Ovarian thecoma-fibroma groups (OTFG) are uncommon sex cord-stromal neoplasms. The objective of the study was to demonstrate clinical and sonographic features of OTFG and compare with surgical histopathology.A total of 61 patients with surgically proven OTFG were enrolled in this retrospective study to demonstrate its clinical and sonographic features and to compare with pathological findings. Gray scale and color Doppler sonography were performed presurgically with either transabdominal or transvaginal approach to image pelvic structures and lesions. The clinical findings and sonographic appearances were compared with the types of the OTFG tumors based on the histopathological diagnosis.p < 0.01) and the amount of ascites fluid (p < 0.05).The mean patient age was 53.57  years. There were 63.93% (39/61) patients in postmenopausal and 63.93% (39/61) patients with no clinical symptoms. Ultrasound findings of OTFG revealed as solid tumors with a typical feature of well-demarcated hypoechoic masses in 70.49% (43/61), among which 74.41% (32/43) tumors were smaller than 5 cm in diameter. There were 17 mixed echogenic masses with calcification, hemorrhage, or cyst, among which 70.59% (12/17) lesions were larger than 5 cm in diameter. Acoustic attenuation of the tumor was presented in 44.26% (27/61) of the cases. Doppler flow signals within the tumors were found in 20 cases (32.79%), in which 80% (16/20) had minimal or moderate flow signals. Ascites was detected in 32.79% (20/61) of the cases, Megi’s syndrome was found in 1 case. Final pathology revealed 41 (67.21%) thecoma-fibromas, 15 (24.59%) fibromas, 4 (6.56%) thecomas and 1 (1.64%) fibrosarcoma. There were 58 patients underwent cancer antigen 125 (CA125) test, and 20.69% (12/58) showed an elevated level. The diameter of tumors was found to be significantly correlated with CA125 level (The typical sonographic features of OTFG include adnexal hypoechoic masses with clear border and acoustic attenuation as well as minimal Doppler flow signals. All the aforementioned features could make ultrasound imaging as a assistent tool improve the preoperative diagnostic accuracy. Ovarian thecoma-fibroma groups (OTFG) are uncommon sex cord-stromal neoplasms, constituting 1.0 to 4.0% of all ovarian tumors , 6. The In this retrospective study, 61 patients with surgically proven OTFG neoplasms were enrolled from Shanghai Ruijin Hospital between June 2009 and November 2015. The clinical information, CA125 test and sonographic results of the OTFG tumors were analyzed and compare to pathological findings. The study was approved by the Ruijin Hospital, Shanghai Jiaotong University School of Medicine institutional ethics committee with exemption to obtain informed consent from individual patients.All 61 patients underwent pre-surgical ultrasound examination of the pelvis using iU22 and HD11 ultrasound machines  associated with a 7.0–9.0 MHz transvaginal and a 3.5 MHz transabdominal probes. Ultrasound parameters were adjusted to optimize the image quality for each patient. Multi-dimensional and multi-angle real-time scans were performed to image the uterus, adnex and masses of their locations, sizes, patterns, echogenic characteristics, color Doppler flow, pelvic effusion, and relationship with surrounding organs.Color Doppler flow imaging within each tumor was recorded and Doppler signal was scored according to established standard by D. Timmerman et al. , i.e., SThe surgical pathological specimens were immediately fixated in 4% formaldehyde and embedded in paraffin. The sectioned slides were stained with hematoxylin-eosin (HE) for histopathological assessment using light microscopes.Each patient of clinical information, CA125 test and ultrasound results were analyzed and compared to intraoperative findings and final pathological diagnosis.T-test was used for comparing the means of two samples; χ2 test was used for comparing measurement data; The Pearson’s Correlation was also performed to show the relationship among the diameter of tumors and the CA125 levels and the amount of ascites fluid. Statistical significance was assumed at a p-value < 0.05.All of the statistical analyses were performed using SPSS 13.0 . Measurement data were expressed as mean ± standard deviation (x ± s). The mean ± SD age of 61 patients was 53.57  years. There were 65.57% (40/61) patients over 50 years old and 63.93% (39/61) in postmenopausal. Among the 61 patients, the neoplasms were discovered by routing physical exam in 39 (63.93%) cases and hospital visiting for abdominal pain or bulge in 16 (26.23%) cases, for menstrual disorders in 4 (6.56%) cases and for postmenopausal bleeding in 2 (3.28%) cases.r = 0.64, p < 0.01).Among 58 of 61 patients who underwent CA125 test, 12 (20.69%) patients showed increase value with a mean of 166.67 U/ml ranged from 37.6 U/ml to 456.2U/ml . In the 12 cases showing an elevated level of CA125, 91.67% (11/12) had a diameter of the tumor greater than 5 cm. By Pearson’s Correlation analysis, there was a statistically significant correlation between the diameter of tumors and CA125 level . The gross appearances of OTFG neoplasms were described as round, oval, lobulated or well-circumscribed solid tumors. The section of the tumor appeared as grayish white or yellow with edema, cystic degeneration, or necrosis. Microscopically, the tumor cells were spindle or short spindle with feather-like or interwoven arrangements. Nucleus of the cell was round or oval, accompanied by calcification, collagen change, and hyalinization degeneration in the tumors. Final pathologic diagnosis had 42 thecofibromas (including 3 cellular thecofibromas), 16 fibromas (including 4 cellular fibromas), 5 thecomas (including 1cellular thecomas), 1 fibrothecoma and 1 fibrosarcoma. Pathological findings are presented in Figs. Intraoperative findings revealed 65 tumors in 61 patients, in which 95.08% (58/61) of the lesions occurred unilaterally. There were one patient with two lesions located in the same side and 3 patients within 6 lesions found bilaterally. In 61 cases, 4/65 (6.15%) tumors were not identified by ultrasound examination before the surgery. Ascites was found in 20 cases (32.79%) with the amount of fluid ranging from 50 ml to 800 ml while 1 case showed Megi’s syndrome, i.e., with massive abdominal and pleural effusion. In the 20 cases with ascites, 80% (16/20) of the tumors had a diameter of the tumor greater than 5 cm. Pearson’s analysis showed a statistically significant correlation between the diameter of tumors and the amount of ascites fluid  patients were followed up for an average of 10.6 months from 3 to 72 months. Postsurgical recurrence was not observed in any cases (including one patient with fibrosarcoma) by clinical and sonographic examination. In one patient with Megi’s syndrome, ascites and pleural effusion disappeared three months after operation. In addition, two patients had full term deliveries 1 year after tumor removal.OTFG neoplasms mostly occur in postmenopausal women, often with a good prognosis. In this study, 63.93% (39/61) of the lesions occurred after menopause, with 65.57% (40/61) in women aged 51 to 70. Most patients visited the hospital because of pelvic masses found in routing physical examination, while 63.93% (39/61) of these patients showed no obvious clinical symptoms . Among tp < 0.05) which consistent with previous report [The most tumors were unilateral, and few were bilateral . In our s report . Ascitess report . IrritatPathologically, OTFG neoplasms are tumors of sex-cord stromal origin and the most of them contain both theca cells and fibroblasts. Of all tumors identified in this study, 41/61 (67.21%) tumors were histologically proved to be thecofibroma. Comparison of ultrasound and pathologic findings of OTFG indicated that typical sonographic features of OTFG were adnexal hypoechoic masses with clear border and acoustic attenuation,which consistent with previous findings , 15. Then = 3), teratoma (n = 1), cystadenomas (n = 2), 1 case with hemorrhage (n = 1), ovary torsion (n = 3), calcification or degeneration changes (n = 7).Large tumors were often associated with torsion, hemorrhage, calcification, or complicated with other cystic lesions, which showed mixed echogenic masses. In 17 tumors (27.87%) with mixed echogenic appearance, there were 8 thecofibroma, 8 fibroma and 1thecoma in which all were associated with other complicated lesions including endometrioma  were thecofibroma and fibroma. The reason of the attenuation is most likely due to the low sound propagation of fibroblast tissue . In geneIn this study, ultrasound examination made correct diagnosis of OTFG in 44  tumors before surgery. Four tumors less than 2 cm in diameter failed to be detected by ultrasound, among which 3 cases had bilateral lesions and 1 case had 2 lesions on the same side. The detection rate of tumors was 93.85% (61/65). Failure to detect some tumors may be caused by small size of the tumors as well as leaving out presence of contralateral lesions.In early days with limited understanding of OTFG tumors, it was often confused with subserous myoma on ultrasound imaging . In the With technological development, high resolution ultrasonography and contrast-enhanced ultrasound imaging have become one of the important imaging modality for clinical diagnosis and differentiation of uterine and ovarian neoplasms . A literIn this study, one cellular thecofibroma was misdiagnosed as malignancy because it was irregular multilocular solid tumor with abundant blood flow, which was a sign of malignancy. Two other misdiagnosed thecofibroma revealed a complex ovarian cyst with homogeneous internal echoes, which contained a small solid-appearing area with undetectable flow in it. These two thecofibroma were misdiagnosed as endometriomas. These misdiagnosis based on ultrasound findings were consistent with previous studies , 22, 23.There are several limitations of the study. First, this is retrospective research that may lack control and desirable study design. Second, all patient’s data is reviewed and analyzed without blind fashion. Third, the study only focused on the OTFG neoplasms and did not include other ovarian tumors for comparison. Further study with prospective design and comparison with other ovarian tumors is needed to provide additional information for differential diagnoses of ovarian tumors.OTFG neoplasms often occur in postmenopausal women with no obvious clinical symptoms. Most of them are benign, with a good prognosis. The typical sonographic features of OTFG are adnexal hypoechoic masses with clear border and acoustic attenuation as well as minimal Doppler flow signals. They are often unilateral with a diameter smaller than 5 cm. Combined with clinical information and CA125, ultrasound imaging could be used as an imaging tool for improving the preoperative diagnostic accuracy.


