MR. NYABOLA LAMBERT ONDOH

Kenya, like many developing nations, continues to experience high childhood mortality in spite of the many efforts put in place by governments and international bodies to curb it. This study sought to investigate the barriers to accessing healthcare services for children aged less than five years in Butere District, a rural district experiencing high rates of mortality and morbidity despite having relatively better conditions for child survival. Methods: Exit interviews were conducted among caregivers seeking healthcare for their children in mid 2007 in all the 6 public health facilities. Additionally, views from caregivers in the community, health workers and district health managers were sought through focus group discussions (FGDs) and key informant interviews (KIs). Results: Three hundred and ninety-seven respondents were surveyed in exit interviews while 45 respondents participated in FGDs and KIs. Some practices by caregivers including early onset of child bearing, early supplementation, and utilization of traditional healers were thought to increase the risk of mortality and morbidity, although reported rates of mosquito net utilization and immunization coverage were high. The healthcare system posed barriers to access of healthcare for the under fives, through long waiting time, lack of drugs and poor services, incompetence and perceived poor attitudes of the health workers. FGDs also revealed wide-spread concerns and misconceptions about health care among the caregivers. Conclusion: Caregivers’ actions were thought to influence children’s progression to illness or health while the healthcare delivery system posed recurrent barriers to the accessing of healthcare for the under-fives. Actions on both fronts are necessary to reduce childhood mortality

To determine the incidence of treatment interruption among head and neck cancer patients undergoing radical radiotherapy. Design: Prospective study Setting: Kenyatta National Hospital (KNH), Nairobi. Subjects: Twenty six (M=16, F=10) patients undergoing radiotherapy for head and neck cancer between March and June 2006. Main outcome measures: Frequency of radiation morbidities and treatment interuptions. Results: There were 26 patients consisting of 16 males and 10 females aged between 21 and 70 years (mean = 49.6 years). Among these patients 12 (46.2%) had tumours in the oral cavity, six (23.1%) had nasopharyngeal tumours, two (7.7%) had pharyngeal tumours, and six (23.1%) had laryngeal tumours. All tumours were primary carcinomas except two pharyngeal tumours which were metastatic. Among the 26 patients, 13(50%) completed the course of radiotherapy within the prescribed duration while another 13(50%) had treatment interruption. Of the 13 patients who had treatment interruption, one patient had a treatment gap of four days, seven patients had treatment gaps ranging between six and ten days, and five patients had treatment gaps of over ten days. The duration of treatment gaps ranged between four and 30 days. At the time of treatment interruption the cumulative radiation dose ranged from 22 to 58 Grey with a mean of 38 Grey (Mode = 44 Grey). The most common side effect was xerostomia (92%). This was closely followed by mucositis (88.5%), skin reactions (88.5%) dysphagia (84.5%) pain and suffering (76.9%). Loss of taste (61.5%), trismus (34.6%) and voice change (30.89%) were relatively less common. Conclusion: Our findings show that the probability of cancer control and cure among head and neck cancer patients treated at KNH could be severely eroded by treatment interruptions as a result of severe radiation morbidity.

Community studies on children and adolescents in Western settings suggest prevalence rates of anxiety and depressive symptoms that require intervention. Aim: To establish equivalent prevalence rates in a Kenyan (developing country) situation Method: Self-administered questionnaires for socio-demographic data, three Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV)-based instruments for anxiety symptoms and syndromes in children, one instrument for depression and one culture sensitive instrument for depression and anxiety were administered in three different sets to 3 775 randomly sampled students drawn from a stratified sample of 34.7% of all public secondary schools in Nairobi, Kenya. Results: The prevalence rates of anxiety and depression symptoms and syndromes varied widely depending on sex and age and also on the emphasis of the different instruments used, and also according to the cut-off points for the various syndromes and instruments. Clinical diagnostic scores for depression were recorded in 43.7% of all the students. Using the cut-off points for the Multidimensional Anxiety Scale for Children (MASC), anxiety was recorded in 12.9% of all students. Nearly half (40.7%) of the respondents who completed the Short Leyton Obsessional Inventory for Children and Adolescents had positive scores for obsessive disorder, 81.1% were positive for compulsive disorder and an average of 69.1% had positive scores for both obsessive and compulsive disorders combined. Amongst those who completed the Ndetei-Othieno-Kathuku (NOK) scale for Depression and Anxiety, 49.3% had positive scores for moderate to severe anxiety with or without depression. The Screen for Child Anxiety Related Disorders - Revised (SCARED-R) yielded high levels (50-100%) for the different syndromes, with obsessive-compulsive disorder at 99.3%, just below separation anxiety and school phobia at 100%. Suicidal thoughts and plans were prevalent at 4.9-5.5%. Conclusion: Anxiety and depression were found at prevalence rates no less than is found in the West. This calls for appropriate clinical practices and policies.

