Risk Factors for Esophageal Squamous Cell Carcinoma in a Kenyan Population

Background: Esophageal squamous cell carcinoma (ESCC) is common in some parts of Kenya. Both the regional factors associated with ESCC in  Kenya and geographic distribution has not been completely described. Methods: We analyzed the association of ESCC with smoking, khat  chewing, alcohol, diet, socioeconomic status, caustic ingestion and firstdegree family history of ESCC in a multi-center based matched case-control study. We also determined the geographic origin, age, gender and ethnicity of patients visiting the participating centers between August 2008 and April 2009. Results: Eighty three cases and 166 controls matched for age and gender were studied. The male to female ratio of cases was 2.1:1, majority were from Central and Eastern provinces of Kenya, about one fifth (19%) were younger than 45 years of age. On multivariate analysis, caustic ingestion (OR 11.3 CI 3.0 – 42.5), first degree family history of ESCC (OR 3.5 CI 1.3 – 9.5) and poor housing (OR 2.0 CI 1.1 – 3.5) were independent predictors.Conclusions: Majority hailed from the Central and Eastern provinces  probably due to proximity to the study centres. A large proportion of cases were young compared to studies in other high incidence regions in the world. Low socio-economic status, family history of ESCC and a history of caustic ingestion were significant risk factors.Key Words: Esophageal, Squamous Cell Carcinoma, Risk Factors, Keny

The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed i) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, ii) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and iii) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes.Methods: The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes.Results: 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses’ station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement.Conclusions: The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of ‘increased postoperative surveillance’ during the ASOS-2 Trial.Keywords: Trial, cluster randomised, Trial, pilot, Implementation science, Mixed methods, Mortality, Surger

Integration of gender practices and promotion of diversity in customs and trade: The case of east and Southern Africa

The East and Southern Africa (ESA) region continues to lag in gender equality, with women remaining largely underrepresented in leadership and high-status positions compared to their sisters in other world regions. This is even though the three Regional Economic Communities (RECs) in ESA have all made efforts at incorporating gender perspectives in their customs and trade policies. This article explores the gender gap in customs and trade across ESA and concludes that the region’s member countries stand to benefit from improved organisational performance and increased global competitiveness by integrating gender perspectives in their customs and trade operations

Prevalence Of Intestinal Worm Infections Among Primary School Children In Nairobi City, Kenya

Objective: The main objective of the study was to determine the prevalence of total, single and multiple intestinal worm infections among the primary school children in Nairobi City. Methods: A cross-sectional descriptive study was used to determine the status of intestinal worm infections whose subjects were drawn from eight city administrative divisions. Proportional random sampling method to select forty five (45) schools out of 320 public, private and non-formal schools was used. Using the school enrolment register for standard 3 and 4, fifty (50) pupils per school were selected to participate in the study. Quantitative data from the study subjects were collected by use of a structured questionnaire. In addition, stool specimens were collected from each study subject and examined by Kato-Katz laboratory method. Results: The four intestinal worms investigated constituted a total prevalence of 12.9%. This prevalence was found to be lower than that in two other previous studies. A. lumbricoides had the highest prevalence and S. mansoni had the lowest. Prevalence of single worm infections constituted 8.6% of the total prevalence. Differences in prevalence between males and females were observed only with respect to T. trichiura and hookworm species. Fourteen to sixteen (14-16) and 11-13 years of age groups had the highest total prevalence of 47% and 30.6% respectively. Differences in prevalence were not found among the school categories with exception of T. trichiura infections. Conclusion: Prevalence of total, single and multiple infections showed a downward trend when compared to the previous studies with Ascaris lumbricoides persisting with the highest prevalence

Pathologic characteristics of breast cancer with special emphasis on prevalence of triple-negative breast cancer from Kenya: A 4-year experience.

