OBJECTIVE To explore the levels and determinants of loss to follow-up (LTF) under universal lifelong antiretroviral therapy (ART) for pregnant and breastfeeding women (“Option B+”) in Malawi. DESIGN, SETTING, and PARTICIPANTS We examined retention in care, beginning at date of ART initiation and up to six months, for women in the Option B+ program. We analysed nation-wide facility-level data on women who started ART at 540 facilities (n=21 939). The study included individual-level data on patients who started ART at 19 large facilities (n=11 534). RESULTS Of the women who started ART under Option B+ (n=21 939), 17% appeared to be LTF six months after start. Most losses occurred in the first 3 months of therapy. Option B+ patients who started therapy during pregnancy were five times more likely than women who started ART in WHO stage 3/4 or with a CD4 cell count ≤350 cells/μl, to never return after their initial clinic visit (odds ratio 5.0, 95% CI 4.2-6.1). Option B+ patients who started therapy while breastfeeding were twice as likely to miss their first follow-up visit (odds ratio 2.2, 95% CI 1.8-2.8). LTF was highest in pregnant Option B+ patients who began ART at large clinics on the day they were diagnosed with HIV. LTF varied considerably between facilities, ranging from 0% to 58%. CONCLUSION Decreasing LTF will improve the effectiveness of the Option B+ approach. Tailored interventions, like community- or family-based PMTCT models could improve its effectiveness.

Recent findings suggested that the age of peak ultra-marathon performance seemed to increase with increasing race distance. The present study investigated the age of peak ultra-marathon performance for runners competing in time-limited ultra-marathons held from 6 to 240 h (i.e. 10 days) during 1975-2013. Age and running performance in 20,238 (21%) female and 76,888 (79%) male finishes (6,863 women and 24,725 men, 22 and 78%, respectively) were analysed using mixed-effects regression analyses. The annual number of finishes increased for both women and men in all races. About one half of the finishers completed at least one race and the other half completed more than one race. Most of the finishes were achieved in the fourth decade of life. The age of the best ultra-marathon performance increased with increasing race duration, also when only one or at least five successful finishes were considered. The lowest age of peak ultra-marathon performance was in 6 h (33.7 years, 95% CI 32.5-34.9 years) and the highest in 48 h (46.8 years, 95% CI 46.1-47.5). With increasing number of finishes, the athletes improved performance. Across years, performance decreased, the age of peak performance increased, and the age of peak ultra-marathon performance increased with increasing number of finishes. In summary, the age of peak ultra-marathon performance increased and performance decreased in time-limited ultra-marathons. The age of peak ultra-marathon performance increased with increasing race duration and with increasing number of finishes. These athletes improved race performance with increasing number of finishes.

The incidence of Kaposi’s Sarcoma (KS) is high in South Africa but the impact of antiretroviral therapy (ART) is not well defined. We examined incidence and survival of KS in HIV-infected patients enrolled in South African ART programs. We analyzed data of three ART programs: Khayelitsha township and Tygerberg Hospital programs in Cape Town and Themba Lethu program in Johannesburg. We included patients aged >16 years. ART was defined as a regimen of at least three drugs. We estimated incidence rates of KS for patients on ART and not on ART. We calculated Cox models adjusted for age, sex and time-updated CD4 cell counts and HIV-1 RNA. 18,254 patients (median age 34.5 years, 64% female, median CD4 cell count at enrolment 105 cells/μL) were included. During 37,488 person-years follow-up 162 patients developed KS. The incidence was 1,682/100,000 person-years (95% confidence interval [CI] 1,406–2,011) among patients not receiving ART and 138/100,000 person-years (95% CI 102–187) among patients on ART. The adjusted hazard ratio comparing time on ART with time not on ART was 0.19 (95% CI 0.13–0.28). Low CD4 cell counts (time-updated) and male sex were also associated with KS. Estimated survival of KS patients at one year was 72.2% (95% CI 64.9–80.2) and higher in men than in women. The incidence of KS is substantially lower on ART than not on ART. Timely initiation of ART is essential to preventing KS and KS-associated morbidity and mortality in South Africa and other regions in Africa with a high burden of HIV.

Background The risk of Kaposi sarcoma (KS) among HIV-infected persons on antiretroviral therapy (ART) is not well defined in resource-limited settings. We studied KS incidence rates and associated risk factors in children and adults on ART in Southern Africa. Methods We included patient data of six ART programs in Botswana, South Africa, Zambia, and Zimbabwe. We estimated KS incidence rates in patients on ART measuring time from 30 days after ART initiation to KS diagnosis, last follow-up visit, or death. We assessed risk factors (age, sex, calendar year, WHO stage, tuberculosis, and CD4 counts) using Cox models. Findings We analyzed data from 173,245 patients (61% female, 8% children aged <16 years) who started ART between 2004 and 2010. 564 incident cases were diagnosed during 343,927 person-years (pys). KS incidence rate overall was 164/100,000 pys (95% confidence interval [CI] 151–178). The incidence rate was highest 30 to 90 days after ART initiation (413/100,000 pys; 95% CI 342–497) and declined thereafter (86/100,000 pys[95% CI 71–105]>2 years after ART initiation). Male sex (adjusted hazard ratio [HR] 1.34; 95% CI 1.12–1.61), low current CD4 counts (≥500 cells/µL versus <50 cells/µL, adjusted HR 0.36; 95% CI 0.23–0.55) and age (5 to 9 years versus 30 to 39 years, adjusted HR 0.20; 95% CI 0.05–0.79) were relevant risk factors for developing KS. Interpretation Despite ART, KS risk in HIV-infected persons in Southern Africa remains high. Early HIV testing and maintaining high CD4 counts is needed to further reduce KS-related morbidity and mortality.