OBJECTIVE: To evaluate chemotherapy induced myelosuppression, its management and outcome. DESIGN: Retrospective analysis of patients aged 13 years and above. SETTING: Hurlingham Oncology Clinic and the Nairobi Hospital during the period of June 1998 to June 2003. SUBJECTS: Two hundred and two solid tumour and lymphoma patients treated with pulsed chemotherapy at Hurlingham Oncology Clinic and those treated by the same service at the Nairobi Hospital. RESULTS: Two hundred patients were evaluable for nadir blood counts. World Health Organisation (WHO) grade 3 neutropaenia complicated 57 (26.1%), and grade 4 complicated 56 (25.7%) treatments. Grade 0 neutropaenia was seen in 40 (18.4%) treatments, 33 having included prophylactic Granulocyte-Colony Stimulating Factors (G-CSF). Neutropaenia was worst following the first and sixth courses, and repeated second line courses but the difference was not statistically significant (p = 0.154). Fever complicated 6 grade 3 and 21 grade 4 neutropenic episodes (23.1% of 117 evaluable). Twenty eight patients were hospitalised because of severe neutropaenia (23 febrile, and five afebrile initially but with absolute neutrophil counts < 0.01 x 10(9)/litre). Eight of them died, six attributable to infections (21.4% mortality) and two attributed to other causes. Median time to neutrophil recovery to 21.5 x 10(9)/litre was three days with a mean of 4.6 days. Anaemia and thrombocytopaenia were not commonly experienced. CONCLUSION: Prophylactic use of G-CSF may have prevented severe neutropaenia and its use in severe neutropaenia may have reduced the duration and severity of neutropaenia but the mortality rate for febrile neutropaenia remained high.

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.

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.

OBJECTIVE: To determine the impact on neutrophils if adriamycin is administered at 60 mg/m2 and cyclophosphamide at 600/m2 (AC 60/600); and at 50 mg/m2 and 500 mg/m2 (50/500) in the treatment of breast cancer. DESIGN: Restrospective analysis of nadir neutrophil counts in female mammary carcinoma patients treated with adriamycin/cyclophosphamide combination. SETTING: Hurlingham Oncology Clinic, Nairobi and The Nairobi Hospital between March 1995 and August 1999. SUBJECTS: Eighteen patients with breast cancer were treated either for adjuvant purposes or for metastatic disease. INTERVENTION: Chemotherapy with adriamycin and cyclophosphamide at 60/600 or 50/500. Patients were advised to avoid crowded places and given prophylactic broadspectrum antibiotics whenever grade 4 neutropenia occurred at nadir. RESULTS: Grade 3-4 neutropenia occurred in 75.5% of treatments at 60/600 and in 56.8% of the treatments at 50/500. Febrile neutropenia followed only one treatment and did not result in death. CONCLUSION: Neutropenia is frequent and severe at A/C 60/600 and need to be watched out for. Sepsis on the other hand is prevented if meticulous attention is given and corrective measures taken. A/C 50/500 was associated with less occurrences of neutropenia though still very high. Neutropenia should therefore be checked and steps be taken to prevent sepsis even at this dosage.

OBJECTIVE: To determine the impact on neutrophils if adriamycin is administered at 60 mg/m2 and cyclophosphamide at 600/m2 (AC 60/600); and at 50 mg/m2 and 500 mg/m2 (50/500) in the treatment of breast cancer. DESIGN: Restrospective analysis of nadir neutrophil counts in female mammary carcinoma patients treated with adriamycin/cyclophosphamide combination. SETTING: Hurlingham Oncology Clinic, Nairobi and The Nairobi Hospital between March 1995 and August 1999. SUBJECTS: Eighteen patients with breast cancer were treated either for adjuvant purposes or for metastatic disease. INTERVENTION: Chemotherapy with adriamycin and cyclophosphamide at 60/600 or 50/500. Patients were advised to avoid crowded places and given prophylactic broadspectrum antibiotics whenever grade 4 neutropenia occurred at nadir. RESULTS: Grade 3-4 neutropenia occurred in 75.5% of treatments at 60/600 and in 56.8% of the treatments at 50/500. Febrile neutropenia followed only one treatment and did not result in death. CONCLUSION: Neutropenia is frequent and severe at A/C 60/600 and need to be watched out for. Sepsis on the other hand is prevented if meticulous attention is given and corrective measures taken. A/C 50/500 was associated with less occurrences of neutropenia though still very high. Neutropenia should therefore be checked and steps be taken to prevent sepsis even at this dosage.

