Delivering new malaria drugs through grassroots private sector.

OBJECTIVE: To demonstrate that micro-franchising system is an effective way of improving access to effective health care such as the introduction of first line antimalarias in populations living in underserved rural areas in Kenya. DESIGN: A descriptive study. SETTING: Child and family wellness (CFW) micro-franchised nurse run clinics in Kenya. RESULTS: In 2007, 39.3% of RDTs carried out were positive for malaria. All malaria positive (RDTs and microscopy) patients received artemether lumefantrine (AL) according to their weight in accordance with the Government approved treatment guidelines. During the same period a total of 3,248 community members were reached with malaria information, however, community expectations took longer to change as patients demanded AL even when the malaria diagnosis was negative. Initially, this led to the dispensing of other antimalarials to patients with malaria like symptoms even with a negative test. This demand decreased with more community education on the importance of the tests. Engaging the private sector though with challenges proved feasible and appropriate in accessing malaria treatment based on clinical diagnosis supported by RDTs to confirm the diagnosis instead of presumptive treatment based on fever. This led to a reduction of antimalarial prescriptions by more than 50%, implying better patient care, rational drug use as well as cost savings on malaria treatment. CONCLUSION: A micro-franchising system is an effective and sustainable way of improving access to effective health care by populations living in underserved rural areas of Africa. With appropriate supportive training and supervision, the system can adapt to changes in treatment guidelines and to new regimens.

Effect of diagnosis and treatment of inoperable cervical cancer on quality of life among women receiving radiotherapy at Kenyatta National Hospital.

BACKGROUND: Cancer of the uterine cervix is the most common female cancer in Kenya. Despite being preventable, it is often diagnosed when it is already late. For this reason, only palliative therapy is provided. Hence, it is expected that their daily routines and that of their caregivers are severely disrupted. OBJECTIVES: To determine the extent to which diagnosis and treatment of inoperable cervical carcinoma affects quality of life (QOL). DESIGN: Cross-sectional descriptive study. Setting Radiotherapy Department at the Kenyatta National Hospital. SUBJECTS: Women undergoing radiotherapy for inoperable cervical cancer. RESULTS: There is high prevalence of profound disruptions in nearly all domains of QOL. In the social domain, between 33% and 44% had the perception that family members and friends had withdrawn social support. Reduction in various economic facets was reported by 47.4%-52.6%, with 44.7% reporting a fall in the overall living standards. There were significant changes in the sexual domain, as a result in which 28.3% reported marital discordance. In the personality domain, decreased self-esteem and self-projection in life occurred in 30.9% and 36.2% respectively. On functional outcomes (EORTC QLQ-C30), only 32%-41% reported not being affected in the various facets of emotional function. Physical functions were affected in 19%-79%, role functions in 69%-75%; symptoms in 49%-80%; cognitive functions in 46%-56%; social functions in 63%-71% and financial aspects by 63%. On global QOL, 53% and 47% respectively reported high level disruption in overall physical health and overall QOL. CONCLUSION: Severe deterioration of QOL occurs as a result of diagnosis of inoperable cervical cancer and subsequent therapies. For this reason there is need to establish severe disease and end-of-life research and management services that would ensure better coping with cancer for patients and for home-based caregivers.

Acceptability of human immunodeficiency virus testing in patients with invasive cervical cancer in Kenya.

Invasive cervical cancer (ICC) is common in areas where human immunodeficiency virus (HIV) is also prevalent. Currently, HIV seroprevalence as well as acceptability of HIV testing in ICC patients in Kenya is unknown. The objective of this study was to determine the acceptability of HIV testing among patients with ICC. Women with histologically verified ICC at Kenyatta National Hospital participated in the study. A structured questionnaire was administered to patients who gave informed consent. HIV pre- and posttesting counseling was done. Blood was tested for HIV using enzyme-linked immunosorbent assay. Overall, 11% of ICC patients were HIV seropositive. The acceptance rate of HIV testing was 99%; yet, 5% of the patients did not want to know their HIV results. Patients less than 35 years old were two times more likely to refuse the result of the HIV test (odds ratio [OR] 2.2). Patients who did not want to know their HIV results were three times more likely to be HIV seropositive (OR 3.1). Eighty four percent of the patients were unaware of their HIV seropositive status. The HIV-1 seroprevalence in ICC patients was comparable to the overall seroprevalence in Kenya. ICC patients were interested in HIV testing following pretest counseling. Offering routine HIV testing is recommended in ICC patients.

Hodgkin's lymphoma in the 1990s: a Kenyatta National Hospital experience.

OBJECTIVE: To re-evaluate clinico-pathologic categorisation of patients with Hodgkin's lymphoma, treatments offered and their appropriateness, and outcome of this disease at Kenyatta National Hospital in the 1990s. DESIGN: Retrospective survey of Hodgkin's lymphoma patients aged 13 years and above at the Kenyatta National Hospital. SETTING: Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS: Patients aged 13 years and above, with diagnosis of Hodgkin's lymphoma. RESULTS: There were 75 males and 36 females. One case had no clear gender details. 14.2% of the cases were of lymphocyte predominant histologic subtype, 23.6% nodular sclerosis, 26.4% mixed cellularity and 17% Lymphocyte depletion (Rye Modification of Lukes and Butler Classification). Disease stages IIIB, IVA and IVB (Ann Arbor) were found in 24.5% of the cases. The majority of the patients (60.3%) were treated with the COPP protocol and 17% with ABVD. Complete remission was realised in 56% of the cases and most cases were lost to follow-up, making it difficult to correlate survival with known prognostic parameters, apart from early stage disease and attainment of complete remission which correlated with prolonged durations of follow-up. CONCLUSION: The patients had earlier stage diseases than in earlier studies locally, the histologic classification is still wanting, and the COPP protocol appeared still popular instead of being abandoned. Response rates were lower than expected and losses to follow-up made it difficult to properly evaluate prognostic parameters. Early disease stage and attainment of complete remission appeared to correlate with longer follow-up duration.

