Utility of CT Scan and CA 19-9 in Predicting Non –Resectability in Malignant Obstructive Jaundice

Background: Most patients with malignant obstructive jaundice (MOJ)  present with non-resectable disease. Non curative laparotomy has been associated with adverse outcome. There is need to predict non-resectable disease and prepare patients for planned palliative procedures.Objective: To study the utility of Ca 19-9 serum levels and CT scan in predicting the non- resectability of MOJ tumours at Kenyatta National Hospital.Methods: Eligible consenting patients were recruited. All had a CT scan of the abdomen and serum CA 19-9 levels determined preoperatively and staging was done using the LRCC criteria. At surgery, intraoperative  findings were then compared in terms of non-resectability with the  preoperative CT scan prediction and the CA 19-9 levels.Results: A total of 49 patients were recruited into the study. During the study, 14 patients were later excluded due to inadequate information of imaging, non-surgical intervention or pre-operative death. At a confidence level of 95%, CA 19-9 level of 466 has 92.3% sensitivity and 100% specificity indicative of non resectability in MOJ lesions. When compared with intra-operative findings on non-resectability, the cut off level of 466 has a positive and negative predictive value of CA19-9 was 100% and 71.4%, respectively. CT scan had 85.2% sensitivity and 100% specificity on predicting non resectability of MOJ lesions, 84% sensitivity in detecting nodal involvement but predicted only 33% of liver metastases.Conclusion: Combining CA 19-9 levels and CT scan are useful tools in detecting non resectability of MOJ lesions preoperatively.Key words: Malignant obstructive jaundice, non-resectability, CA 19-9, CT scan

Sigmoid volvulus in pregnancy

Sigmoid volvulus in pregnancy is a rare condition that poses a myriad of challenges in diagnosis and management of the patient. It demands on the clinician a high index of suspicion, immediate treatment involving resuscitation and good judgment in handling of the bowel in face of added potential morbidity and mortality to the mother and fetus. We report a case of gangrenous sigmoid volvulus with a viable third trimester pregnancy and discuss potential pitfalls in diagnosis and management

Priority mental, neurological and substance use disorders in rural Kenya: Traditional health practitioners’ and primary health care workers’ perspectives

Background: Over 75% of people with mental neurological and substance use disorders (MNSD) live in low and middle-income countries with limited access to specialized care. The World Health Organization’s Mental Health Gap Action Program (mhGAP) aims to address the human resource gap but it requires contextualization. Aim: We conducted a qualitative study in rural coastal Kenya to explore the local terms, perceived causes and management modalities of priority MNSD listed in the mhGAP, to inform implementation in this setting. Methods: We conducted 8 focus group discussions with primary health care providers and traditional health practitioners and used the framework method to conduct thematic analysis. We identified local terms, perceived causes and treatment options for MNSD. We also explored possibilities for collaboration between the traditional health practitioners and primary health care providers. Results: We found local terms for depression, psychoses, epilepsy, disorders due to substance use and self-harm/ suicide but none for dementia. Child and adolescent mental and behavioral problems were not regarded as MNSD but consequences of poor parenting. Self-harm/suicide was recognized in the context of other MNSD. Causes of MNSD were broadly either biological or supernatural. Treatment options were dependent on perceived cause of illness. Most traditional health practitioners were willing to collaborate with primary health care providers mainly through referring cases. Primary health care providers were unwilling to collaborate with traditional health practitioners because they perceived them to contribute to worsening of patients’ prognoses. Conclusions: Local terms and management modalities are available for some priority MNSD in this setting. Community level case detection and referral may be hindered by lack of collaboration between traditional health practitioners and primary health care providers. There is need for training on the recognition and management of all priority MNSD

Adult Wilms’ tumour in pregnancy

Wilms’ tumor (nephroblastoma) is the most common primary renal malignancy in children, with a peak presentation in the ages 3-4 years. Wilms’ tumor is extremely rare in adults with around 300 cases described in literature. This presents both a diagnostic and treatment challenge in adults due to lack of standard protocols. Herein, we report a case of a 28-year-old primigravida who underwent nephrectomy postpartum for presumed renal cell carcinoma that was diagnosed as Wilms’ tumor at histology. This case is being reported on account of its peculiar presentation, and its presentation in pregnancy, to provoke further research and thus improve management in the adult patient

Antimalarial drugs and the prevalence of mental and neurological manifestations: A systematic review and meta-analysis.