Background: Previous sub classification of breast cancer in Kenya has been fraught by small sample size, non uniform staining methodology and lack of independent review. Triple Negative Breast Cancer (TNBC) is a “special interest” cancer since it represents a significant proportion of breast cancer patients and is associated with a poorer prognosis. We aimed to determine the estrogen receptor (ER), progesterone receptor (PR) and Her2/neu receptor characteristics of breast cancers and the prevalence of TNBC diagnosed at Aga Khan University Hospital, Nairobi (AKUHN) between 2007 to date. Methods: Slides and blocks of archived invasive breast cancers diagnosed at AKUHN were identified, retrieved and reviewed by two independent pathologists. Histological type, grade and pathological stage were documented. Representative sections from available blocks were stained for ER, PR, Her2 with appropriate internal controls. Scores for ER/PR were interpreted based on the ALLRED system, Her2 /neu scoring followed CAP guidelines. The initial 111 cases were validated and confirmed at Sunnybrook Health Sciences Centre, Toronto. Results: 456 cases of invasive breast cancers were diagnosed at AKUHN during the study period. 91% of cases were invasive ductal carcinomas (NOS).The rest were special types. 37% of the tumors were grade 3 and 63% were grade 2. Blocks for 318 of 456 cases were available for receptor analysis. 54% were ER and/or PR positive, with 52% of these in women \u3c 50 yrs. 86% of the ER and/or PR positive tumors were grade 2. Only 12% were Her2/neu positive. Of the 318 cases studied, 111 (32%) were identified as TNBC. Median age was 53 yrs. 88% were grade 3. Conclusions: Invasive ductal carcinoma (NOS) was the most common breast cancer in our study. Nearly half of our cases were ER and/or PR positive and a third were TNBC. Both occurred predominantly in women less than 50 yrs. This represents the largest validated pathologic sub classification of breast cancer from a tertiary academic hospital in Kenya. Expansion of this study to encompass all breast cancers diagnosed in Kenya is underway

Postoperative Outcomes Associated With Procedural Sedation Conducted by Physician and Nonphysician Anesthesia Providers: Findings From the Prospective, Observational African Surgical Outcomes Study.

BACKGROUND: There is an unmet need for essential surgical services in Africa. Limited anesthesia services are a contributing factor. Nonphysician anesthesia providers are utilized to assist with providing anesthesia and procedural sedation to make essential surgeries available. There is a paucity of data on outcomes following procedural sedation for surgery in Africa. We investigated the postoperative outcomes following procedural sedation by nonphysicians and physicians in Africa. We hypothesized that the level of training of the sedation provider may be associated with the incidence of severe postoperative complications and death. METHODS: A secondary analysis of a prospective cohort of inhospital adult surgical patients representing 25 African countries was performed. The primary outcome was a collapsed composite of inhospital severe postoperative complications and death. We assessed the association between receiving procedural sedation conducted by a nonphysician (versus physician) and the composite outcome using logistic regression. We used the inverse probability of treatment weighting propensity score method to adjust for potential confounding variables including patient age, hemoglobin level, American Society of Anesthesiologists (ASA) physiological status, diabetes mellitus, urgency of surgery, severity of surgery, indication for surgery, surgical discipline, seniority of the surgical team, hospital level of specialization, and hospital funding system using public or private funding. All patients who only received procedural sedation for surgery were included. RESULTS: Three hundred thirty-six patients met the inclusion criteria, of which 98 (29.2%) received sedation from a nonphysician provider. The incidence of severe postoperative complications and death was 10 of 98 (10.2%) in the nonphysician group and 5 of 238 (2.1%) in the physician group. The estimated association between procedural sedation conducted by a nonphysician provider and inhospital outcomes was an 8-fold increase in the odds of severe complications and/or death, with an odds ratio (95% confidence interval [CI]) of 8.3 (2.7-25.6). CONCLUSIONS: The modest number of observations in this secondary data analysis suggests that shifting the task of procedural sedation from physicians to nonphysicians to increase access to care may be associated with severe postoperative complications and death in Africa. Research focusing on identifying factors contributing to adverse outcomes associated with procedural sedation is necessary to make this practice safer