Human Immunodeficiency Virus (HIV), syphilis, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are sexually transmitted infections (STIs) and share modes of transmission. These infections are generally more prevalent among female sex workers (FSWs).This is a cross-sectional study conducted among female sex workers (FSWs) in Rwanda in 2015. Venue-Day-Time (VDT) sampling method was used in recruiting participants. HIV, syphilis, HBV, and HCV testing were performed. Descriptive analyses and logistic regression models were computed.In total, 1978 FSWs were recruited. The majority (58.5%) was aged between 20 and 29 years old. Up to 63.9% of FSWs were single, 62.3% attained primary school, and 68.0% had no additional occupation beside sex work. Almost all FSWs (81.2%) had children. The majority of FSWs (68.4%) were venue-based, and most (53.5%) had spent less than five years in sex work. The overall prevalence of syphilis was 51.1%; it was 2.5% for HBV, 1.4% for HCV, 42.9% for HIV and 27.4% for syphilis/HIV co-infection. The prevalence of syphilis, HIV, and syphilis + HIV co-infection was increasing with age and decreasing with the level of education. A positive association with syphilis/HIV co-infection was found in: 25 years and older (aOR = 1.82 [95% CI:1.33–2.50]), having had a genital sore in the last 12 months (aOR = 1.34 [95% CI:1.05–1.71]), and having HBsAg-positive test (aOR = 2.09 [1.08–4.08]).The prevalence of HIV and syphilis infections and HIV/syphilis co-infection are very high among FSWs in Rwanda. A strong, specific prevention program for FSWs and to avert HIV infection and other STIs transmission to their clients is needed. Human Immunodeficiency Virus (HIV), syphilis, Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are sexually transmitted diseases (STIs) and have shared modes of transmission. Female sex workers (FSWs) are at high risk to contract STIs due to the work and their behavior , 2. The A meta-analysis study conducted in African countries found that the HIV prevalence among FSWs varied between 19% and 60% . DespiteWHO reported that 10 countries had greater than 10% syphilis prevalence among sex workers, while some countries reported a syphilis prevalence of more than 20% , and 3.3Few data about HCV and HBV among FSWs have been published. WHO estimated the worldwide number of people living with chronic HCV between 130 and 150 million  and 1.1%The prevalence of HBV in India was estimated at 7.6%  while itThe interaction between syphilis and HIV is not well documented . SyphiliCurrently, few data are published on HBV and HCV among FSWs in Rwanda. A study conducted in 2013 found that the prevalence of HBV was 1.6% among blood donors, while the prevalence of HCV was 2.9% among health workers . A meta-The aim of this study is to describe the burden of syphilis, HIV, HBV, HCV and HIV/syphilis co-infection and associated factors among FSWs in Rwanda.This study was a cross-sectional behavioral and biological survey among FSWs in Rwanda in 2015. Venue-Day-Time (VDT) sampling method was used to identify specific places and times where FSWs await their subsequent sexual clients . The timBefore the data collection process, a rapid assessment to estimate the number of expected FSWs was conducted. The number of FSWs at each site was estimated by key informants selected in the same target population. The survey was conducted in all hot spots with 5 or more FSWs per day. The number of participants recruited in each hot spot was determined using probability proportional to size of each selected site.Self-reported FSW aged 15 years or more found in a FSW hot spot area identified by a FSW key informant was eligible to participate. Excluded from the survey were: FSWs less than 15 years old, not self-identifying as a female sex worker, declining to consent to participate in the survey.A two-stage sampling method using VDT sampling, referring to the specific peak time and place that FSWs were present at their hot spot was used. The primary sampling unit was the time and place where FSWs were present at the hotspot, and the secondary sampling unit was FSWs in the selected time and place. A “take-all” approach sampling was used. Once the expected sample size at the site was obtained, data collection was closed at that site. For primary sampling unit (PSU) selection, 180 hotspots were selected from the sampling frame in the country.The sample size calculation used the Z score value of 1.96 with an alpha level of 0.05 (95% confidence), the design effect of 3.2, a relative 10% precision around a point estimate  of 51% among female sex workers in 2010. A minimum sample size of 1980 FSWs was calculated.FSWs were contacted by data collectors to take part in the survey. If eligible, a verbal informed consent was administered with no identifying information. After verbal consent was received, pre-test counselling was conducted by a nurse counsellor. The laboratory technician drew blood by venipuncture. A Personal Digital Assistant (PDA) questionnaire was administered by survey staff. Rapid diagnostic test results were returned to the participant and post-test counselling was conducted in few minutes. Participants whose test was positive for HIV, syphilis, HBV or HCV were referred to the health centre of the patient’s choice for clinical care. Blood samples were transported to the National Reference Laboratory (NRL) for confirmatory HIV testing for survey purposes.HIV rapid testing was performed by a trained laboratory technician using the nationally approved algorithm of three serial rapid tests . For the survey purpose, ELISA-based testing was used  for all samples. For samples testing positive with ELISA, a confirmatory test used a second EIA called Murex HIV Ag/Ab Combination 4th Generation Murex®.Screening for syphilis was conducted on site using the SD BIOLINE SYPHILIS 3.0 rapid test to detect syphilis anti-bodies. A reacting sample was retested using the RPR test at NRL. A sample that was positive for both tests was recorded as positive; a non-reacting sample to the second test was recorded as negative.Screening for HBV was performed using the SD BIOLINE HBV rapid test to detect HBV surface antigen (HBsAg). A reacting sample was recorded as positive.Screening for HCV was performed using the SD BIOLINE HCV rapid test. The test detected HCV antibody (anti-HCV). A reacting sample was recorded as positive.All FSWs with positive tests for any test were transferred to the nearest health facility or the health facility of their choice in order to provide quick results for clinical care.STATA 13 software was used for data analysis. Mean, proportion, and 95% confidence interval were computed for descriptive analysis of variables. Prevalence in different socio-demographic characteristics was estimated for HIV, syphilis, HBV, HCV infections and for HIV and syphilis co-infection.p < 0.05 level in bivariate analysis were included in a multivariable logistic regression model. Multivariable analysis was computed to determine the effect of independent variables to HIV and syphilis co-infection. Variables were retained in the final model when achieving p < 0.05 significance.HIV and syphilis co-infection associated factors significant at the Table Table The prevalence of HBsAg-positive test among FSWs was 2.5% [95% CI:1.8–3.2]; the prevalence of HCAb-positive test among FSWs was 1.4% [95% CI:0.8–1.9].The overall prevalence of HIV was 42.9% [95% CI:39.5–43.8]. This prevalence was increasing with age up to 34 years old. It was 22.3% [95% CI:16.5–28.2] among FSWs 15–19 years age group while it was more than two times higher among FSWs with 30–34 years old. The HIV prevalence was higher among divorced or separated (47.3% [95% CI:43.2–51.3]) and widowed (59.4% [95% CI:49.7–69.1]) compared to single (37.5% [95% CI:34.9–40.2]) FSWs. By province, the highest prevalence of HIV was in the city of Kigali (54.3% [95% CI:48.5–60.0]), the lowest was found in the Eastern province (36.3% [95% CI:32.6–40.0]). The prevalence of HIV was significantly decreasing with the level of education. It was 52.6% [95% CI:34.5–44.9], 42.1% [95% CI:39.3–44.9] and 30.3% [95% CI:25.7–34.9] respectively in none, primary and secondary/higher education levels. The prevalence of HIV was significantly increasing with the duration of sex work. It was 33.7% [95% CI:30.8–36.6], 47.8% [95% CI:44.1–51.4] and 61.0% [95% CI:53.3–68.7] respectively among FSW with 0–5 years, 6–15 and more than 16 years of duration of sex work  compared to the Eastern and the Northern provinces with respectively (21.6% [95% CI:18.4–24.8]) and 21.7% [95% CI:17.6–25.8]. By level of education the prevalence of syphilis and HIV co-infection decreased with the level of education. It was 37.5% [95% CI:34.5–44.9], 27.7% [95% CI:25.1–30.2] and 15.7% [95% CI:12.0–19.4] respectively in none, primary and secondary/higher education levels. The prevalence of syphilis and HIV co-infection increased with the duration of sex work. It was 21.7% [95% CI:19.2–24.3] and 32.6% [95% CI:29.2–36.1] respectively among FSWs with 0–5 years and 6–15 years duration of sex work  compared to those less than 25 years old, having had a genital sore in the last 12 months (aOR = 1.34 [95% CI:1.05–1.71]) compared to FSWs without STI symptoms, and having HBsAg-positive test (aOR = 2.09 [1.08–4.08]) compared to FSWs with HBsAg-negative test (Table 3–2.50) cFSWs are among key drivers of HIV and other STIs in many countries. The current study was conducted among self-identified FSWs at different hot spots in the country to characterize the scope of this public health problem in Rwanda.Two important findings resulted from this survey. Syphilis and HIV prevalence among FSWs in Rwanda was very high and increased with age and the duration of sex work. FSWs with any positive test were transferred to the nearest health facility or the health facility of choice for appropriate clinical care.Overall HBV and HCV prevalence among FSWs in Rwanda was low (<5% each). Older FSWs, secondary or higher education, STIs symptoms, and HBV infection are independent predictors of HIV and syphilis co-infection.Compared to the prevalence of the general population 3.0%) , the HIV.0% , theThe overall prevalence of syphilis of our study was (51.1%) while it was 1.0% in the general population of Rwanda . AlthougHIV and syphilis have similar modes of transmission. The burden of HIV and syphilis among FSWs is considerable in Rwanda; it could contribute to high morbidity and mortality rates in this key population. The prevalence of syphilis and HIV co-infection was high (27.4%). In terms of proportion of co-infection, in Nepal, the proportion of syphilis infection among HIV-positive FSWs was 31.0% , it was Older age was identified as an associated factor of high HIV and syphilis co-infection; the same factor was identified in prevalence of syphilis in a Chinese study .Secondary or higher education was negatively