Identifying determinants of under-five child mortality in northern Togo

Background

Although global rates of under-five mortality have declined, many low- and middle-income countries (LMICs), including Togo, have not achieved sufficient progress. We aimed to identify the structural and intermediary determinants associated with under-five mortality in northern Togo.

Methods

We collected population-representative cross-sectional household surveys adapted from the Demographic Household Survey (DHS) and Multiple Indicator Cluster Survey from women of reproductive age in northern Togo in 2018. The primary outcome was under-five mortality for children born to respondents in the 10-year period prior to the survey. We selected structural and intermediary determinants of health from the World Health Organization Conceptual Framework for Action on the Social Determinants of Health. We estimated associations between determinants and under-five mortality for births in the last 10 years (model 1 and 2) and two years (model 3) using Cox proportional hazards models.

Results

Of the 20 121 live births in the last 10 years, 982 (4.80%) children died prior to five years of age. Prior death of a sibling (adjusted hazard ratio (aHR) = 5.02; 95% confidence interval (CI) = 4.23-5.97), maternal ethnicity (i.e. Konkomba, Temberma, Lamba, Losso, or Peul), multiple birth status (aHR = 2.27; 95% CI = 1.78-2.90), maternal age under 25 years (women <19 years: aHR = 2.05; 95% CI = 1.75-2.39; women 20-24 years: aHR = 1.48; 95% CI = 1.29-1.68), lower birth interval (aHR = 1.51; 95% CI = 1.31-1.74), and higher birth order (second or third born: aHR = 1.45; 95% CI = 1.32-1.60; third or later born: aHR = 2.14; 95% CI = 1.74-2.63) were associated with higher hazard of under-five mortality. Female children had lower hazards of under-five mortality (aHR = 0.80; 95% CI = 0.73-0.89). Under-five mortality was also lower for children born in the last two years (n = 4852) whose mothers received any (aHR = 0.48; 95% CI = 0.30-0.78) or high quality (aHR = 0.51; 95% CI = 0.29-0.88) prenatal care.

Conclusion

Compared to previous DHS estimates, under-five mortality has decreased in Togo, but remains higher than other LMICs. Prior death of a sibling and several intermediary determinants were associated with a higher risk of mortality, while receipt of prenatal care reduced that risk. These findings have significant implications on reducing disparities related to mortality through strengthening maternal and child health care delivery.

Growth and CD4 patterns of adolescents living with perinatally acquired HIV worldwide, a CIPHER cohort collaboration analysis

INTRODUCTION

Adolescents living with HIV are subject to multiple co-morbidities, including growth retardation and immunodeficiency. We describe growth and CD4 evolution during adolescence using data from the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) global project.

METHODS

Data were collected between 1994 and 2015 from 11 CIPHER networks worldwide. Adolescents with perinatally acquired HIV infection (APH) who initiated antiretroviral therapy (ART) before age 10 years, with at least one height or CD4 count measurement while aged 10-17 years, were included. Growth was measured using height-for-age Z-scores (HAZ, stunting if <-2 SD, WHO growth charts). Linear mixed-effects models were used to study the evolution of each outcome between ages 10 and 17. For growth, sex-specific models with fractional polynomials were used to model non-linear relationships for age at ART initiation, HAZ at age 10 and time, defined as current age from 10 to 17 years of age.

RESULTS

A total of 20,939 and 19,557 APH were included for the growth and CD4 analyses, respectively. Half were females, two-thirds lived in East and Southern Africa, and median age at ART initiation ranged from <3 years in North America and Europe to >7 years in sub-Saharan African regions. At age 10, stunting ranged from 6% in North America and Europe to 39% in the Asia-Pacific; 19% overall had CD4 counts <500 cells/mm3 . Across adolescence, higher HAZ was observed in females and among those in high-income countries. APH with stunting at age 10 and those with late ART initiation (after age 5) had the largest HAZ gains during adolescence, but these gains were insufficient to catch-up with non-stunted, early ART-treated adolescents. From age 10 to 16 years, mean CD4 counts declined from 768 to 607 cells/mm3 . This decline was observed across all regions, in males and females.