OBJECTIVE: To determine the impact on neutrophils if adriamycin is administered at 60 mg/m2 and cyclophosphamide at 600/m2 (AC 60/600); and at 50 mg/m2 and 500 mg/m2 (50/500) in the treatment of breast cancer. DESIGN: Restrospective analysis of nadir neutrophil counts in female mammary carcinoma patients treated with adriamycin/cyclophosphamide combination. SETTING: Hurlingham Oncology Clinic, Nairobi and The Nairobi Hospital between March 1995 and August 1999. SUBJECTS: Eighteen patients with breast cancer were treated either for adjuvant purposes or for metastatic disease. INTERVENTION: Chemotherapy with adriamycin and cyclophosphamide at 60/600 or 50/500. Patients were advised to avoid crowded places and given prophylactic broadspectrum antibiotics whenever grade 4 neutropenia occurred at nadir. RESULTS: Grade 3-4 neutropenia occurred in 75.5% of treatments at 60/600 and in 56.8% of the treatments at 50/500. Febrile neutropenia followed only one treatment and did not result in death. CONCLUSION: Neutropenia is frequent and severe at A/C 60/600 and need to be watched out for. Sepsis on the other hand is prevented if meticulous attention is given and corrective measures taken. A/C 50/500 was associated with less occurrences of neutropenia though still very high. Neutropenia should therefore be checked and steps be taken to prevent sepsis even at this dosage.

OBJECTIVE: To determine the impact on neutrophils if adriamycin is administered at 60 mg/m2 and cyclophosphamide at 600/m2 (AC 60/600); and at 50 mg/m2 and 500 mg/m2 (50/500) in the treatment of breast cancer. DESIGN: Restrospective analysis of nadir neutrophil counts in female mammary carcinoma patients treated with adriamycin/cyclophosphamide combination. SETTING: Hurlingham Oncology Clinic, Nairobi and The Nairobi Hospital between March 1995 and August 1999. SUBJECTS: Eighteen patients with breast cancer were treated either for adjuvant purposes or for metastatic disease. INTERVENTION: Chemotherapy with adriamycin and cyclophosphamide at 60/600 or 50/500. Patients were advised to avoid crowded places and given prophylactic broadspectrum antibiotics whenever grade 4 neutropenia occurred at nadir. RESULTS: Grade 3-4 neutropenia occurred in 75.5% of treatments at 60/600 and in 56.8% of the treatments at 50/500. Febrile neutropenia followed only one treatment and did not result in death. CONCLUSION: Neutropenia is frequent and severe at A/C 60/600 and need to be watched out for. Sepsis on the other hand is prevented if meticulous attention is given and corrective measures taken. A/C 50/500 was associated with less occurrences of neutropenia though still very high. Neutropenia should therefore be checked and steps be taken to prevent sepsis even at this dosage.

Records were available for 197 patients with malignant lymphomas (MLs) aged 13 years and above seen at Kenyatta National Hospital (KNH) between the years 1973 and 1986. There were 110 cases of Hodgkin's disease (HD) and 87 cases of non-Hodgkin's lymphomas (NHLs). The distribution of the two groups according to sex and histologic sub-types was not significantly different. HD patients were on average significantly younger than NHL patients (28.8 years versus 41.1 years). Over 70% of both HD and NHL cases presented in stages III and IV and the distribution of the groups according to stage of disease was not statistically significant. There was no significant correlation between stage of disease at diagnosis and histologic subtypes for either group. Losses to follow-up were high in both groups. Female sex was associated with longer periods of follow-up in both groups, being statistically significant for HD and not so for NHLs. Age was not correlated with duration of follow-up for NHLS whereas for HD cases, older age (above 53 years) was associated with shortened follow-up periods. The mortality rate was higher in NHLs than in HD cases.

Records were available for 197 patients with malignant lymphomas (MLs) aged 13 years and above seen at Kenyatta National Hospital (KNH) between the years 1973 and 1986. There were 110 cases of Hodgkin's disease (HD) and 87 cases of non-Hodgkin's lymphomas (NHLs). The distribution of the two groups according to sex and histologic sub-types was not significantly different. HD patients were on average significantly younger than NHL patients (28.8 years versus 41.1 years). Over 70% of both HD and NHL cases presented in stages III and IV and the distribution of the groups according to stage of disease was not statistically significant. There was no significant correlation between stage of disease at diagnosis and histologic subtypes for either group. Losses to follow-up were high in both groups. Female sex was associated with longer periods of follow-up in both groups, being statistically significant for HD and not so for NHLs. Age was not correlated with duration of follow-up for NHLS whereas for HD cases, older age (above 53 years) was associated with shortened follow-up periods. The mortality rate was higher in NHLs than in HD cases.