associated with higher prevalence of HIV and syphilis co-infection (aOR = 0.50). The assumption behind this finding may be the fact that FSWs with secondary and higher education could have additional occupation to the sex work, thus reduce the risk of exposure. In addition, they may have possibility to access prevention programmes, and could have power for condom use negotiation. They could also access to STIs treatment compared to illiterate FSWs. In China, researchers also found that years of education was a protective factor of STIs .A recent history of genital sores was identified as an independent variable positively associated with high HIV and syphilis co-infection (aOR = 1.34 [95% CI: 1.05–1.71]). Ulcerative STIs facilitate HIV and other blood borne diseases transmission and acquisition. The same observation regarding HIV infection risk factors was found in India .The prevalence of HBV among FSWs in our study was lower (2.4%). There is no previous estimated prevalence of HBV in the general population or in any other key population including FSWs in Rwanda. HBV prevalence was 8.8% in Brazil  whereas The prevalence of HCV was 1.1% in our study. HCV is not a high burden among FSWs in Rwanda compared to HIV (42.9%) and syphilis (51.1%). Few data on this area are available. However, a study on HCV and HBV conducted among health workers in a tertiary hospital reveled that the prevalence of HBsAg-positive and anti-HCV-positive was respectively 2.9% and 1.3% . AnotherSeveral limitations were encountered in our study. First home-based FSWs and those operating inside hotels were underrepresented in the study because the recruitment was focused on streets and around venues where FSW are found such as hotels, cabarets and night clubs. Second, venues with FSWs less than five per day were excluded by the sampling methodology. Third, specific sexual practices and behaviors and other risk factors associated with STIs among sex workers were not explored in depth. Fourth, the syphilis prevalence reported in this study was first performed using SD Bioline rapid test; confirmed with RPR test. Due to budget constraints a confirmatory test using TPHA test was not performed.Based on our findings, we conclude that HIV and syphilis prevalence are very high among FSWs in Rwanda. A strong specific prevention program to avert HIV infection and other STIs transmission to their clients; and proper treatment should be reinforced. Current programs sponsored by the Ministry of Health can help to fight against stigma and discrimination against sex workers – specifically, promoting outreach approach to test and treat all HIV FSWs; testing and treating other STIs among FSWs using rapid tests in their community and improve prevention program for HIV and other STIs reduction. Strengthening HIV and STIs prevention program including condom distribution in the community, training peer educators to be involved in program implementation and linking FSW’s community to care providers in confidential way. Organizing a regular campaign for HIV and STIs testing and treatment in the community. Supporting income generating activities and regular mentorship in order to improve the poor socio-economic status of most of FSWs.


Background: Combination chemotherapy is accepted as a high efficacy treatment for gastric cancer, whereas choice of standard treatment is unclear. Multiple chemotherapeutic regimens have been used to achieve higher efficacy and lower toxicity. This study was designed to evaluate the treatment results of advanced gastric cancer with Capecitabine and Oxaliplatin regimen.Subjects and Methods: All cases with documented gastric adenocarcinoma and advanced disease were candidates for receiving Xelox regimen .Results: Twenty five cases with advanced gastric cancer entered in study while 24 cases continued treatment protocol and were evaluated. Mean age was 59.5 ± 12.1 years (range: 20-75), male and female cases were 66.7% and 33.3%, respectively. All cases received at least four cycles of Xelox regimen. Overall response rate was 74.99% with 29.16% complete response. Overall survival rate was 13 ± 0.53 months and DFS  was 6 ± 1.09 months. Extremities neuropathy (62.5%), headache (45.8%) and muscle cramps (29.2%) were the most common complains. Haematological changes were rare and 16.7% of cases had mild cytopenia. Treatment related death was not observed.Conclusion: Xelox regimen is a safe and highly effective first line treatment for gastric cancer; however, considering it as first line therapy needs larger studies. This leads to poor prognosis and switching treatment protocol to palliative chemotherapy. Hence, researches are in progress for more effective treatments.5-8 There is no standard treatment for advanced gastric cancer and classic regimen with cisplatin, fluorouracil and epirubicine lead to response rate of 20-40%.9 This classic regimen had large toxicity and was poorly tolerated.10,11 Capecitabine  had potential effects of 5-FU with better tolerance rate and oral consumption.12,13 This drug is active in advanced gastric cancer with response rate of 28% in literatures.14 In combination with other drugs as first line therapy such as cisplatin, oxaliplatin, epirubicin and docetaxel, it had a response rate of 40-68%.15-17 Oxaliplatin is an alkylating agent with better effect on inhibition of DNA synthesis than cisplatin.18 Toxicity of oxaliplatin is less than cisplatin.19 In literature review, it has been reported that combination of capecitabine and oxaliplatin (Xelox) is more effective in treatment of advanced gastric cancer.20-22 The aim of this study was to evaluate treatment results of advanced gastric cancer with capecitabine and oxaliplatin. Gastric cancer is one of the five most common types of cancers in the world and second most common cause of cancer-related death in the world.Patient selectionPatients with documented unresectable gastric adenocarcinoma  or metastatic disease were registered and entered the study. This study was approved by ethical committee of Zahedan University of Medical Sciences and consent forms were filled by all participants in the study . Inclusion criteria were: age>18 years, performance status>70 according to karnofsky score, life expectancy>4 months, Hb>9 gr/dl, normal liver and kidney and heart function tests. Exclusion criteria were: non cooperative patients, performance status<70, abnormal vital organ function tests, brain metastasis, bone marrow involvement, previous treatment.Treatment protocol2 in day 1 and capecitabine 750 mg/m2 BID for 2 weeks and 1 week rest and then other course of treatment protocol was repeated. If the patients could not receive at least 3 cycles of Xelox regimen, or showed disease progression in the first 3 cycles of treatment protocol, or were non cooperative for continuing oral drug administration or severe experienced treatment-related toxicities due to oxaliplatine, the treatment protocol would changed. Patients' evaluations prior to start of treatment were: careful physical examination, performance status estimation, Complete Blood Count (CBC), biochemistry, chest X-Ray. During treatment, all parameters were checked prior to beginning of next courses of treatment. Spiral abdominal CT scan was done at baseline and after every three courses of Xelox regimen to evaluate tumor response. Tumor response was evaluated according to RECIST guidelines. Treatment-related toxicities were reported according to National Cancer Institute Common Toxicity Criteria (NCI-CTC) version 2.0 toxicity scale.All eligible cases received at least 3 cycles (3-8 cycles) of Xelox regimen; oxaliplatin 125 mg/m Over three years (2011-2013), 24 cases continued treatment protocol and were evaluated out of 25 eligible cases. Male and female cases were 66.7% and 33.3% of all, respectively. Mean age was 59.5 ± 12.1 years (ranged between 20 and 75). All cases received at least four courses of Xelox regimen. Patients' characteristics are summarized in Response rates in male and female are summarized in We observed partial response in 11 cases (45.83%), progressive disease in three cases (12.5%) and no response with stable disease in three cases (12.5%). Overall survival rate was 13 ± 0.53 months  and dise23 75 cases with advanced gastric cancer, who were treated with Xelox regimen had overall response rate of 62.2%; while 4.1% had complete response, 58% partial response and stable disease and progressive disease were 21.6% and 13.5%, respectively. The response rate in Yang and et al. study was lower than our study and complete response differed significantly with our study (4.1% vs. 29%). Median time for progression and median overall survival rate were 5.9 months and 10.8 months. Delay in treatment protocol and dose reduction occurred in 28.3% and 14.6%, which was completely different from our study. Anaemia related to treatment protocol was 62% and neuropathy was 59.5%, which was completely different to our study.23 In the study of Dong et al. in 2009, 41 cases with gastric cancer were evaluated.24 In this study, 51.2% had response and two cases had complete response. This response rate and complete response were different from our study. Median follow-up time was 9.5 months, median time for progression was 5.6 months and overall survival rate was 9.8 months.24 In another study in 2014,25 48 cases with median age of 63.5 years were evaluated. In this study complete response, partial response, stable disease and progressive disease were 4.2%, 44.68%, 36.17%, 14.89 %, respectively.25 Response rate was 49.0%. Median time to progression was 10 months and overall survival rate was 29.8 months. The cause of these differences with our study might be related to use of surgery for many cases in the study of Wang.25 In another study in 2009 with Mashhadi et al. on advanced gastric cancer, the overall response rate was 60%. They reported 10% complete response and 50% partial response and 10% stable disease. Median survival was 13 months and median event-free survival was 8 months.26 In this small study, response rate was acceptable but high grade toxicity was the major problem. In this single-center study, majority of cases with advanced gastric cancer had a response to Xelox regimen as first line therapy. Xelox regimen had high efficiency with minor toxicities. Overall response rate was 74.99% and nearly 30% of cases had complete response. Our results showed favourable and comparable outcome in comparison to previous study. In the study of Tingsong Yang et al. in 2011,  Our results showed efficacy and tolerability of Xelox regimen for advanced gastric cancer. High percentage of clinical improvement in patients with advanced gastric cancer, out-patient treatment and low incidence of life threatening toxicities revealed that this regiment might be a rational modality for the treatment of gastric cancer. Further larger studies are needed to confirm these data.