CONCLUSIONS

Growth patterns during adolescence differed substantially by sex and region, while CD4 patterns were similar, with an observed CD4 decline that needs further investigation. Early diagnosis and timely initiation of treatment in early childhood to prevent growth retardation and immunodeficiency are critical to improving APH growth and CD4 outcomes by the time they reach adulthood.

PrEP for key populations: results from the first PrEP demonstration project in the Democratic Republic of the Congo

Oral pre-exposure prophylaxis (PrEP) is recommended for persons at substantial risk for HIV, including female sex workers (FSW), men who have sex with men (MSM), people who inject drugs (PWID), and transgender women (TGW). We report on a PrEP demonstration project at seven clinics in the Democratic Republic of the Congo. Routinely collected data were abstracted to assess PrEP uptake, scheduled visit attendance, and self-reported adherence. Between February and May 2018, 469 eligible clients were offered daily oral PrEP; 75.1% accepted: 78.7% FSW, 20.5% MSM, and 0.9% TGW. Two percent also identified as PWID. Attendance was 64.5% at one-month visits; 82.1% at three-month visits; and among 47.7% of clients who initiated PrEP at least six months before data abstraction, 85.8% at six-month visits. Among 66.3% of clients with at least one adherence assessment, 39% self-reported low adherence. Results demonstrate the acceptability of PrEP delivered in healthcare settings serving FSW, MSM, PWID, and TGW.

Growth and Metabolic Changes After Antiretroviral Initiation in South African Children

BACKGROUND

Poor growth and metabolic disturbances remain concerns for children living with HIV (CLHIV). We describe the impact of viral load (VL) on growth and lipid outcomes in South African CLHIV <12 years initiating World Health Organization recommended first-line antiretroviral therapy (ART) from 2012 to 2015.

METHODS

Z scores for length-for-age (LAZ), weight-for-age (WAZ) and body mass index-for-age were calculated. Lipids (total cholesterol, low-density lipoprotein and high-density lipoprotein) were measured. Hemoglobin A1C ≥5.8 was defined as at risk for type 2 diabetes. Mixed effects models were used to assess the association of VL at ART initiation with Z scores and lipids over time.

RESULTS

Of 241 CLHIV, 151 (63%) were <3 years initiating LPV/r-based ART and 90 (37%) were ≥3 years initiating EFV-based ART. Among CLHIV <3 years, higher VL at ART initiation was associated with lower mean LAZ (ß: -0.30, P=0.03), WAZ (ß: -0.32, P=0.01) and low-density lipoprotein (ß: -6.45, P=0.03) over time. Among CLHIV ≥3, a log 10 increase in pretreatment VL was associated with lower mean LAZ (ß: -0.29, P=0.07) trending towards significance and lower WAZ (ß: -0.32, P=0.05) as well as with more rapid increases in LAZ (ß: 0.14 per year, P=0.01) and WAZ (ß: 0.19 per year, P=0.04). Thirty percent of CLHIV were at risk for type 2 diabetes at ART initiation.

CONCLUSIONS

CLHIV initiating ART <3 years exhibited positive gains in growth and lipids, though high viremia at ART initiation was associated with persistently low growth and lipids, underscoring the need for early diagnosis and rapid treatment initiation. Future studies assessing the long-term cardiometabolic impact of these findings are warranted.

Human Immunodeficiency Virus Infection in Adolescents and Mode of Transmission in Southern Africa: A Multinational Analysis of Population-Based Survey Data

Background

Adolescents aged 10–19 years living with human immunodeficiency virus (HIV) (ALHIV), both perinatally infected adolescents (APHIV) and behaviorally infected adolescents (ABHIV), are a growing population with distinct care needs. We characterized the epidemiology of HIV in adolescents included in Population-based HIV Impact Assessments (2015–2017) in Zimbabwe, Malawi, Zambia, Eswatini, and Lesotho.

