Little or no research has been conducted on the epidemiology of leukemias in Eritrea . In this retrospective study, we evaluated the burden and trends of acute lymphoblastic leukemia (ALL), Acute myelogenous leukemia (AML), chronic myelogenous leukemia (CML), chronic lymphocytic leukemia (CLL) and overall leukemia in Eritrea. Methods: An audit of leukemia cases recorded in laboratory logbooks at the National Health Laboratory (NHL) and Orotta Referral and Teaching Hospital (ORTH) between January 2010 and December 2021 was performed. Aside from leukemia sub-types, additional variables that were retrieved included age, sex, years of incidence, residency. Relevant estimates assessed included crude incidence rates (CIR), age-standardised rates (ASIR) and estimated annual percentage change (EAPC). Results: In total, 372 confirmed cases of leukemia were recorded between, 2010-2020. The median [interquartile range (IQR)] age, maximum – minimum age, and male/female ratio were as follows: 48 years (24.5 – 60 years), 2 - 91 years, and 210/161 (1.3: 1), respectively. Estimated all-age CIR and ASIR over the study period was 9.22 per 100 000 and 30.1 per 100 000 respectively. Analysis of cumulative (2010 - 2020) CIR per 100 000 (ASIR per 100 000) for ALL, AML, CLL, and CML were as follows: 2.01(3.87); 0.94(2.38); 2.94(15.37) and 3.61(24.03). Additionally, median (IQR) age differed significantly across different subtypes of leukemia – ALL (23.0 years, IQR: 10.0 – 39.0); AML (30 years, IQR: 20 – 56 years), CLL (59.0 years, IQR: 40.75 – 66.75 years), and CML (49 years, IQR: 39.25 – 60 years), p value (Kruskal Wallis), < 0.05). No sex specific differences were observed in median (IQR) for different types of leukemia. Unlike other leukemia sub-types evaluation of EAPC demonstrated that the incidence of leukemia has increased overtime, 21.9 (95 CI: 3.1-44.1), p-value = 0.025. Conclusions: The burden of leukemia was relatively stable . However, due to underreporting and underdiagnosis, it’s our belief that the true burden of leukemia is likely higher. Further, an upward trend in the burden of ALL was uncovered. Lastly, expansion of diagnostic services to other sub-zones, establishment of a national cancer registry and research remains a priority in Eritrea.

Subdural Empyema -A Rare Complication of Chronic Otitis Media: A Case ReportEmnet Tekeste1*+, Genet Tekeste2+, Nahom Daniel3, Samuel Tekle Mengistu41. General practitioner, Barentu Military Hospital, Barentu, Eritrea, Email: [email protected], ORCID: https://orcid.org/0000-0002-8820-85642. Surgical resident, Orotta National Referral Hospital, Asmara, Eritrea, Email: ORCID:, 3. General practitioner, Mendefera Zonal Referral Hospital, Medefera, Eritrea, Email: [email protected]. Nakfa Hospital, Ministry of Health Northern Red Sea branch, Nakfa, Eritrea. Email: [email protected] ORCID: https://orcid.org/0000-0002-2817-1421*Correspondence: Emnet Tekeste MD, General practitioner, Barentu Military Hospital, Barentu, Eritrea. Tel +291-1-7205051, Email [email protected] any equal contribution of authors that you want to acknowledge+: These authors contributed equally to this work

Background: Many view attrition as one of the biggest barriers to effective delivery of cART in resource-limited settings in sub-Saharan Africa (SSA). In this study, our objective was to describe the incidence and predictors of attrition among adults enrolled in cART programs in two referral hospitals in the northern coastal areas of Eritrea. Methods: This was a retrospective review of patient records of 464 patients [Male: 149(35.6%) vs. Females: 269(64.4%)] aged 18 years who initiated cART between 2005 and 2021. The main outcome measures were attrition (loss-to-follow-up (LTFU) plus mortality) and associated outcomes. Kaplan-Meier statistics were used to evaluate survival probability of attrition. Independent predictors of attrition were evaluated using a multivariable Cox proportional hazard model. Results: A total of 418 patients [Male: 149(35.6%) vs. Female: 269 (64.4%)] were studied. At baseline, the mean (±SD) age (SD) was 34(±11.2) years; median (±IQR) CD4 + T-cell count was 151 (IQR: 87-257) cells/µL. After a follow-up time of 39,883 months, 127 ((30.4%), 95% CI [26-35]) attrition events were reported, translating into a cumulative incidence of 2.9/1000(2.4-3.5) per 1,000 people-months (PMs) were reported. During the same period, 97 (23.11%) patients died, 32(7.7%) were LTFU, and 47(11.2%) transferred out. In the adjusted multivariate Cox regression model, an increased risk of attrition was associated with the year of enrollment (aHR = 1.07, 95% CI 1.00-1.15, p-value = 0.04); ethnicity (Afar: aHR=3.21, 95% CI: 1.84-5.59, p value < 0.001) (Others: aHR = 2.67, 95% CI: 1.14-6.25, p value = 0.024) and cART backbone: (TDF+FTC: aHR=2, 95% CI: 1.21-3.32, p value = 0.007). On the contrary, the risk of attrition decreased per unit increase in baseline CD4 + T-cells/μL (uHR=0.998, 95% CI 0.996-0.999, p-value<0.001). Conclusion: Despite expanded treatment and decentralization of cART programs, mortality due to advanced disease at enrollment remains high in peripheral settings. A concerted effort is required to reduce late enrollment and improve the management of patients with advanced disease in decentralized programs.