Hepatitis B (HBV) and C (HCV) are important causes of morbidity and mortality in people living with human immunodeficiency virus (HIV). The burden of these co-infections in sub-Saharan Africa is still unclear. We estimated the prevalence of the hepatitis B surface antigen (HBsAg) and hepatitis C antibody (HCVAb) among HIV-infected individuals in Rwanda and identified factors associated with infection.Between January 2016 and June 2016, we performed systematic screening for HBsAg and HCVAb among HIV-positive individuals enrolled at public and private HIV facilities across Rwanda. Results were analyzed to determine marker prevalence and variability by demographic factors.Overall, among 117,258 individuals tested, the prevalence of HBsAg and HCVAb was 4.3%  and 4.6% (95% CI 4.5–4.7) respectively; 182 (0.2%) HIV+ individuals were co-infected with HBsAg and HCVAb. Prevalence was higher in males  and increased with age; HCVAb prevalence was significantly higher in people aged ≥65 years (17.8% [16.4–19.2]). Prevalence varied geographically.HBV and HCV co-infections are common among HIV-infected individuals in Rwanda. It is important that viral hepatitis prevention and treatment activities are scaled-up to control further transmission and reduce the burden in this population. Particular efforts should be made to conduct targeted screening of males and the older population. Further assessment is required to determine rates of HBV and HCV chronicity among HIV-infected individuals and identify effective strategies to link individuals to care and treatment. Viral hepatitis has emerged as an important public health issue globally, characterised by high prevalence, a high burden of morbidity and mortality, and suboptimal diagnosis and management approaches , 2.Viral hepatitis disproportionately affects persons living with human immunodeficiency virus (HIV) , 4. WhilSub-Saharan Africa (SSA) has the highest burden of infectious diseases and remains the epicentre of the global HIV epidemic , 10. DesData from Rwanda is limited. Among 402 HIV-infected, ART naïve individuals recruited from a major Kigali-based urban healthcare facility, a 5.2% hepatitis B surface antigen (HBsAg) and a 5.7% hepatitis C antibody (HCVAb) prevalence were reported . The HBsAdvances in prevention and treatment have facilitated the development of public health programmes to control viral hepatitis in resource limited settings , 16. RwaThe present study set out to characterise the prevalence and characteristics of HBsAg and HCVAb in HIV-positive individuals in Rwanda using data collected through this screening programme. Our data provide a picture of HBV and HCV co-infection with HIV in a setting where resources for screening, diagnosis, and treatment are limited. Findings will be fundamental for informing future policy and decision-making in Rwanda.The primary objective of this study was to quantify the prevalence of HBsAg and HCVAb in HIV-positive individuals enrolled into care using data collected during a national screening activity. Secondary objectives were to analyse data by subgroups.Data were obtained from the nationally representative electronic database compiled throughout the screening activity conducted between January and June 2016. The programme targeted all individuals with HIV nationwide, enrolling individuals at all public and private health facilities providing HIV services across Rwanda (approximately 500 facilities). Screening was offered free-of-charge to all HIV-positive individuals enrolled in care at a routine appointment, regardless of ART status. HIV-positive individuals are followed up monthly at health facilities and as such, all eligible individuals had the opportunity to undergo screening during the implementation period. All HIV-positive individuals screened were included in the database which captures demographic data, HIV infection and disease characteristics, and HBV and HCV clinical test results.In brief, testing procedures were as follows: individuals were invited for screening during a routine HIV appointment, specimens were collected at the site of enrolment, and samples transported to a testing facility. Testing was performed at 13 sites across Rwanda using Murex enzyme-linked immunosorbent assays (ELISA) for HBsAg (version 3.0) and HCVAb . All testing was supervised by a team of laboratory technicians from the National Reference Laboratory.The database was de-identified for the present study and no persons involved in the analysis of data were able to access the linked database. For comparison, aggregate population data for HIV-infected individuals were obtained from the Rwanda national HIV health record system (TRACnet) and were correct as of June 2016.Sample weighting was applied in all analyses to ensure results were nationally representative of people with HIV enrolled into care in Rwanda. The post-stratification weights were calculated using known age, gender, and ART distributions. All continuous variables were categorised for analysis based on appropriate thresholds.Descriptive statistics were performed for all variables. National prevalence estimates for HBV (HBsAg) and HCV (HCVAb) were calculated and presented with the corresponding 95% confidence intervals (95% CIs). HBsAg and HCVAb prevalence by demographic and HIV characteristics were determined; bivariate associations were tested using Pearson’s chi-square tests. All analyses were performed using Stata software .The routinely collected programme data analysed for this study are maintained by the Rwanda Biomedical Centre (RBC), Division of HIV/AIDS, STIs and Other Blood Borne Infections; the ethical procedures for the collection of these data are governed by the Medical Research Council of Rwanda. Secondary analyses of routinely collected data are exempt by the Rwanda Ethics Committee for routine program implementation activities conducted by the RBC, as was the case in this analysis.A total of 117,258 HIV-positive individuals were screened between January and June 2016 and were included in the present analysis. This corresponds to a coverage level of 64.9% of the total HIV population enrolled to care at facilities across Rwanda. The characteristics of the screened population did not differ significantly from the overall HIV-positive population enrolled to care.Table The overall HBsAg and HCVAb prevalence in the HIV-infected population and the prevalence by socio-demographic and HIV characteristics are shown in Table In total, HBsAg result were available for 114,040/117,258 (97.3%) individuals included in the database. Overall, 4876/114,040 individuals were HBsAg positive. The unadjusted and adjusted prevalence of HBsAg were equal at 4.3% (95% CI 4.2–4.4%). Prevalence was significantly higher in males compared with females (5.4% [95% CI 5.1–5.6%] vs. 3.7% [95% CI 3.5–3.8%]). Prevalence varied by age group and was lowest in individuals less than 15 years of age (2.1% [95% CI 1.7–2.6%]). HBsAg prevalence was slightly higher at hospital enrolment compared with enrolment at primary care level . By geographical region, prevalence was highest in the Eastern province (5.5% [95% CI 5.2–5.8%]) and in the City of Kigali (5.0% [95% CI 4.7–5.3%]); prevalence was significantly higher in urban areas compared with rural areas (4.9% [95% CI 4.7–5.2%] vs. 4.0% [95% CI 3.9–4.2%]). Prevalence by district is shown in  individuals included on the database. For HCVAb, 5470/116,868 individuals were found to be positive. The unadjusted prevalence was 4.7% (95% CI 4.5–4.8%) and the adjusted prevalence was 4.6% (95% CI 4.5–4.7%). Like HBsAg, prevalence was higher in males than females (5.0% [95% CI 4.8–5.2%] vs. 4.4% [4.3–4.6%]). Prevalence increased with age, and was significantly higher in individuals aged 55–64 (8.8% [95% CI 8.3–9.3%]) and those aged 65 or over (17.8% [95% CI 16.4–19.2%]). Prevalence was slightly higher at hospitals compared with primary care facilities (5.0% [95% CI 4.7–5.3%] vs. 4.5% [95% CI 4.4–4.7%]). HCVAb prevalence was highest in the Southern (5.9% [95% CI 5.6–6.2%]) and Eastern (5.2% [95% CI 4.9–5.5%]) provinces of Rwanda. In contrast to HBsAg prevalence, HCVAb prevalence was higher in rural areas (4.7% [95% CI 4.5–4.8%]) than urban areas (4.3% [95% CI 4.0–4.6]); however, this difference was not significant. Prevalence of HCVAb by district is shown in Fig. Of 117,258 individuals included in the database, 113,681 (96.9%) had results for both HBsAg and HCVAb. A total of 182/113,681 individuals were coinfected with HBsAg and HCVAb, corresponding to an adjusted co-infection prevalence of 0.2% (95% CI 0.1–0.2%).Advances in treatment and the benefits of early detection have validated the scale-up of viral hepatitis screening efforts in resource-limited settings , 18. AccOur study estimates the prevalence of HBsAg among HIV-infected individuals to be 4.3%. This is consistent with other studies conducted in Rwanda and should be considered a robust estimate given the large sample size , 14. DueThe epidemiology of HBsAg is characterised by a higher prevalence in males, whereby males have an almost 50% greater risk of becoming HBV infected. This finding is in concordance with other studies conducted in SSA . HIV/HBVOf note, the HBsAg prevalence is lowest in children below 15 years, motivated by the roll-out of HBV vaccination activities since 2002. Despite this decrease, our findings indicate that strengthening of vaccination activities is required. At present, the HBV birth-dose vaccination, administered within 24 h of birth is not implemented and should be considered as a strategy to reduce perinatal transmission . FurtherWe found an HCVAb seroprevalence of 4.6% among HIV-infected individuals, marginally lower than that observed in previous studies (4.9–5.6%) , 14. ConHCVAb prevalence varies geographically from 2.7% to 8.4% across Rwanda’s 30 districts and key districts in which mass screening activities should be implemented have been identified. Efforts should also be made to scale up screening in border districts where HCVAb prevalence in the HIV population has been observed to be higher than average.The main limitation of the present study is the absence of confirmation of chronic HCV infection with HCV RNA testing. Several studies have suggested that HCV serology is prone to false-positive results, especially in HIV-infected patients in SSA where the proportion of individuals confirmed by detection of HCV RNA after a positive HCVAb test is lower than other parts of the world , 30, 31.This study was further limited by its retrospective nature. Ideally, this would have been an opportunity to collate risk factors for viral hepatitis infection in Rwanda. The authors decided against a risk factor regression analysis as many key risk factors for infection were not collected and the model would have been of limited application.This study adds to the understanding of viral hepatitis among HIV-infected individuals in Rwanda. The expanded viral hepatitis testing activity has achieved early diagnosis of individuals that will facilitate linkage to further testing and care, reducing hepatitis-related morbidity and curbing onward disease transmission. The findings presented should be used to inform policy and targeted screening activities, and should be extrapolated beyond the HIV positive population. Additional studies should be performed in HIV positive and HIV negative individuals to fill the remaining gaps in the epidemiological profile of these diseases and to determine risk factors for infection. In particular, molecular characterisation and detection of other markers should be conducted to determine the exact prevalence of viral hepatitis in this population.


