du Millénaire pour le Développement (OMD) relatifs à la santé. L'adoption de la Vision 2035 d'un Cameroun économiquement émergent rend prioritaire la mise en place d'un socle national de solidarité autour du risque humain le plus certain, la maladie ; en effet, tous les pays membres de l'Organisation de Coopération pour le Développement Economique et les pays émergents ont reconnu l'exceptionnalité des soins et services de santé en les excluant du marché courant de biens et services.

Impact of measles elimination activities on immunization services and health systems: findings from six countries.

BACKGROUND: One of the key concerns in determining the appropriateness of establishing a measles eradication goal is its potential impact on routine immunization services and the overall health system. The objective of this study was to evaluate the impact of accelerated measles elimination activities (AMEAs) on immunization services and health systems in 6 countries: Bangladesh, Brazil, Cameroon, Ethiopia, Tajikistan, and Vietnam. METHODS: Primary data were collected from key informant interviews and staff profiling surveys. Secondary data were collected from policy documents, studies, and reports. Data analysis used qualitative approaches. RESULTS: This study found that the impact of AMEAs varied, with positive and negative implications in specific immunization and health system functions. On balance, the impacts on immunization services were largely positive in Bangladesh, Brazil, Tajikistan, and Vietnam, while negative impacts were more significant in Cameroon and Ethiopia. CONCLUSIONS: We conclude that while weaker health systems may not be able to benefit sufficiently from AMEAs, in more developed health systems, disruptions to health service delivery are unlikely to occur. Opportunities to strengthen the routine immunization service and health system should be actively sought to address system bottlenecks in order to incur benefits to eradication program itself as well as other health priorities.

Practices in health (CDPBH): improving governance for health district development in Cameroon: executive summary

In the early 1990s, Cameroon implemented a decentralised health system in accordance with the health district and primary healthcare frameworks recommended by the Africa Regional Office of the World Health Organization (AFRO-WHO). To enhance both responsiveness and equity and to foster participation in the financing and management of the district health system, community dialogue structures were established as governing bodies. Such participatory governance was intended to elicit the views of stakeholders (bureaucrats, health development promoters, community representatives, healthcare providers and patients), and to improve accountability and to strengthen district health systems in order to achieve better health status for the population. During the mid-term evaluation of the 2001-10 Health Sector Strategy (HSS), stakeholders expressed dissatisfaction and identified poor governance and weak health district development as major reasons for Cameroon being unable to achieve its health-related Millennium Development Goals. Several underlying factors were identified for the failure to effectively implement the recommended changes within the framework of health decentralization reforms. Accordingly, recommendations were made for the improvement of district development governance as a key priority for the revised 2001-2015 HSS. The Technical Secretariat of the Steering and Follow-up Committee for the Implementation of the HSS asked the Centre for Development of Best Practices in Health (CDBPH) to summarise the available evidence.

Retaining human resources for health in remote rural areas in Cameroon

This policy brief was prepared at the request of the Human Resources Directorate of the Ministry of Public Health to inform the deliberations leading to the development of the national strategic plan for the health workforce. It describes the magnitude, the consequences and the underlying factors of the desertion of rural Integrated Health Centres (IHC), District Health Centres (DHC) and some district hospitals considered "difficult areas" by health care staff. It offers three evidence-based options and related implementation considerations to improve access to the priority minimum package of primary health care. This is part of health service delivery for the districts and contributes to the fight against rampant poverty (55% of the population) in rural areas. "Difficult" rural areas are remote or landlocked health areas, subdivisions and health districts underserved by modern amenities where health services are provided by low-skilled professionals and poorly equipped in health technology. Typically, it is a rural area located between 80 and 400 km or between 1-4 hour drive in good weather from the first referral hospital as these delays make it impossible to guarantee a continuity of care. The ten regions of Cameroon have difficult rural areas, but Adamawa, East, the Far North and North and the areas reassigned after the resolution of the Cameroon-Nigeria border dispute have the largest number of IHC and DHC deserted by health staff.