Methods

Adolescents were tested for HIV using national rapid testing algorithms. Viral load (VL) suppression (VLS) was defined as VL <1000 copies/mL, and undetectable VL (UVL) as VL <50 copies/mL. Recent infection (within 6 months) was measured using a limiting antigen avidity assay, excluding adolescents with VLS or with detectable antiretrovirals (ARVs) in blood. To determine the most likely mode of infection, we used a risk algorithm incorporating recency, maternal HIV and vital status, history of sexual activity, and age at diagnosis.

Results

HIV prevalence ranged from 1.6% in Zambia to 4.8% in Eswatini. Of 707 ALHIV, 60.9% (95% confidence interval, 55.3%–66.6%) had HIV previously diagnosed, and 47.1% (41.9%–52.3%) had VLS. Our algorithm estimated that 72.6% of ALHIV (485 of 707) were APHIV, with HIV diagnosed previously in 69.5% of APHIV and 39.4% of ABHIV, and with 65.3% of APHIV and 33.5% of ABHIV receiving ARV treatment. Only 67.2% of APHIV and 60.5% of ABHIV receiving ARVs had UVL.

Conclusions

These findings suggest that two-thirds of ALHIV were perinatally infected, with many unaware of their status. The low prevalence of VLS and UVL in those receiving treatment raises concerns around treatment effectiveness. Expansion of opportunities for HIV diagnoses and the optimization of treatment are imperative.

How long should suction drains stay in after breast surgery with axillary dissection?

Daily suction drainage volumes were recorded for 63 patients after wide local excision of a breast carcinoma with axillary dissection (n = 37) or mastectomy with axillary dissection (n = 26). Suction drains were removed at the discretion of the clinical ward staff after a median of 4 days (range 1-7 days). In all, 32 patients (51%) later developed seromas requiring needle aspiration. Minor wound infection rate was not significantly higher in patients who developed seromas than those who did not (5 vs 2). Seroma formation was associated with a larger total suction drain volume (mean 480 ml (range 28-1150 ml) vs 240 ml (range 10-635 ml); P = 0.0001). The median yield of axillary lymph nodes was significantly greater in those who developed seromas (11 (range 4-20) vs 8 (range 1-19); P = 0.002). There was no difference in the volume drained in the 24 h preceding drain removal (mean 60 ml (range 0-150 ml) vs 50 ml (range 0-290 ml); NS). Keeping drains in situ longer did not protect against seroma formation. By 48 h, 74% of the total volume drained by each drain had been collected. Seroma formation after breast surgery with axillary dissection is an inconvenience for a high proportion of patients. This complication does not seem to be reduced by prolonged suction drainage of the wound, which in itself delays patient discharge and causes further inconvenience.

Simple method of orientating breast biopsies following hook-wire or ultrasonographic localization of impalpable mammographic abnormalities

Localization of impalpable breast lesions with fine wires is standard practice and several variations of the hook-wire device have been described1. More recently ultra-sonography2 has been used as an accurate and rapid method of preoperative localization of mass lesions. Accurate biopsy of all clinically impalpable suspicious mammographic abnormalities is essential and complete excision is important in those patients with malignant disease3. Having performed a localization biopsy, precise specimen orientation allows further excision if original margins are involved. A simple and inexpensive method of orientating tissue specimens following excision biopsy is described.

Ultrasound localization of screen detected impalpable breast tumours

Accurate localization of a tumour is imperative before excision biopsy for impalpable breast lesions seen on screening mammography. Ultrasound localization has the advantages of being simple, quick and noninvasive. In a 3-year period from September 1989, 185 women have required localization of a breast tumour prior to biopsy, 159 were performed using a wire localization technique and 26 (14%) were performed using ultrasound alone. Twenty-two out of the 26 were malignant lesions. The mean maximum diameter of tumour diagnosed by ultrasound compared to histological sample was 10.6 mm (8.5-12.7*) to 11.1 mm (8.9-13.3*) with a correlation of r = 0.87. In the malignant cases the mean maximum diameter of tissue excised was 63.0 mm (57.2-65.9*). Complete excision was obtained in 21 out of the 22 patients with malignant disease by one operation. Ultrasound alone has been used successfully as a means of preoperative localization in selected cases prior to excision biopsy of a breast tumour.