China consumes about 40% of the world's cigarettes, predominantly by men, following a large increase in recent decades. We assess sex-specific prevalence and changing patterns of smoking in Chinese adults in the current decade.A nationally representative survey of smoking was conducted in 2010 among 100 000 Chinese adults aged ≥18 years, using a multistage stratified cluster sampling method. Information on smoking frequency, type, amount, age started and quitting was collected. Sex-specific standardised prevalence and means were analysed and compared with estimates in the 1996 national survey.In Chinese men aged ≥18, 62.4% were ever-smokers in 2010, including 54.0% current smokers and 8.4% ex-smokers. The smoking prevalence was higher in rural than in urban men (63.9% vs 58.4%). In younger men, the age to start smoking was earlier and exclusive cigarette use was much higher. Among current smokers, only 17.3% intended to quit. Compared with a similar survey in 1996 among adults aged 30–69, more smokers had quit in 2010 than in 1996 (11.0% vs 4.2%), but the number of cigarettes smoked per current smoker was higher (17.9 vs 15.2). In Chinese women, only 3.4% ever smoked and there has been a large intergenerational decrease in smoking uptake rates. In 2010, there were 318 million current smokers in China, consuming an estimated 1740 billion cigarettes.The prevalence of smoking remained extremely high in men, but low and falling in Chinese women. Tobacco smoking remains an important public health issue in China, and stronger and more efficient tobacco control is urgently needed. Smoking is one of the most important avoidable causes of premature deaths and disability globally, causing an estimated six million deaths worldwide in 2010, including one million in China.6Long-term monitoring of tobacco use in the general population can inform development and evaluation of disease control policies, as advocated by the WHO MPOWER measures,12We present the relevant data from the 2010 CCDRFS that covered a large nationally representative sample of ∼100 000 adults aged ≥18 years with detailed information on smoking.The details about CCDRFS rational, design, methods and sampling schemes have been described previously.1310.1136/jech-2016-207805.supp1Supplementary dataAt each DSP, a multistage proportionate to population size sampling scheme was used to select four rural townships or urban neighbourhoods. In each selected township or neighbourhood, 3 administrative villages/communities were further selected randomly and within each of them, 1 residential group with 50 households was selected by simple random sampling. For each selected household, one individual who was ≥18 years of age and had lived locally for at least 6 months was selected by Kish grid.13In each household, trained health workers measured height, weight, waist circumference and blood pressure; took blood for subsequent measurements of fast and oral glucose tolerance test blood glucose, lipid, insulin and glycated hemoglobin in a central laboratory; and completed a standard questionnaire in response to answers from participants on demographics, smoking, alcohol drinking, physical activity, diet and self-reported medical history.National and local ethics approvals were obtained prior to start of the project. All participants provided written informed consent.Questions about smoking included frequency, type, amount, age started, intention or attempt to quit (for current smokers), with additional information on knowledge towards smoking cessation and tobacco promotion . Appropriate weighting strategies based on a complex sampling design was applied to the prevalence or mean estimates.Among men, 62.4% (60.3% to 64.4%) of adults aged ≥18 years ever smoked, including 54.0% (52.2% to 55.9%) current smokers and 8.4% (7.8% to 9.0%) ex-smokers. The prevalence of current smoking was higher at age 40–59 than other age groups, higher in rural residents and in those with lower education, but varied little by household income . Large rIn urban and rural men, the smoking prevalence was higher in those born before the 1950s than in those born after the 1950s and the urban–rural difference was seen in each birth cohort, with the difference becoming smaller in those born after the 1950s . These pAmong male smokers, the overall mean age to start smoking daily was 20.3 (20.1 to 20.6) years, falling steadily in urban and rural men with later year of birth (23.8 in those born in 1930–1939 vs 21.5 in 1950–1959 vs 19.8 in 1970–1979). Nearly all male current smokers used manufactured cigarettes only , higher in urban  than in rural areas . However, among those born after the 1970s, nearly all smokers in urban and rural areas smoked manufactured cigarettes only (96.1% in 1970–1979 vs 86.8% in 1950–1959 vs 69.0% in 1930–1939). The number of cigarette smoked averaged 15.3 (14.8 to 15.7) cigs/day, higher in rural than urban men (15.6 (15.0 to 16.2) vs 14.2 (13.7 to 14.7)). For any tobacco combined, the mean total consumption per smoker was 16.5 (16.1 to 16.9) g/day (14.7 (14.2 to 15.1) for urban men and 17.1 (16.6 to 17.6) for rural men; Among women, only 3.4% (2.7% to 4.0%) ever smoked (2.6% (2.0% to 3.2%) current smokers, 0.8% (0.6% to 1.0%) ex-smokers). The smoking prevalence was higher in those with poor education, in urban residents and in those with a lower household income, which is different from men, possibly because income is not positively correlated with education for men and family income mainly comes from men in China. It also increased with increasing age, being 2.1% (1.5% to 2.7%), 2.6% (1.8% to 3.3%), 4.4% (3.2% to 5.5%) and 6.5% (4.6% to 8.3%) at ages 30–39, 40–49, 50–59 and 60–69, reflecting mainly the significant decrease in uptake rates of smoking across successive generations of women . The preAmong female smokers, the mean age first began smoking daily was 26.9 (25.4 to 28.3) years, again falling with the increasing year of birth from 31.3 (28.4 to 34.1) years for those born 1930–1939 to 22.7 (21.6 to 23.9) in those born 1970–1979. Similar patterns and temporal trends for smoking type and amount to those seen in men were also observed  2.Among current male smokers, the proportion who intended and attempted to quit smoking were 17.3% (15.9% to 18.7%) and 15.6% (14.3% to 16.9%), respectively. The proportions were higher in the younger generation, in those living in urban areas and better educated. The proportion of successful quitters was 10.9% (10.1% to 11.7%), higher in those of old age, lower education, lower household income or living in urban areas .Among male ex-smokers, the mean years of quitting smoking were 7.5 (7.0 to 7.9), higher in urban  than in rural men . Among female ex-smokers, the mean quitting duration was 8.2 (7.1 to 9.3) years, with little difference between urban and rural areas  3.A small proportion of male current (0.9%) and ex-smokers (3.5%) reported having tried nicotine replacement therapy (NRT) or other Western drugs to quit smoking. About half of the current male smokers reported having received general advice about smoking cessation while seeking medical care in hospital  3.Over one-quarter of men reported having noticed tobacco promotion advertisement/logo on 1 or more of 10 types of media in the past 30 days, with the proportion higher in younger men, in those living in urban areas or better educated. In contrast, approximately one-third of men, higher in the elderly, in rural areas or those with lower education, reported not having noticed any health warning message about smoking hazards or message related to smoking cessation across all of nine types of media  4.By applying the smoking prevalence and tobacco consumption from this nationally representative survey to the 2010 China census population, it was estimated that in 2010, 318 million adults (304 million men and 14 million women) were current smokers, consuming a total 1740 billion manufactured cigarettes.Compared with the National Smoking Prevalence Survey (NSPS) in 1996 of 86 770 adults aged 30–69,This large nationally representative survey provided new evidence about the prevalence of smoking in China in the current decade. It showed that about two-thirds of Chinese adult men were ever regular smokers and most of the current smokers, especially those born after 1970, smoked exclusively manufactured cigarettes, consuming on average almost one pack a day. Encouragingly, a higher proportion of male smokers had stopped compared with a decade ago and far fewer Chinese women than men smoked, and there was a large intergenerational decrease in the female prevalence of smoking from about 10% among women born in the 1930s down to only about 2% among women born around the 1970s. In 2010, there were almost 320 million current smokers in China, predominantly men, consuming about 1740 billion cigarettes annually.Compared with a similar survey in 1996, although the smoking rate had slightly decreased, the number of male current smokers in 2010 had increased mainly due to the population growth. According to China's official cigarette sale figures,5The recent report from the Global Adult Tobacco Survey (GATS) in 2010 among 14 low-income and middle-income countries showed that China had the highest male smoking prevalence only after Russia. The GATS included 13 354 participants  aged 15 and above in