Améliorer la gouvernance pour la viabilisation du district de santé au Cameroun

Au début de la décennie 90, le Cameroun a mis en œuvre un système de santé décentralisé conformément aux cadres conceptuels du district de santé et des soins de santé primaires recommandés par le Bureau régional de l'Organisation mondiale de la Santé (AFRO). Des structures de dialogue communautaire ont été mises en place en tant qu'instances dirigeantes, dans le but d'améliorer la réceptivité aux doléances des usagers et l'équité, mais également pour favoriser la participation dans le financement et la gestion du service public de santé. Cette gouvernance participative se proposait d'améliorer la prise en compte des valeurs et préférences des acteurs de terrain (fonctionnaires, gestionnaires, soignants, communautés et patients), de les responsabiliser davantage et de renforcer le système de santé du district afin d'améliorer l'état de santé des populations. Lors de l'évaluation à mi-parcours de la Stratégie du secteur de la santé (SSS) 2001-2010, les parties prenantes ont exprimé leur insatisfaction quant à la performance du système et identifié la mauvaise gouvernance et le faible niveau de viabilisation des districts de santé comme étant les principales raisons de l'incapacité du Cameroun à atteindre les Objectifs du millénaire pour le développement (OMD) liés à la santé. Plusieurs facteurs sous-jacents ont été identifiés s'agissant de l'incapacité à mettre effectivement en œuvre la réforme de décentralisation/déconcentration dans le secteur de la santé. Aussi a-t-il été retenu que l'amélioration de la gouvernance du district de santé soit une priorité majeure de la stratégie sectorielle de santé révisée pour la période 2001- 2015. Le Secrétariat technique du Comité et de suivi pour la mise en œuvre de la SSS a demandé au Centre pour le Développement des Bonnes Pratiques en Santé (CDBPS) de synthétiser les bases factuelles relatives à la gouvernance sanitaire.

Risk factors for HIV-associated neurocognitive disorders (HAND) in sub-Saharan Africa: the case of Yaoundé-Cameroon.

BACKGROUND: The prevalence of HIV-associated neurocognitive disorders (HAND), especially HIV-associated dementia (HAD) is influenced by several risk factors. The prevalence as well as risk factors for HAD are not well known in sub-Saharan Africa (SSA). We have shown that the International HIV Dementia Scale (IHDS) is a useful screening tool for HAND in Yaoundé [Njamnshi AK, Djientcheu VdP, Fonsah JY, Yepnjio FN, Njamnshi DM, Muna WFT. The IHDS is a useful screening tool for HAD/Cognitive Impairment in HIV-infected adults in Yaoundé-Cameroon. Journal of Acquired Immune Deficiency Syndromes 2008;49(4):393-397], but no study in Cameroon has yet investigated the risk factors for HAND or HAD. PATIENTS AND METHODS: A cross-sectional study was conducted in Yaoundé, the capital of Cameroon from September to December 2006. One hundred and eighty-five HIV-positive subjects were included. Diagnosis of HAND was done using the IHDS with a score < or = 10 considered as abnormal. Age, sex, level of education, IV drug use, body mass index (BMI), CDC clinical stage, CD4 counts, hemoglobin levels, administration of highly active antiretroviral therapy (HAART) and type of regimen used, were considered in univariate analysis, with level of significance set at P < or = 0.05. A binary logistic regression was used to determine independent risk factors. RESULTS: The following factors were independent predictors of HAND: advanced clinical stage (OR=7.43, P=0.001), low CD4 count especially CD4 < or = 200 cells/microL (OR=4.88, P=0.045) and low hemoglobin concentration (OR=1.16, P=0.048). CONCLUSION: This first study of the risk factors for HAND in Yaoundé-Cameroon shows findings similar to those described in other studies. These results call for rapid action by policy makers to include HAND prevention strategies such as providing early universal access to HAART based on these risk factors, in the management of HIV patients at risk of HAND in resource-limited settings of SSA like ours.

[Diffusion and perfusion MR imaging in cerebral lymphomas]. / IRM de diffusion-perfusion dans l'évaluation des lymphomes cérébraux.