Should endoscopic stenting be the initial treatment of malignant biliary obstruction?

Forty-two patients with biliary obstruction caused by a stricture had a diagnostic ERCP with subsequent insertion of a straight 10G endoprosthesis. These patients represented 70% of a cohort in which stent insertion had been attempted. The majority (63%) had pancreatic carcinoma, but 22% had malignant hilar obstruction. Five patients (12%) died within a few days of stent insertion; ERCP may have contributed to two deaths. Jaundice was relieved in all survivors. Median hospital stay was 6 days (range 2-32 days). After further investigation, nine patients were thought to be potentially curable and underwent laparotomy. Late complications after stent insertion alone included cholangitis (26%) and recurrent jaundice (28%). Only one patient developed gastric outlet obstruction and needed a gastroenterostomy. Median survival in the endoprosthesis group was 11 weeks (range 2-84 weeks). Survival was longer for patients with bile duct (14 weeks) rather than hilar strictures (6 weeks). Median survival after subsequent surgery was 40 weeks (range 4-80 weeks) with two long-term survivors. This study confirms that ERCP and stent insertion is a useful initial treatment for obstructive jaundice due to a biliary stricture, being both diagnostic and therapeutic. Subsequent evaluation for curative surgery is not precluded and in the majority of cases worthwhile palliation may be achieved by stenting alone.

Primary squamous cell carcinoma of the caecum

A case of primary squamous cell carcinoma of the caecum arising in a tubulo-villous adenoma is described. This rare lesion develops following genomic derangement of the multipotential colonic stem cells. The literature is reviewed and factors contributing towards squamous cell differentiation discussed.

Signet ring cell adenocarcinoma of bladder secondary to long-term catheterization

A case of signet ring cell adenocarcinoma of the bladder occurring in association with long-term suprapubic catheterization is presented, the tumor appearing to have arisen in dysplastic glands of metaplastic urothelium. The possible implications of this findings are presented.

Single dose cefotaxime plus metronidazole versus three dose cefuroxime plus metronidazole as prophylaxis against wound infection in colorectal surgery: multicentre prospective randomised study

OBJECTIVE

To establish whether a single preoperative dose of cefotaxime plus metronidazole was as effective as a standard three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery.

DESIGN

Prospective randomised allocation to one of two prophylactic antibiotic regimens in a parallel group trial. Group sequential analyses of each 250 patients were performed.

SETTING

14 District general and teaching hospitals.

PATIENTS

1018 Adults having colorectal operations were randomised, of whom 943 were evaluated. Demographic features, conditions requiring surgery, and operative procedures were similar in the two groups. Most patients had surgery for carcinoma of the colon or rectum.

INTERVENTIONS

Group 1 received cefotaxime 1 g intravenously plus metronidazole 500 mg intravenously preoperatively. Group 2 received cefuroxime 1.5 g intravenously plus metronidazole 500 mg intravenously preoperatively, followed by cefuroxime 750 mg intravenously plus metronidazole 500 mg intravenously eight hours and 16 hours postoperatively.

MAIN OUTCOME MEASURES

Development of surgical wound infection (as evidenced by the presence of pus), death, or discharge from hospital.

RESULTS

Wound condition was scored on a five point scale on alternate days until discharge or for up to 20 days postoperatively. Wound infection rates were: group 1, 32/453 (7.1%; 95% confidence interval 4.7% to 9.4%); group 2, 33/454 (7.3%; 95% confidence interval 4.9% to 9.6%). Death rates (group 1: 26/470 (5.5%); group 2: 31/471 (6.6%], the incidence of postoperative complications, the median duration of hospital stay (12 days), and antibiotic tolerance were all similar in the two groups. Pooled data from groups 1 and 2 showed that wound infections were more frequent when minor faecal contamination had occurred at operation and when the duration of operation exceeded 90 minutes (greater than 90 min 11.2% of cases; less than 90 min 4.8%) and were associated with an extended hospital stay.