China and found that 53% of Chinese men were current smokers,20Our survey showed that Chinese men who were born in the 1970s had a high smoking prevalence and smoked almost exclusively manufactured cigarettes from early adulthood. If the current situation continues, they will probably be the first generation in China to experience the full hazards from tobacco use unless they stop.Previous studies in China showed that many smokers in China quit smoking mainly due to poor health.China officially ratified the FCTC in 2006 and ever since progress has been made in tobacco control.A potential limitation of this study is that all of the smoking-related data were collected by self-report without biochemical validation, which might probably cause information bias, but replication of this design is comparable.Although the overall smoking prevalence rate is declining, the Chinese male smoking rate is one of the highest worldwide, with a continuously increasing amount of tobacco consumption and lowering age at started smoking. Tobacco smoking remains an important public health issue in China, and stronger and more efficient tobacco control is urgently needed in China, with a priority on those belonging to the younger generation, in rural areas and less educated. Monitoring and evaluation based on large prospective studies and the current nationally representative survey will provide essential and accurate information about the smoking epidemic and tobacco control profile in China.More than 300 million smokers, predominantly men, make China the largest tobacco consumer in the world, following a huge attributed burden of disease.The very high prevalence of smoking in Chinese men, but very low in women, has been reported in a variety of related surveys since 1996, mostly on either a relatively small sample size or limited smoking information.The rate of smoking cessation remains very low and most current smokers do not intend to quit in China.This study, as the third milestone, comprehensively provides the sex-specific patterns of smoking by subgroup based on a large nationally representative sample after 1984 and 1996.Despite the smoking prevalence slightly decreasing in Chinese men and women, the amount of cigarette consumption increased and the age to start to smoke became younger compared with that in 1996.The men born after 1970, smoking exclusively manufactured cigarettes, will be the first generation to experience the full hazards of cigarette smoking in China.There was a large intergenerational decrease with younger age in the female prevalence of smoking.


Tuberculosis and HIV co-epidemics are problems in many parts of the world. Xinjiang is a high tuberculosis and HIV prevalence area in China. We aimed to investigate the prevalence and cure rate of tuberculosis among HIV positive patients in Xinjiang.In a retrospective study between 2006 and 2011, clinical and laboratory data on 333 patients with HIV and tuberculosis were compared to 2668 patients with HIV only. There were 31 HIV positive patients with no data on tuberculosis.p < 0.0001).The prevalence of tuberculosis co-infection among the HIV positive patients was 11% (95% CI 10–12%), significantly higher than the national figure in China of 2%. In most cases HIV was diagnosed late, with advanced immunodeficiency. The use of isoniazid preventive therapy was only 57.9% in patients without tuberculosis who fulfilled the criteria for receiving this prevention. The cure rate one year after diagnosis was 69.2%, which was lower than the officially reported 91.4% in all tuberculosis cases in Xinjiang in 2011. The hazard of not surviving over the five years was significantly higher in patients with HIV + tuberculosis compared to HIV only after adjusting for sex and Intravenous drug use with HR = 1.84 (95% CI 1.43-2.35; The prevalence of tuberculosis among HIV positive patients in Xinjiang was higher than in China taken as a whole, and HIV was diagnosed late, with underuse of isoniazid preventive therapy. The low cure rate and reduced survival can be due to late diagnosis of HIV and no testing for antibiotic resistance, together with insufficient control of adherence to the treatment regimens for tuberculosis and HIV. Mycobacterium tuberculosis (TB) and human immune deficiency virus (HIV) infections are major public health problems in many parts of the world, particularly in low and middle-income countries [ountries , 2. In 2ountries . China hountries . WHO estountries .Several studies have indicated that TB co-infection increases the risk of HIV progression and death, particularly in persons with untreated HIV .HIV infection is associated with immunosuppression, which in turn increases the risk of latent TB infection developing into active TB , 7.After contact with tuberculosis bacteria, patients with HIV have 20 times the normal incidence of TB . This ri+ T-lymphocyte counts (<100 cells/mm3), more often present with atypical chest X-rays and negative acid-fast bacilla (AFB) sputum smears, compared to HIV-negative patients [HIV positive patients with TB and low CD4patients .Xinjiang Uygur Autonomous Region is a province in the Northwestern part of China, with 21,815,815 inhabitants in 2011. The incidence of TB in Xinjiang was 2003–2008 estimated at 463 cases per 100,000 persons per year . The infOne study from January 2007 to June 2010, including 11 counties in Xinjiang, reported that the HIV screening rate was 79.1% in the TB patients’ group, and the rate of positive HIV was 2.2% among those tested. TB was tested for in 85.3% of the HIV positive patients, of whom 10.8% were diagnosed with TB .At screening for HIV among patients with tuberculosis in the 15 counties in Xinjiang 2007, the prevalence was 1.2% [The availability of HIV testing in Xinjiang was not the same the whole time period and many times offered in projects directed towards high risk groups. In Xinjiang the HIV infection prevalence in the drug users was 21.4% from one study 2010 .The objectives of the study were to investigate the prevention, prevalence, and cure rate of tuberculosis among HIV-positive patients in Xinjiang, China.A cross-sectional retrospective study was carried out between November 2006 and December 2011, and identified 3032 HIV-positive patients at the HIV clinics of three city hospitals in Xinjiang, China. The patients were treated in Urumqi (729), Yili (1861) and Kuqa (442). The total populations in the three cities were respectively 3.11 million (2011), 515,000 (2011) and 475,000 (2010).Doctors and nurses specializing in infectious diseases at these hospitals were responsible for the collection of data. Register forms were used to collect data on demographic factors and clinical features.Mycobacterium tuberculosis from sputum, tissue, blood, liver, spleen, lymph nodes, biopsy or pleural effusion. 2. Persistent high fever (>38.5 °C) more than two weeks, or night sweats, or more than 10% weight loss (3–6 months),or weakness. 3. Positive tuberculin test (PPD), where the scleroma was moderate (10–19 mm) or intense (>20 mm), or with blister, local necrosis, lymphangitis). 4. Chest X-ray image showing changes typical of tuberculosis. Patients fulfilling the first criterion, or two of the others, were diagnosed with TB.The 2001 revised diagnostic criteria for the diagnosis and treatment of pulmonary tuberculosis were used : 1. PosiAll the patients, irrespective of whether they had signs and symptoms of chest infection, were screened for pulmonary TB by chest X-ray, and then by examination of sputum for AFB using standard techniques. Blood samples were collected periodically every 6 months and tests included a CD4 cell count. Routine blood tests included red blood cells, white blood cells, platelet count and hemoglobin. HIV viral loads were not routinely analyzed.Candida albicans infection.Patients with CD4+ T lymphocyte count <350 /μl, or CD4+ T lymphocyte count >350 /μl together with one of the following symptoms were eligible for anti-retroviral treatment: enlarged lymph nodes,persistent fever for several months, night sweats, more than 10% weight loss, diarrhea, generalized herpes infection, oral The first line antiretroviral treatment (ART), given was two nucleoside reverse transcriptase inhibitors (NRTIs) plus a non-nucleoside reverse transcriptase inhibitor (NNRTIs) as combination therapy. The available first line drug combinations were: zidovudine (AZT) + lamivudine (3TC) + nevirapine (NVP), AZT + 3TC+ efavirenz (EFV) or stavudine (D4T) + 3TC+ NVP. The second line treatments were tenofovir (TDF) + 3TC + lopinavir (LPV) or TDF + 3TC + EFV. The drugs were supplied by the state free of charge.In China, the National TB Control Program (NTP) is implemented directly through a network of TB centers and TB hospitals, and is also used at HIV clinics . TubercuHIV positive patients with CD4 < 100/μl were recommended IPT. In addition, patients with CD4 < 250/μl together with weight loss, lymph node enlargement or PPD where the scleroma was 5–10 mm, were recommended IPT.In this study, no patient underwent the TB resistance test, because it was not available at the general hospitals in Xinjiang. The study from between 2009 and 2011 on the prevalence of MDR-TB  did not During the treatment, the patients were monitored for CD4 cell count, levels of liver enzymes, chest X-ray in cases with lung symptoms like