Because of the increasing incidence of cerebral lymphoma, it is critical for patient management to recognize the MR features of this disease. We present the characteristic morphological and functional MRI features of this tumor. The findings on MRI studies, including morphological, diffusion and perfusion imaging, performed in 9 biopsy-proven cases of cerebral lymphoma with 13 lesions are presented and analyzed, and are discussed in comparison with published literature data. All patients underwent diffusion-weighted imaging with a single shot echo-planar pulse sequence. Dynamic susceptibility-contrast MRI was performed using a T2*-weighted gradient-echo echo-planar sequence after intravenous injection of chelates of gadolinium at the rate of 6 ml/s and a temporal resolution of 1 second. All cases of cerebral lymphoma appeared hypointense or isointense on T1-weighted images and in 75% of cases iso- or hypointense on T2-weighted images. All lesions enhanced except one in a patient receiving steroid therapy. On diffusion-weighted images, tumours were hyperintense with normal or decreased ADC values (0.717+/-0.152.10-3 mm2/sec, range: 0.550-1.014) and an ADC ratio tumour/normal white matter of 0.974+/-0.190 (range: 0.768-1.410). On perfusion, the signal intensity-time curve of each tumour showed a characteristic type of curve with a significant increase of the signal intensity above the baseline and a low maximum relative cerebral blood volume ratio (rCVBmax) of 1.43+/-0.64 (0.55-2.62). Due to their higher cellularity, the lack of neoangiogenesis, and the increased permeability of the blood-brain barrier related to the infiltration of blood vessels wall by lymphomatous cells, cerebral lymphoma presents characteristic diffusion and perfusion MRI features that should be useful for diagnosis and patient follow-up.

Depressed skull fractures in children: Treatment using an obstetrical vacuum extractor.

INTRODUCTION: A depressed skull fracture is an inward buckling of the skull bones. It is referred to as a ping-pong ball fracture in neonates; in older children, some fractures take a cup shape mimicking 'ping-pong' ball fractures. OBJECTIVE AND METHODS: The aim of this study was to assess the use of an obstetric vacuum extractor to elevate cup-shaped depressed skull fractures in children irrespective of age. All children admitted into the Central Hospital of Yaounde between 1999 and 2004 with a cup-shaped simple depressed skull fracture and treated with the vacuum extractor were included. RESULTS: Nine children aged from 3 months to 17 years were treated with the vacuum extractor. The cosmetic and radiographic results were satisfactory. The procedure was simple and without any complication. CONCLUSION: The elevation of 'ping-pong-ball-like' or 'cup-shaped' skull fractures in older children (beyond the neonatal period) is a simple, effective and safe procedure.

The epidemiology of stroke in sickle cell patients in Yaounde, Cameroon.

BACKGROUND AND PURPOSE: Stroke, a severe and recurrent but preventable complication of sickle cell disease (SCD), has not been well studied in Cameroon. To obtain baseline data towards the development of a national stroke prevention programme in SCD, we studied a sample of sickle cell patients with the aim of determining stroke prevalence, clinical presentation and management practices. PATIENTS AND METHODS: Homozygous sickle cell patients in two centres in Yaounde were screened for stroke, in a cross-sectional study. Stroke was diagnosed clinically and confirmed where possible with brain computerized tomography. The National Institutes of Health Stroke Score (NIHSS) and modified Rankin scale (mRS) were used to assess stroke severity. Management practices were noted from patient charts. RESULTS: One hundred and twenty patients aged 7 months to 35 years (mean age 13.49+/-8.79 years) were included. Eight cases of stroke (mean age 16.6+/-11.2 years) were identified, giving a stroke prevalence of 6.67%. Cerebral infarction was thrice as common as cerebral hemorrhage and clinical presentation was classical. Cerebral infarction was more frequent in patients aged below 20 years and hemorrhage in those above 20 (p=0.11). The annual recurrence rate was 25%. Missed diagnosis rate by attending physician was 25%. The NIHSS and mRS showed high stroke severity. Stroke management practices were insufficient and no patient received any form of stroke prophylaxis. CONCLUSION: Stroke prevalence and presentation in sickle cell patients in Yaounde is similar to that observed in developed countries, but the wide management gap calls for rapid action. Our situation is ideal for the study of the natural history of stroke in sickle cell disease.

Growing skull fractures.