Background Antimalarial drugs affect the central nervous system, but it is difficult to differentiate the effect of these drugs from that of the malaria illness. We conducted a systematic review to determine the association between anti-malarial drugs and mental and neurological impairment in humans. Methods We systematically searched online databases, including Medline/PubMed, PsychoInfo, and Embase, for articles published up to 14th July 2016. Pooled prevalence, heterogeneity and factors associated with prevalence of mental and neurological manifestations were determined using meta-analytic techniques. Results Of the 2,349 records identified in the initial search, 51 human studies met the eligibility criteria. The median pooled prevalence range of mental and neurological manifestations associated with antimalarial drugs ranged from 0.7% (dapsone) to 48.3% (minocycline) across all studies, while it ranged from 0.6% (pyrimethamine) to 42.7% (amodiaquine) during treatment of acute malaria, and 0.7% (primaquine/dapsone) to 55.0% (sulfadoxine) during prophylaxis. Pooled prevalence of mental and neurological manifestations across all studies was associated with an increased number of antimalarial drugs (prevalence ratio= 5.51 (95%CI, 1.05-29.04); P=0.045) in a meta-regression analysis. Headaches (15%) and dizziness (14%) were the most common mental and neurological manifestations across all studies. Of individual antimalarial drugs still on the market, mental and neurological manifestations were most common with the use of sulphadoxine (55%) for prophylaxis studies and amodiaquine (42.7%) for acute malaria studies. Mefloquine affected more domains of mental and neurological manifestations than any other antimalarial drug. Conclusions Antimalarial drugs, particularly those used for prophylaxis, may be associated with mental and neurological manifestations, and the number of antimalarial drugs taken determines the association. Mental and neurological manifestations should be assessed following the use of antimalarial drugs.</p

An overview of mental health care system in Kilifi, Kenya: results from an initial assessment using the World Health Organization’s Assessment Instrument for Mental Health Systems

Abstract Background Little is known about the state of mental health systems in Kenya. In 2010, Kenya promulgated a new constitution, which devolved national government and the national health system to 47 counties including Kilifi County. There is need to provide evidence from mental health systems research to identify priority areas in Kilifi’s mental health system for informing county health sector decision making. We conducted an initial assessment of state of mental health systems in Kilifi County and documented resources, policy and legislation and spectrum of mental, neurological and substance use disorders. Methods This was a pilot study that used the brief version of the World Health Organization’s Assessment Instrument for Mental Health Systems Version 2.2 to collect data. Data collection was based on the year 2014. Results Kilifi county has two public psychiatric outpatient units that are part of general hospitals. There is no standalone mental hospital in Kilifi. There are no inpatients or community based facilities for people with mental health problems. Although the psychiatric facilities in Kilifi have an essential drugs list, supply of drugs is erratic with frequent shortages. There is no psychiatrist or psychologist in Kilifi with only two psychiatric nurses for a population of approximately 1.2 million people. Schizophrenia was the commonest reason for visiting outpatient facilities (47.1%) while suicidal ideation was the least common (0.4%). Kenya’s mental health policy, which is being used by Kilifi County, is outdated and does not cater for the current mental health needs of Kilifi. There is no specific legislation to protect the rights of people with mental health problems. No budget exists specifically for mental health care. There have been no efforts to integrate mental health care into primary care in Kilifi, and there is no empirical research work to evaluate its feasibility. Conclusion There is an urgent need to increase resources allocated for mental health in particular infrastructure and human resource. Policy and legislations need to be established to protect the rights of people with mental illnesses, and mental health should be integrated with primary care to increase access to services