cough or sputum.P-values < 0.05 were regarded statistically significant.For comparison of proportions between groups we used Chi-square test. The differences in hazard between groups were analyzed by Cox proportional hazard analysis. Survival curves based on Kaplan-Meier estimates are presented. We analyzed the cure rate one year from the diagnosis of TB. We defined a TB cure as patients surviving the treatment period, having a negative sputum smear if previously the smear was positive, no remaining TB- related symptoms, and an improvement in chest or extrapulmonary X-ray findings, and no relapse after the end of TB treatment, relapse was defined as having a positive culture 30 days after the last treatment date . PatientThe flow chart describing the included patients in the study is shown in Fig. The demographic data on the patients with HIV + TB and HIV only are shown in Table p < 0.05).The prevalence of TB among the HIV positive patients was 333/3032 (11%), it was higher in men than in women  the mean age was 39.2 years .p <0.05.The main route of the HIV infection among patients with HIV + TB was Intravenous Drug Use (IVDU) at 58.3% (95% CI 53–63.6), which was significantly higher than for patients with HIV only, at 38.9% (95% CI 37.1-40.7); Of the patients with HIV + TB, 72.7% (95% CI 68–77.4) were men, which was significantly higher than for patients with HIV only where the figure was 55.3% (95% CI 53.4-57.2).Hepatitis B surface antigen (HBsAg) was positive in 21 (6%) of all 333patients with HIV + TB, with 14/21 (67%) being HBV-DNA positive. Hepatitis C antibodies were found in 83 (25%) of the 333 patients, and 33/83 (40%) were HCV-RNA positive.Among the 1247 IVDUs 38% were HBsAg positive and 40% were HCV- RNA positive. Data on treatment for hepatitis were not registered, but treatments were not free and it is likely most patients were untreated.The symptoms among patients with HIV + TB and HIV without TB are shown in Table The average CD4 count at the time of HIV diagnosis was 169/μl in patients with HIV + TB, , compared to 230/μl  in the patients without TB. Out of the patients with HIV + TB 51.1% (95% CI 45.8-56.4) had CD4 counts of less than 150, which was significantly more common than in patients with HIV only, at 35.2% (95% CI 33.4-37).Thirty-eight patients (11.4%) had EPTB, of which 28 (74%) were men. The largest proportion of EPTB cases had tubercular lymphadenitis (53%), followed by pleural tuberculosis (18%).Of the 333 patients with TB, 292 (87.7%) received treatment for TB. Six surviving patients had less than one year of follow-up, 7 (2.4%) were lost to follow up, and 4 (1.4%) were transferred to other clinics. Among the remaining 275 patients, 256 (93.1%) started the TB treatment before the ART. But we have no any details regarding reasons for stopping treatment and for being lost during follow-up period.Among the 1161 patients without TB who fulfilled the criteria for IPT, it was given to 57.9% during the study period. Patients with intravenous drug use (IVDU) had lower rates of IPT 51.4% (95% CI 47.7-55.1) than non-IVDU patients, where 63.1% (95% CI 59.4-66.8) received the treatment. Men had a lower rate of IPT at 53.7% (95% CI 50–57.4), than women, at 64.5% (95% CI 61–68). Of the IVDU patients, 93.9% were men. No statistically significant difference was seen between ethnic groups, see Table In our study the cure rate one year after diagnosis of TB could be evaluated for 234 patients and was 162/234 (69.2%). Twenty-three other patients (9.8%) had improved. No improvement in symptoms was seen among 18 patients (7.7%) and 31 (13.2%) had died. The causes of death were unfortunately not registered.p < 0.0001).The survival time of HIV + TB patients was significantly shorter than in the patients with HIV only Fig. . We noteFor the patients with IVDU there was no significantly different survival the first year. However, during the following years, this group had reduced survival rates year by year starting from the second year Fig. .Fig. 3SuPneumocystis jiroveci pneumonia (PCP), 2 oral hairy leukoplakia, 1 Kaposi sarcoma.). Among 72 patients who had died, 16 had oral candida, 3 generalized herpes infection, 5 PCP, 2 Kaposi sarcoma. The rate of opportunistic infections in dead patients was 26/72 (36% (95% CI 24-47%), statistically significantly higher than among the surviving patients.Among the 333 patients with HIV + TB data on other opportunistic infections were available for 275 patients. The surviving 203 patients had a median time of follow-up on 39 months. Out of them 21  had one or more previous or actual opportunistic infections . This could be due to the fact that 67.5% of the men and only 5.9% of the women were IVDU. TB/HIV co-infection was more prevalent in men also in a Tanzanian study [The prevalence of TB co-infection in the HIV positive patients in Xinjiang was 11% (95% CI:10–12%), which was significantly higher than the national figure in China of 2%  in 2012 Out of the patients in our study, 87.7% of patients co-infected with HIV and TB started treatment for both HIV and TB. This is a better figure than for China as a whole, where it is reported that only 23% of TB patients were tested for HIV in 2011 with 4715 (2%) being HIV positive. Of these, only 1677 (36%) received ART .More than half of the patients with HIV + TB (51.1%) had CD4 counts of less than 150, which was significantly more common than in patients with HIV only, at 35.2%. It indicated a late diagnosis of HIV among the patients with TB.Among the 1161 patients fulfilling the criteria for isoniazid prophylaxis, only 57.9% received the prophylaxis. Men had lower rate for prophylaxis treatment than women in our study. This could due to the fact that most of IVDUs were men, for whom preventive treatment is more difficult.Extrapulmonar tuberculosis (EPTB) was seen among 11.4% (95% CI:8.1-14.4) of patients in our study, which is similar to the global figure of 13% on all TB cases reported by WHO , but lowThe cure rate of TB in our study was 162/234 (69.2%) (95% CI 66.2–72.2%), lower than the officially reported 91.4% for all cases of TB in Xinjiang 2011 , but sim. The incidence of drug resistance is higher in the north, west, and central areas of China, and lower in south and east China [According to WHO estimates, approximately 1 million new TB cases and 54,000 MDR-TB cases in 2013  occur inst China –32.However, testing for resistance was not performed in Xinjiang during the studied period, which blocked optimal treatment and control of TB.Rapid and timely detection of TB cases and strengthened capacity to diagnose cases of drug-resistant TB are thus global priorities for TB care and control . The GenTreatment discontinuation is considered as one of the risk factors for MDR-TB –38. AlthIn this study the survival time of the IVDU patients was shorter than of non-IVDU patients. One important reason for low survival among HIV + IVDU patients can be the high proportion of patients with untreated hepatitis B and C. Of the patients with IVDU 27% were HBsAg positive and 40% were HCV-RNA positive. There was no free treatment for hepatitis B or C in Xinjiang .There are very limited economic resources in Xinjiang compared to developed cities like Beijing, Shanghai and Guangzhou. Although the Chinese government in recent years has implemented a new healthcare system, there is not enough money for patients in the whole country to receive good medical treatment from the onset of the disease.There is also limited skill in medical treatment in most of the rural hospitals. In addition, the patients’ living conditions are often poor, with people crowding in the same living spaces to reduce costs of heating.In the case of TB symptoms, many patients did not pay attention to them, because of lack of money. Although the TB drug are free for tuberculosis patients, they must afford the cost for auxiliary treatment, including drugs for reducing adverse reactions . They haAccording to the results of a national general survey of tuberculosis between 2001 and 2010 in China, only 47% of patients with pulmonary tuberculosis went to the hospitals, and knowledge of TB prevention and control was only 57% .A beneficial effect of immediate antiretroviral therapy was evident for reductions in rates of TB, Kaposi’s sarcoma, and malignant lymphomas, meanwhile, the significant benefit in the immediate antiretroviral therapy in patients with HIV infection regardless of CD4+ count . Hence, This study was carried out in HIV clinics from 3 hospitals in Xinjiang. The data is dependent on the quality of the patient records, and we did not include CDC clinics, and private hospitals. For these reasons the results might not reflect the overall TB situation in this region. We lack data on the treatment outcomes of patients who were transferred. We have no data on whether patients were living in cities or rural areas. We also lack data on the causes of death.The low cure rate of TB and reduced 5- year survival in the HIV positive patients could be caused by late diagnosis of HIV, no availability of TB resistance tests, together with a lack of documented high levels of adherence to HIV and TB treatment regimens.Hence, economic assistance should be available to ensure that TB patients with economic hardship can complete treatment, thus reducing the emergence of drug-resistant TB.