Non-Hodgkin's lymphomas at Kenyatta the National Hospital Nairobi in the 1990's.

OBJECTIVES: To determine the clinico-pathologic and prognostic factors, treatment and outcome of non-Hodgkin's lymphomas as seen at the Kenyatta National Hospital in the 1990s. DESIGN: Retrospective study of patients with non-Hodgkin's Iymphoma. SETTING: Kenyatta National Hospital, Nairobi, Kenya, between January 1990 and January 2000 inclusive. SUBJECTS: Patients aged 13 years and above, with non-Hodgkin's Iymphomas. RESULTS: Case records were available for 207 patients, 146 males and 60 females, with one having had gender not clarified. Fifty two per cent of the patients were aged less than 40 years and 18.4% over 60 years. Forty one per cent were not properly classified histologically, seventy patients out of 190 evaluable (36.8%) had stages IVA and IVB disease at diagnosis. Twenty five out of 77(32.5%) tested positive for HIV infection, none of them being of the indolent variety. Up to 57.1% of cases of Burkitt's lymphoma tested positive for HIV infection. Cyclophosphamide, doxorubicin, vincristine and prednisone, (CHOP) chemotherapy was given to 68.7% of the patients with complete remission rates of 55.6% for those who got a minimum of six courses of chemotherapy. Only 15.3% of 105 patients evaluable were followed up for 36 months and above, the majority of patients having been lost to follow-up. Poor performance status at diagnosis correlated with shorter follow-up durations (p<0.05). CONCLUSION: A good percentage of the patients were not comprehensively characterized pathologically. Standard treatment was offered to the majority of patients, and those who could afford to purchase the medicines stood good chance of achieving complete remission. Poor performance status at diagnosis correlated with shorter follow-up durations and early stage disease correlated with longer follow-up durations. Overall, the outlook for NHLs treated at KNH in the 1990s appears to have improved tremendously.

Early development of vaginal shortening during radiation therapy for endometrial or cervical cancer.

Vaginal necrosis can occur following radiation therapy for gynecological malignancies. The distal vaginal mucosa has a poorer radiation tolerance than the mucosa in the upper region. We examined the extent of vaginal shortening in patients treated by intravaginal brachytherapy with or without pelvic irradiation. Maximal extension of the vaginal cylinder above the pubis was measured for each insertion. We found that the difference in mean values between insertions (2.3 vs. 1.7 cm) was highly statistically significant (P < 0.0001). Our study shows that vaginal shortening can occur during the course of intracavity and external irradiation. These alterations in vaginal anatomy can have important consequences on doses received by the distal vaginal mucosa.

Oral etoposide for Merkel cell carcinoma in patients previously treated with intravenous etoposide.

We describe three patients with advanced Merkel cell carcinoma who were treated with etoposide given orally for recurrent regional lymph node involvement 18 to 30 months after exposure to etoposide given intravenously. Etoposide given orally (100 mg/day) was given for 10 to 14 consecutive days and repeated every 21 to 28 days for a median of three courses (range: two to four). Toxicity was minimal and mainly hematologic. Two patients showed a complete response and one a partial response, all of very rapid onset. All three patients are alive 6, 9, and 42 months from the start of oral treatment. Two remain progression free, and one had a recurrence 1 month after completion of chemotherapy. We suggest that orally administered etoposide, a topoisomerase II inhibitor, has a strong antitumor effect in advanced Merkel cell carcinoma, even in patients previously treated parenterally with the same drug. This action may be explained by the greater dependence of the drug's efficacy on the duration of administration rather than the dose intensity.

Role of radiation therapy in the management of cutaneous malignant melanoma.

Traditionally, cutaneous malignant melanoma is regarded as a radioresistant tumor. Recently, however, an increasing number of clinical studies have refuted this notion. The authors examined the role of radiation therapy in the palliative and/or adjuvant treatment of cutaneous malignant melanoma. The records of 69 patients with cutaneous malignant melanoma were reviewed. Twenty-five patients with extensive regional lymph node involvement received adjuvant radiation therapy after primary surgical treatment, and the remainder received palliative radiation therapy. The therapeutic significance of fraction size was analyzed. In the palliative radiation therapy group, the response rate was 52% with a fraction size < or = 300 cGy and 35% with a larger fraction size (p > 0.05, NS). Local regional control rates after adjuvant radiation therapy using conventional fractionation and larger fraction size were 87% and 82%, respectively (p > 0.05, NS). Radiation therapy is effective in the management of cutaneous malignant melanoma. It plays an important role in the palliation of metastatic disease and as an adjuvant treatment. No advantage in using a large fraction size over conventional dose schedules was found.