CONCLUSIONS

A single preoperative dose of cefotaxime plus metronidazole is an efficacious as a three dose regimen of cefuroxime plus metronidazole in preventing wound infection after colorectal surgery and has practical advantages in eliminating the need for postoperative antibiotics.

Pleomorphic rhabdomyosarcoma of the urinary bladder in association with recurrent urinary-tract infection

An unusual case of pleomorphic rhabdomyosarcoma is presented which arose in the urinary bladder of an adult male in association with recurrent urinary-tract infection and bladder outflow obstruction, secondary to a chronic post-traumatic urethral stricture.

Percutaneous electrohydraulic lithotripsy of retained bile duct calculus

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Squamous cell carcinoma of the anus arising within condyloma acuminatum

Condyloma acuminatum are 'warty' lesions of viral aetiology. Four cases of squamous carcinoma arising within such condyloma are reported and discussed.

Does the addition of disinfectant to urine drainage bags prevent infection in catheterised patients?

The value of adding chlorhexidine to urine drainage bags of male patients treated with indwelling catheters after prostatectomy and other transurethral operations was assessed in a randomised, prospective, controlled was assessed in a randomised, prospective, controlled study. Chlorhexidine kept the contents of all drainage bags sterile, but the frequency of urinary infection in the chlordexidine group (51%) did not differ significantly from that in the control group (45%). Most infections were endogenous, caused by organisms which probably came from the patient's own urethra. It was concluded that the method has no value in urology units where standards of catheter care and closed drainage are properly maintained. Controlled studies in other types of catheterised patients are needed, especially when the risks of cross-infection are high.

Acute necrotizing colitis and obstruction

Acute necrotizing colitis is a rare complication of colonic obstruction. Six cases occurring during a 20-month period are described. The presenting features were those of colonic obstruction with shock but without perforation. At laparotomy changes ranged from mucosal necrosis to frank gangrene in the colon proximal to the obstructing lesion. Gram stains of resected colon showed Gram-positive bacilli, resembling clostridia, invading the mucosa and submucosa. Two patients treated by defunctioning colostomy alone died but the remaining 4 survived after total colectomy. The cause is not known but raised intraluminal pressure may result in terminal mucosal ischaemia allowing anaerobic organisms to invade the bowel wall.

Arterial embolisation in renal carcinoma: a useful procedure?

Twenty-eight patients underwent embolisation over a 2-year period. III effects followed embolisation in 16 (57%), 2 of whom died. Attention is drawn to the intolerance of many patients to the length of the procedure. Of 24 patients undergoing operation, one case was inoperable and difficulty was encountered in 9. No perirenal plane of oedema was identified. No specimen examined histologically showed complete infarction. The tumour tissue was more resistant to infarction than normal kidney and 8 tumours (35%) appeared to have escaped completely. It is concluded that the role of embolisation is limited and that a combination of methods for achieving adequate arterial occlusion must be used for the optimum effect.

A randomised controlled trial to compare local with general anaesthesia for short-stay inguinal hernia repair

A series of 117 consecutive unselected patients with clinically reducible unilateral inguinal herniae were admitted for short-stay repair. Seven expressed a strong preference for one form of anaesthesia (6 general (GA)) local (LA) and 7 were unfit for GA; these were excluded from the trial. The remaining 103 patients were allocated at random to receive either LA or GA in order to compare the two methods of anaesthesia. The resulting groups (53 LA, 50 GA) were well matched for age and obesity. Perand postoperative symptoms were assessed with linear analogues self-assessment questionnaires. Statistically significant differences were demonstrated between the groups; those patients having LA were able to walk, eat, and pass urine earlier than those having GA, who experienced more nausea, vomiting, sore throat, and headache. The postoperative course and additional symptoms were otherwise similar. Forty-five LA patients experienced mild pain during the operation, but nevertheless 85% of the total group said they would consent to its use again. Ninety-three patients (90%) were discharged at 24 h. LA was applicable to all types of clinically reducible inguinal hernia and was an acceptable, safe, and satisfactory alternative to GA.