C-reactive protein (CRP) point-of-care testing (POCT) is increasingly being promoted to reduce diagnostic uncertainty and enhance antibiotic stewardship. In primary care, respiratory tract infections (RTIs) are the most common reason for inappropriate antibiotic prescribing, which is a major driver for antibiotic resistance. We systematically reviewed the available evidence on the impact of CRP-POCT on antibiotic prescribing for RTIs in primary care. Thirteen moderate to high-quality studies comprising 9844 participants met our inclusion criteria. Meta-analyses showed that CRP-POCT significantly reduced immediate antibiotic prescribing at the index consultation compared with usual care (RR 0.79, 95%CI 0.70 to 0.90, p = 0.0003, I2 = 76%) but not during 28-day (n = 7) follow-up. The immediate effect was sustained at 12 months (n = 1). In children, CRP-POCT reduced antibiotic prescribing when CRP (cut-off) guidance was provided (n = 2). Meta-analyses showed significantly higher rates of re-consultation within 30 days (n = 8, 1 significant). Clinical recovery, resolution of symptoms, and hospital admissions were not significantly different between CRP-POCT and usual care. CRP-POCT can reduce immediate antibiotic prescribing for RTIs in primary care (number needed to (NNT) for benefit = 8) at the expense of increased re-consultations (NNT for harm = 27). The increase in re-consultations and longer-term effects of CRP-POCT need further evaluation. Overall, the benefits of CRP-POCT outweigh the potential harms (NNTnet = 11).

Background Polypharmacy is an increasing problem, leading to increased morbidity and mortality, especially in older, multimorbid patients. Consequently, there is a need for reduction of polypharmacy. The aim of this study was to explore attitudes, beliefs, and concerns towards deprescribing among older, multimorbid patients with polypharmacy who chose not to pursue at least one of their GP’s offers to deprescribe. Methods Exploratory study using telephone interviews among patients of a cluster-randomized study in Northern Switzerland. The interview included a qualitative part consisting of questions in five pre-defined key areas of attitudes, beliefs, and concerns about deprescribing and an open explorative question. The quantitative part consisted of a rating of pre-defined statements in these areas. Results Twenty-two of 87 older, multimorbid patients with polypharmacy, to whom their GP offered a drug change, did not pursue all offers. Nineteen of these 22 were interviewed by telephone. The 19 patients were on average 76.9 (SD 10.0) years old, 74% female, and took 8.9 (SD 2.6) drugs per day. Drugs for acid-related disorders, analgesics and anti-inflammatory drugs were the three most common drug groups where patient involvement and the shared-decision-making (SDM) process led to the joint decision to not pursue the GPs offer. Eighteen of 19 patients fully trusted their GP, 17 of 19 participated in SDM even before this study and 8 of 19 perceived polypharmacy as a substantial burden. Conservatism/inertia and fragmented medical care were the main barriers towards deprescribing. No patient felt devalued as a consequence of the deprescribing offer. Our exploratory findings were supported by patients’ ratings of predefined statements. Conclusion We identified patient involvement in deprescribing and coordination of care as key issues for deprescribing among older multimorbid patients with polypharmacy. GPs concerns regarding patients’ devaluation should not prevent them from actively discussing the reduction of drugs. Trial registration ISRCTN16560559 . Electronic supplementary material The online version of this article (10.1186/s12875-019-0953-4) contains supplementary material, which is available to authorized users.

The aim of the present study was to examine sex differences across years in performance of runners in ultra-marathons lasting from 6 h to 10 days (i.e. 6, 12, 24, 48, 72, 144, and 240 h). Data of 32,187 finishers competing between 1975 and 2013 with 93,109 finishes were analysed using multiple linear regression analyses. With increasing age, the sex gap for all race durations increased. Across calendar years, the gap between women and men decreased in 6, 72, 144 and 240 h, but increased in 24 and 48 h. The men-to-women ratio differed among age groups, where a higher ratio was observed in the older age groups, and this relationship varied by distance. In all durations of ultra-marathon, the participation of women and men varied by age (p < 0.001), indicating a relatively low participation of women in the older age groups. In summary, between 1975 and 2013, women were able to reduce the gap to men for most of timed ultra-marathons and for those age groups where they had relatively high participation.

The aims of the present study were to investigate the changes in the age and in swimming performance of finalists in World Championships (1994–2013) and Olympic Games (1992–2012) competing in all events/races (stroke and distance). Data of 3,295 performances from 1,615 women and 1,680 men were analysed using correlation analyses and magnitudes of effect sizes. In the World Championships, the age of the finalists increased for all strokes and distances with exception of 200 m backstroke in women, and 400 m freestyle and 200 m breaststroke in men where the age of the finalists decreased. The magnitudes of the effects were small to very large (mean ± SD 2.8 ± 2.7), but extremely large (13.38) for 1,500 m freestyle in women. In the Olympic Games, the age of the finalists increased for all strokes and distances with exception of 800 m freestyle in women and 400 m individual medley in men. The magnitudes of the effects were small to very large (mean ± SD 4.1 ± 7.1), but extremely large for 50 m freestyle in women (10.5) and 200 m butterfly in men (38.0). Swimming performance increased across years in both women and men for all strokes and distances in both the World Championships and the Olympic Games. The magnitudes of the effects were all extremely large in World Championships (mean ± SD 20.1 ± 8.4) and Olympic Games (mean ± SD 52.1 ± 47.6); especially for 100 m and 200 m breaststroke (198) in women in the Olympic Games. To summarize, in the last ~20 years the age of the finalists increased in both the World Championships and the Olympic Games with some minor exceptions (200 m backstroke in women, 400 m freestyle and 200 m breaststroke in men in World Championships and 800 m freestyle in women and 400 m individual medley in men in Olympic Games) and performance of the finalists improved.