INTRODUCTION: Growing skull fractures are a rare complication of head injuries (Ersahin et al. in Neurosurg Rev 23:139-144, 2000; Hayashi et al. in Childs Nerv Syst 13:349-351, 1997; Ramamurthi and Kalyanaraman in Neurosurgery 32:427-430, 1970; Zegers et al. in Eur J Pediatr 162:556-557, 2003). Although early diagnosis and prompt treatment are important to prevent the underlying progressive brain damage, the clinical presentation and the morphological investigations are rarely specific or sensitive shortly after the trauma. DISCUSSION: The authors present three cases of growing skull fractures: the use of ultrasonography (US) via the fracture line contributed to early diagnosis and prompt treatment in two cases. US was not performed in the third case, and this delayed management. Treatment consisted of a watertight duraplasty with a free flap of pericranium without cranioplasty. US via the fracture line appears to be a sensitive and reliable method of detecting the dural tears in the early stages of growing skull fractures. CONCLUSION: Duraplasty alone with a flap of pericranium remains the simplest and least expensive method of treatment. Cranioplasty is not necessary in young children.

Les hematomes extra-duraux post traumatiques : prise en charge medico-chirurgicale a Yaounde (post-traumatic extra dural hematoma: medical and surgical management in Yaounde)

Introduction : L'hematome extra dural (HED) est une urgence chirurgicale majeure. Son diagnostic et sa prise en charge dans les pays en voie de developpement se heurtent a des difficultes inherentes a la fois a la modestie des plateaux techniques et au cout trop onereux des soins pour des malades souvent demunis; sans systeme d'entraide national. Objectif : Le but de cette etude est d'etablir le profil epidemiologique des patients victimes d'un HED a Yaounde; de relever les difficultes dans la prise en charge et d'evaluer les resultats a court et a moyen terme.Patients et Methodes Il s'agit d'une etude descriptive allant de Janvier 1999 a Decembre 2004. Tous les patients pris en charge (trousse neurochirurgicale d'urgence) pour un hematome extra dural dans l'une des formations hospitalieres de Yaounde ont ete inclus. Resultats : Sur les 38 patients recrutes; le sexe masculin etait preponderant avec un sexe ratio de 3.8/1. L'age moyen etait de 24;5 ans (extreme allant de 3 a 48 ans). Les accidents de la voie publique constituaient l'etiologie la plus frequente (55;3des cas). Le traitement chirurgical etait principalement une craniotomie (81;1des patients operes). Le traitement medical avant la chirurgie etait variable. Le GOS dans le collectif etait evalue a 5 (2 patients decedes); 2 (4 patients avec des sequelles) et 1 (32 patients avec une recuperation complete). Conclusion : Ce travail demontre l'interet de disposer d'une trousse neurochirurgicale d'urgence pour une prise en charge optimale dans notre contexte

[Retinal hemorrhages after ivermectin treatment for onchocerciasis in a patient with Loa loa microfilaremia]. / Survenue d'hémorragies rétiniennes lors du traitement de l'onchocercose par l'ivermectine chez une patiente co-infectée par la loase.

A case of retinal hemorrhages with special features and degradation of the general condition is reported in a 27-year-old female patient, following the ingestion of ivermectin for the treatment of onchocerciasis. The patient was infested by both Onchocerca volvulus and Loa loa. A bilateral peripheral temporal location of the retinal lesions was observed. The role of L. loa microfilarial load in the occurrence of the retinal lesions as well as the transient character of the lesions are discussed, based on the clinical observation and with reference to the literature. The authors call for setting up a rapid therapeutic system to take care of serious adverse reactions following treatment with ivermectin in areas with a high prevalence of L. loa infestation.

Follow-up of neurocysticercosis patients after treatment using an antigen detection ELISA.

Seven patients with active neurocysticercosis (NCC) received an eight days treatment with albendazole and were followed up using computed tomography (CT-scan) and a monoclonal antibody based ELISA for the detection of circulating antigen (Ag-ELISA). Only three patients were cured as was shown by CT-scan and by the disappearance of circulating antigens one month after treatment. After a second course of albendazole therapy, two other patients became seronegative. CT-scan showed the disappearance of viable cysts in all persons who became seronegative whereas patients who were not cured remained seropositive. These preliminary results show that this Ag-ELISA is a promising technique for monitoring the success of treatment of NCC patients because of the excellent correlation between the presence of circulating antigens and of viable brain cysts.