Biochemical aids to the staging of breast cancer

Up to fifteen plasma proteins were measured before treatment in 249 women presenting with lumps in the breast. Concentrations showed considerable overlap between the various clinical stages, and were often normal even in metastatic disease. A discriminant function is proposed, based on measurement of C-reactive protein, beta 2-microglobulin, carcinoembryonic antigen and ferritin and calculation of a score for each subject. High-risk scores resulted for all 18 patients with Stage 4 (i.e., metastatic) disease, and the number of Stage 1 patients attaining high scores was consistent with the reported incidence of development of metastases in such a group. Follow-up studies are in progress.

The macrophage electrophoretic mobility (MEM) test--an investigation of its value as a routine laboratory test in the detection of malignant disease

A previous study of the MOD-MEM test showed promising results. We have attempted to repeat the study using a blind coded series of 210 blood samples from normal subjects and patients with either benign or malignant disease. Using standard criteria the false negative rate for cancer patients averaged 43% and the false positive rate for non-cancer patients averaged 34%. The results indicate that the test at the present time, under routine laboratory conditions, is not reliably reproducible and does not have the ability to effectively discriminate between benign and malignant disease. It is suggested that blind coded studies be used more frequently in assessment of tests with cancer detection potential.

Serum beta2-microglobulin in controls and cancer patients

Serum beta2-microglobulin levels have been measured in 210 cancer and control patients to assess the significance of this investigation in cancer patients. Subjects studied included patients with breast and gastrointestinal cancer, corresponding control patients in both categories, and healthy volunteers. The composition of these groups allowed an assessment of the relative importance of changes related to cancer, benign disease, age and sex. A significant rise in serum beta2-microglobulin levels with advancing age was demonstrated in the control subjects. Mean levels were also consistently higher in females than in males in each patient group. After statistical correction for these age and sex effects, mean values remained significantly higher in each of the various cancer groups than in their controls. Patients with more advanced breast cancer had higher levels than those with 'early' disease, as did patients with stomach cancer compared to those with colo-rectal cancer. One possible interpretation is that levels increase with increasing tumour bulk, and therefore the estimation of serum beta2-microglobulin may be useful as one of a battery of tests in the management of cancer patients.

Masking of receptors for sheep erythrocytes on human T-lymphocytes by sera from breast cancer patients

Sera from 140 breast cancer patients and 38 controls were tested for their ability to inhibit sheep erythrocyte (E) rosette formation by normal, allogeneic lymphocytes. Inhibition of rosette formation by greater than 20% was found with 65% of stage I sera, 91% of stage II sera, 56% of stage III sera, and all stage IV sera. In contrast, only 13% of control sera was inhibitory. The inhibitory factor was found to bind to only a proportion of T-lymphocytes and could be removed from these lymphocytes by mild proteolytic digestion or extended washing. Examination of the properties of the inhibitory factor indicated that it differed from other substances that reportedly inhibited E-rosette formation.

T and B lymphocytes in breast cancer stage relationship and abrogation of T-lymphocyte depression by enzyme treatment in vitro

B and T lymphocytes have been measured in 100 women--71 patients with breast cancer and 29 controls--using sheep-erythrocyte rosetting techniques. Compared with controls (healthy women or patients with benign breast disease), there is a highly significant depression of T-cell percentage in all stages of breast cancer except locally advanced (stage 3) disease. These stage-3 cases seem to constitute a biologically distinct group. T-cell percentages in early (stage 1) patients overlap with those seen in stages 3 and 4, raising the possibility that there are in stage 1 two subpopulations of T-cell values that are associated with differences in subsequent tumour progression. B-lymphocyte levels are similar in all groups. Low T-cell levels return to normal after incubation with papain in virto but fall again after resuspending the treated lymphocytes in autologous (cancer) serum. The results suggest that T-cell depression is due to a masking factor on the surface of some T lymphocytes which is also present in the serum of cancer patients, and removable by enzyme digestion.