Malaria causes the greatest public health burden in sub-Saharan Africa where high mortality occurs mainly in children under 5 years of age. Traditionally, malaria has been reported mainly in the lowlands endemic regions of western Kenya, while the highlands of the Rift Valley have been relatively free except for the sporadic epidemics in some areas. Baringo County is located in the Kenyan highlands. The county generally experiences seasonal transmission of malaria. A few hotspots which experience continuous malaria transmission in the county do however exist. The objective of this study was to assess malaria infection status and identify areas with continuous transmissions with a view to mapping out probable transmission hot spots useful in mounting focused interventions within the county.Systematic sampling was employed to identify 1668 primary school pupils from fifteen primary schools located in 4 ecological zones  of three sub-counties of Baringo. Finger prick blood sampling was done every 4 months . Malaria occurrence was tested using rapid diagnostic test kit (CareStart HRP-2 Pf). Microscopic examination was done on all RDT positive and 10% of negative cases.Plasmodium falciparum by RDT; 78% had a single episode, 16.8% had 2 episodes, 4.9% had 3 episodes and 0.4% had 4 episodes. The riverine zone had the highest malaria cases (23.2%) followed by lowlands (0.9%). No malaria cases were detected in the midland zone while highland zone recorded only few cases during the third follow up. Up to 10.7% of malaria cases were reported in the dry season, 2.9% during the long rains and 5.7% in short rains season.A total of 268 (16.1%), out of 1668 pupils tested positive for Malaria infection was prevalent in Baringo County and was mainly restricted to the riverine zone where transmission is continuous throughout the year. High malaria prevalence occurred in the dry season compared to the wet season. Even though malaria transmission is relatively low compared to endemic regions of Kenya, there is a need for continued monitoring of transmission dynamics under changing climatic conditions as well as establishing expanded malaria control strategies especially within the riverine zone which would include an integrated mosquito control and chemotherapy for infected individuals. In spite of substantial efforts towards malaria control in many endemic countries, the disease continues to be an important vector-borne parasitic disease worldwide . GloballDecline in malaria burden in most regions of the world has been linked to intensification of high impact control interventions , 7. CurrUnderstanding the current incidence and transmission patterns of malaria can positively influence the choice of control tools deployed in different epidemiological zones. Baringo County is considered a low malaria transmission area, with seasonal patterns , 7. SuchInformation on infection risks and clinical epidemiology in Baringo County is limited  and onlyThe study was conducted in three sub-counties  of Baringo County between February 2015 and February 2016. Baringo County is located within the Rift Valley and lies between longitude 35.602°–36.277°E, and latitude 0.541°–0.723°N at altitudes ranging between 870 and 2499 m above sea level (asl). The study area represents arid and semi-arid parts of Baringo County. The study area was divided into four strata running parallel to each other in a North–South direction. These strata were identified based on the hydrology, soil types, rainfall patterns, vegetation cover and altitude  and the hot months (January and February). It experiences two rainy seasons, March to June (long rains) and November (short rains). It receives between 1000 and 1500 mm of rainfall annually in the highlands and 600 mm in the lowlands. Malaria transmission in this region is seasonal with peaks during the rainy season. The current incidence of malaria is about 12% based on outpatient visits to local health facilities [According to 2009 Kenya national population census, Baringo County has a population of 555,561 people distributed in 11,075.3 kmn is the sample size, Z is the value for the selected alpha level, e.g. 1.96 for (0.25 in each tail) a 95 percent confidence level. p is the estimated proportion of an attribute that is present in the population (0.5). q is 1 − p. (p)(q) are the estimate of variance. e is the acceptable margin of error for proportion being estimated (0.05).The study was longitudinal in design where 15 public day primary schools were selected from the four zones based on their close proximity to mosquito breeding (aquatic) habitats. These breeding sites had been identified by a parallel entomological study by the same team, and were equitably spatially distributed across the study area. From these, the school closest to a breeding site included in the study was conveniently selected, and based on the populations of the respective schools, 15 were adequate for the desired sample. From these schools, at least 1540 pupils aged between 5 and 15 years were required for the study, was estimated using a formula proposed by Cochran . The stuPlasmodium spp. were treated for malaria using the recommended drug (Artemether + Lumefantrine) by the nurse; the pupils were given the first dose instantly, and instructed to complete the remaining doses at home. The average monthly rainfall data was downloaded from IRI/LDEO climate data library from January 2015 to January 2016 [Following parental or guardian informed consent, 1668 pupils were recruited to mitigate against possible loss during follow-ups . R version 3.0.3 was used to calculate point prevalence at 95% confidence interval of proportions while frequencies and cross tabulation to determine asymptomatic cases were calculated using SPSS version 22.Ethical approval to conduct the study was obtained from Kenyatta National Hospital and University of Nairobi Ethics and Research Committee (P70/02/2013). Authority to conduct research was granted by the Director of Health Services, Baringo County. Written informed consent was obtained from each parent or guardian, and only willing children were enrolled into the study.P. falciparum infections. The highest point prevalence was recorded from the riverine zone (22.8%) (95% CI 19.9–26.0) followed by the Lowlands (0.2%) (95% CI 0.01–1.5). Both midland and highland zones had no cases of Plasmodium species infections (Fisher’s exact test = 0.005).A total of 1668 primary school pupils were recruited and tested for malaria parasites during the baseline survey carried out in the dry season (January/February 2015) (Table During the first follow-up conducted towards the end of long rains (June/July 2015) the overall prevalence dropped from 10.5% (95% CI 9.1–12.1) to 2.6% (95% CI 1.8–3.6), although this difference was not statistically significant (Fisher’s exact test = 1.000). The number of pupils who were tested also dropped from 1668 to 1372 (17.7% loss to follow up). All positive cases were from the riverine zone giving a prevalence of 6.5%.The second follow up was carried out during the short rains (October/November 2015). Malaria prevalence rose up to 5.5% (95% CI 4.3–6.9) from 2.6% (95% CI 1.8–3.6) (Fisher’s exact test = 0.551). The loss to follow up rose to 23.4%. The prevalence of malaria in the riverine zone was 11.4% (95% CI 9.1–14.4), while that in the lowland Zone was 0.6% (95% CI 0.1–2.5). No positive cases were reported in the highland and midland zones. The third follow-up was conducted immediately after the end of the El Niño rains (January/February 2016). The riverine zone recorded the highest prevalence of malaria infection (12.7%) (95% CI 5.0–7.7) compared to highlands (1.9%) (95% CI 0.7–4.7) and the Lowlands with 0.3% (95% CI 0.02–2.0). The overall point prevalence of malaria infection was 6.2% (95% CI 5.0–7.7). The midland Zone had no malaria cases during the entire period of the study.Plasmodium species infection was slightly high during dry season compared to long rain season and short rain season.In general, prevalence varied with altitude where the riverine zone recorded higher prevalence followed by the lowland and the highland (Fisher’s exact test = 0.005) Table . PlasmodP. falciparum infection. Out of these, 209 (78.0%) pupils had a single episode of infection, 45 (16.8%) had 2 episodes, 13 (4.9%) had 3 episodes while 1 (0.4%) had 4 episodes of malaria. No death due to malaria was reported during the surveillance period.During the baseline survey and the three subsequent follow-ups, a total of 268 (16.1%) pupils were positive for P. falciparum infection every month. Malaria incidence varied greatly when categorized into geographical zones, with the riverine recording the highest (RR = 40.2 (95% CI 7–1623). While the highland and midland zones recorded zero incidence during the entire study period, the lowland had an incidence of 0.5/1000 person-month. The riverine zone had ant incidence of 14/1000 person-months  when compared to 5–9 years age group (4/1000 person-months) although this was not statistically significant (RR = 1.63 (95% CI 0.9–3.1). Similarly, the rate of Plasmodium species infection between males and females was not significantly different within the study area. IRR = 1.02 (95% CI 0.55–1.88)  was determined using both RDT and microscopy. During baseline survey, 61.1% (95% CI 0.53–0.68) of the positive cases by RDT were asymptomatic. The proportion of asymptomatic cases were relatively high in both first follow up and second follow up, 65.7% (95% CI 0.48–0.8) and 62.9% (95% CI 0.5–0.7), respectively. During the third follow up, 48.9% of the positive cases were asymptomatic. Pearson Chi square was used to determine the possible association between asymptomatic Plasmodium species infection to gender and age groups. Males were slightly more asymptomatic than females, however, the results indicated no statistically significant difference . Similarly, there was no difference of asymptomatic Plasmodium species infection between children aged 5–9 and 10–15 years   compared to endemic regions of Kenya (over 20%) , the rivPlasmodium sp. infection, but the risk greatly varied with ecological zones. The riverine zone recorded the highest risk while lowlands, highlands and midlands recorded least or no risk of infection. These findings are consistent with other studies which demonstrated micro-epidemiological variations in malaria exposure especially in low transmission areas [The entire study area indicated low risk of on areas , 9, 30. on areas , 32. Infon areas . It is hPlasmodium species infections by RDT was high during the entire study period except in the third follow up. Microscopy also indicated that over 50% of the confirmed cases during the study had no clinical symptoms, supporting previous findings showing that school-age children represent the group with high cases of asymptomatic malaria [The proportion of asymptomatic  malaria , 36. Asy malaria . Baringo malaria , 38. HowThis study reports the occurrence of malaria in Baringo County, which is confined mainly to the lower altitude riverine areas, and which exhibit perennial transmission. High malaria prevalence is recorded during the dry season in the months of January to March. There is therefore a need for sustained and expanded malaria control strategies especially within the riverine zone of the county.