Dismal salvage of testicular torsion: A call to action!

Background: Testicular ischaemia and infarction in cases of torsion depend on the duration and degree of twisting. Early evaluation and treatment are associated with high salvage reports.Objective: To determine the salvage rates of testicular torsion in selected hospitals at the Coast Province of KenyaDesign: A retrospective study of patients managed for testicular torsion and related conditions between 1999 and 2011.Setting: Coast Province General Hospital, Mombasa (1999 - 2008) and Moi District Hospital, Voi (2009 - 2011).Patients and Methods: Case records of 44 patients were reviewed. Forty two underwent scrotal explorations while two patients with bilateral  testicular loss due to torsion had no surgery. Patients were reviewed for age, operative diagnoses, testicular salvage, surgical procedures  performed and recurrence of symptoms.Results: Of 29 patients operated for acute testicular torsion, four had viable testes (salvage rate of 14%). Seven patients had bilateral orchidopexyfor intermittent testicular torsion. Three patients who had missed torsions with resultant total testicular atrophy, had orchidopexy of the contralateral testes. At scrotal exploration 2 patients with epididymorchitis and one patient with a torsion of appendix testis that was excised, were not subjected to orchidopexy. There was no occurrence of torsion after orchidopexy.Conclusion: Testicular torsions were associated with low salvage rates. Increased public awareness coupled with clinician, parental, teacher,  teenage and adult male education with respect to the consequences of acute scrotal pain is warranted

Trypanosomiasis challenge estimation using the diminazene-aceturate (Berenil) index in Zebu in Gabon

A longitudinal study was conducted within a cattle ranch in Gabon to determine the diminazene aceturate (Berenil) index (DAI) in a group of Zebu, raised under low tsetse density; this measure providing an assessment of trypanosomiasis risk. The objective was to evaluate the trypanosomiasis pressure thus informing trypanosomiasis control methods and cattle management. Twenty female adult Zebu were monitored for 24 weeks during the dry season. Blood samples were collected on aweekly basis and subjected to parasitological and haematological analysis (n = 480), using the buffy-coat method and the packed cell volume value (PCV), respectively, infected animals were treated with a single intramuscular injection of diminazene aceturate (8 mg/kg). Twenty-nine single infectious events were recorded and a DAI of 1.45 was calculated. Two trypanosome species were identified: Trypanosoma congolense (96.2%) and Trypanosoma vivax (3.8%). The mean PCV value of the infected animals was lower (26.6) compared to non-infected animals (32.0). This study shows that DAI may be a useful tool to assess trypanosomiasis. However, this is a time-consumingmethod that may be improved by using randomly selected sentinel animals to adapt the chemoprophylactic schemes, hence decreasing the costs and the drug resistance risk

Peste des Petits Ruminants

Heartwater (or cowdriosis) is a tick-borne disease caused by Ehrlichia ruminantium, an obligatory intracellular bacterium of the order Rickettsiales, transmitted by several ticks of the genus Amblyomma. The organism is genetically highly variable which prevented until now the development of efficient vaccines. The disease is enzootic in sub-Sahelian Africa and in some Caribbean islands. It affects domestic and wild ruminants, the susceptibility to cowdriosis varying greatly between breeds and species: African wildlife shows mainly asymptomatic infections; local cattle breeds are generally protected due to enzootic stability; and introduced cattle breeds and small ruminants, even in enzootic regions, are usually susceptible to heartwater and can suffer high mortality rates. Cowdriosis is characterized by a sudden and acute fever followed by nervous, respiratory, and gastrointestinal symptoms and by hydrothorax and hydropericardium during postmortem examination. In West Africa, the only vector is Amblyomma variegatum, present in areas where pluviometry is higher than 500 mm. Therefore, animals of a high proportion of the Sahelian region are usually not infested by the tick and not infected by the bacterium. They are thus susceptible when introduced in southern parts of the Sahel or in the subhumid neighboring areas of the West African countries, for example during transhumance. Tetracyclines are effective drugs to treat heartwater when administered before occurrence of the nervous symptoms. Various vaccines have been tested, and are still developed, but, up to now, none of them showed enough effectiveness against all the field strains of E. ruminantium to allow its marketing. Prevention is therefore mainly achieved by drastic vector control or, on the contrary, acquisition of enzootic stability following tick infestation combined with tetracycline treatment as soon as hyperthermia occurs

Enhanced infection prophylaxis reduces mortality in severely immunosuppressed HIV-infected adults and older children initiating antiretroviral therapy in Kenya, Malawi, Uganda and Zimbabwe: the REALITY trial

Meeting abstract FRAB0101LB from 21st International AIDS Conference 18–22 July 2016, Durban, South Africa. Introduction: Mortality from infections is high in the first 6 months of antiretroviral therapy (ART) among HIV‐infected adults and children with advanced disease in sub‐Saharan Africa. Whether an enhanced package of infection prophylaxis at ART initiation would reduce mortality is unknown. Methods: The REALITY 2×2×2 factorial open‐label trial (ISRCTN43622374) randomized ART‐naïve HIV‐infected adults and children >5 years with CD4 <100 cells/mm3. This randomization compared initiating ART with enhanced prophylaxis (continuous cotrimoxazole plus 12 weeks isoniazid/pyridoxine (anti‐tuberculosis) and fluconazole (anti‐cryptococcal/candida), 5 days azithromycin (anti‐bacterial/protozoal) and single‐dose albendazole (anti‐helminth)), versus standard‐of‐care cotrimoxazole. Isoniazid/pyridoxine/cotrimoxazole was formulated as a scored fixed‐dose combination. Two other randomizations investigated 12‐week adjunctive raltegravir or supplementary food. The primary endpoint was 24‐week mortality. Results: 1805 eligible adults (n = 1733; 96.0%) and children/adolescents (n = 72; 4.0%) (median 36 years; 53.2% male) were randomized to enhanced (n = 906) or standard prophylaxis (n = 899) and followed for 48 weeks (3.8% loss‐to‐follow‐up). Median baseline CD4 was 36 cells/mm3 (IQR: 16–62) but 47.3% were WHO Stage 1/2. 80 (8.9%) enhanced versus 108(12.2%) standard prophylaxis died before 24 weeks (adjusted hazard ratio (aHR) = 0.73 (95% CI: 0.54–0.97) p = 0.03; Figure 1) and 98(11.0%) versus 127(14.4%) respectively died before 48 weeks (aHR = 0.75 (0.58–0.98) p = 0.04), with no evidence of interaction with the two other randomizations (p > 0.8). Enhanced prophylaxis significantly reduced incidence of tuberculosis (p = 0.02), cryptococcal disease (p = 0.01), oral/oesophageal candidiasis (p = 0.02), deaths of unknown cause (p = 0.02) and (marginally) hospitalisations (p = 0.06) but not presumed severe bacterial infections (p = 0.38). Serious and grade 4 adverse events were marginally less common with enhanced prophylaxis (p = 0.06). CD4 increases and VL suppression were similar between groups (p > 0.2). Conclusions: Enhanced infection prophylaxis at ART initiation reduces early mortality by 25% among HIV‐infected adults and children with advanced disease. The pill burden did not adversely affect VL suppression. Policy makers should consider adopting and implementing this low‐cost broad infection prevention package which could save 3.3 lives for every 100 individuals treated