Myelopathy and sciatica induced by an extradural S1 root haemangioblastoma.

Haemangioblastomas are vascular tumours which mainly involve the central nervous system and retina, often in the setting of von Hippel-Lindau disease. Haemangioblastomas occurring outside the central nervous system are uncommon. Wherever it is, recognising this tumour prior to surgery is desirable, as preoperative embolisation may be considered. We report the clinical, imaging and pathological features of a sporadic sacral root haemangioblastoma in a 58-year-old man with chronic sciatica and myelopathy. The diagnosis was questioned preoperatively because an enlarged sacral foramen, seen to be filled by a highly vascular, enhancing mass and dilated vessels. Myelopathy was attributed to the presumed high venous pressure resulting from increased flow in veins draining the vascular tumour. Microneurosurgical excision was performed after endovascular embolisation and led to persistent clinical improvement.

Primary cerebral lymphomas: unsolved issues regarding first-line treatment, follow-up, late neurological toxicity and treatment of relapses. The FNCLCC. French Fédération Nationale des Centres de Lutte contre le Cancer.

BACKGROUND: Primary cerebral non-Hodgkin's lymphomas (NHL) in immunocompetent patients (PCL) are located exclusively in the central nervous system, the eye, or meninges. Clinical management of these patients remains controversial. PATIENTS AND METHODS: Clinical characteristics of the patients and parameters influencing their outcome as of December 1998 were investigated and registered in a database of 226 patients treated in the French Federation of Cancer Centers between 1980 and 1995. RESULTS: Most PCL are diffuse large-cell NHL with a B phenotype. The incidence of PCL has been steadily increasing over the past 20 years in some but not all countries. The overall survival of primary cerebral lymphoma (PCL) patients in the published series, a median of 12-16 months and a five-year survival of 5%-20%, is poor. Several series have now reported long-term survivals of more than 10 years and PCL may therefore be a curable tumor in some patients. The optimal treatment of PCL is not known. Complete resection of the tumor does not improve outcome and multidisciplinary approaches combining chemotherapy and radiotherapy are now commonly used, although the superiority of combination over radiotherapy- or chemotherapy-alone has never been demonstrated in a phase III trial. The optimal chemotherapy regimen, the dose and even the usefulness of brain radiotherapy after chemotherapy are therefore still matters of debate. Recently, several authors have reported a relatively high incidence of late neurological sequelae after PCL treatment. CONCLUSIONS: The optimal treatment of PCL patients remains to be defined. Large cooperative international phase III trials are now required to define and improve the optimal treatment of PCL and reduce its sequelae.

Acute gastroduodenal peptic ulcer perforation: contrast-enhanced and thin-section spiral CT findings in 10 patients.

BACKGROUND: To describe contrast-enhanced and thin-section spiral computed tomography (SCT) findings in patients with acute gastroduodenal peptic ulcer perforation (GPUP). METHODS: Abdominal SCTs in 10 patients with confirmed acute perforated gastroduodenal (GD) peptic ulcer were retrospectively reviewed. Patients were 24-76 years old (mean = 44 years); seven were men and three were women. Diagnosis of GD peptic ulcer was done by endoscopy or surgery. Eleven ulcers were identified, two in the antrum and nine in the duodenum. SCTs were obtained after intravenous contrast medium without oral administration. Slice thickness was 3 or 5 mm. CT findings were correlated with surgical (n = 5) or endoscopic (n = 5) findings. RESULTS: Eight patients had pneumoperitoneum. All patients had evidence of GD wall thickening and enhancement and inflammatory changes in perigastroduodenal soft tissues or organs. Discontinuity in the GD wall and/or tiny air bubbles in close proximity indicated the site of perforation in eight cases. CONCLUSIONS: Abdominal SCT enables diagnosis and location of GPUP. A well-controlled prospective study with a larger group is needed to determine the sensitivity and specificity of this technique.