Khama Rogo

HIV and cervical cancer in Kenya

Objectives: To determine the effect of the HIV epidemic on invasive cervical cancer in Kenya. Methods: Of the 3902 women who were diagnosed with reproductive tract malignancies at Kenyatta National Hospital (KNH) from 1989 to 1998, 85% had invasive cervical cancer. Age at presentation and severity of cervical cancer were studied for a 9‐year period when national HIV prevalence went from 5% to 5–10%, to 10–15%. Results: There was no significant change in either age at presentation or severity of cervical cancer. Of the 118 (5%) women who were tested for HIV, 36 (31%) were seropositive. These women were 5 years younger at presentation than HIV‐negative women. Conclusions: A two‐ to three‐fold increase in HIV prevalence in Kenya did not seem to have a proportional effect on the incidence of cervical cancer. Yet, HIV‐positive women who presented with cervical cancer were significantly younger than HIV‐negative women.

Carcinoma of the cervix in the African setting.

Carcinoma of the cervix is the commonest female malignancy in sub‐Saharan Africa today. A brief description of its prevalence and distribution is given. Kenyan data is then used to illustrate the predominance of advanced disease in mostly premenopausal women (70%) of high parity. Follow up is characteristically poor and treatment results, although difficult to calculate with accuracy, are also poor. These are compared to FIGO statistics. Against this background aspects peculiar to the tumor, patient and treatment facilities in Africa are cited and discussed with reference to current relevant literature.

Preventing Unsafe Abortion in Western Kenya: An Innovative Approach Through Private Physicians

Abstract Complications of unsafe abortion remain one of the major causes of maternal morbidity and mortality in Africa - up to 55 per cent of deaths and chronic and debilitating sequelae.1I Where there are restrictive abortion laws and/or limited access to trained service providers, women are forced to resort to clandestine, unsafe methods. In such places, there is often a large body of private physicians who are assumed to be either aloof or mercenary with regard to post-abortion care; their potential contribution to reproductive health care remains under-utilised. This paper describes the firstyears experiences of a project we launched in Western Kenya to form a network of private physicians and train them to provide comprehensive, affordable post-abortion care and family planning. Links between this network and primary health care workers and local womens groups are currently being made and will further enhance the potential for reducing the incidence of both unwanted pregnancies and dangerous abortions. Setting up and expanding such networks is an important practical and innovative approach to realising the goals of safe motherhood.

Evaluation of a ketamine-based anesthesia package for use in emergency cesarean delivery or emergency laparotomy when no anesthetist is available

To assess the safety of a ketamine‐based rescue anesthesia package to support emergency cesarean delivery and emergency laparotomy when no anesthetist was available.

Safety and Feasibility of a Ketamine Package to Support Emergency and Essential Surgery in Kenya When No Anesthetist is Available: Reply

In Reply, Litswa and four members of the World Federation of Societies of Anaesthesiologists (WFSA) comment on our manuscript, ‘‘Safety and Feasibility of a Ketamine Package to Support Emergency and Essential Surgery in Kenya when No Anesthetist is Available: An Analysis of 1216 Consecutive Operative Procedures’’ [1]. Like our colleagues from the WFSA, we fully support national workforce planning and training of anesthetists in lowand middle-income countries. We urge expansion of accredited anesthetist training programs around the world. Everyone should have access to safe and timely emergency and essential surgical care when needed, which includes trained and qualified anesthetists. But, it is important to recognize that anesthetists are often unavailable in lowresource settings, the consequences of which are unnecessary death and disability [2]. Clearly, it will be at least decades before there are sufficient anesthetists in many low-resource countries. According to the WFSA Global Anesthesia Workforce Survey, the density of anesthesia providers in Kenya is 0.44 per 100,000 population [3]. Compounding this, the College of Anesthesiologists of East, Central, and Southern Africa (CANECSA) report that anesthesia providers are unevenly distributed. For example, CANECSA reports that in Mandera County there officially are 0.14 anesthetists per 100,000 population. Audits by our research team and members of the Kenya Obstetrics and Gynecology Society (KOGS), and independent analysis by the Boston Consulting Group demonstrate that the presence of anesthesia providers is far less than reported. The lack of anesthetists contributes to very low number of surgical procedures in lowand middle-income countries in Africa (median of 29 procedures per hospital per week) [4]. With cesarean delivery rates as low as 6.7% of WHO recommendations for optimal outcomes in several Kenyan counties and beyond [5], we challenge Dr. Litswa, the WFSA and all of us to stand together and listen to the cries of dying mothers in obstructed labor, and the pleas of surgeons at their sides who are stymied by the lack of anesthesia services. All patients in our study had comprehensive preoperative evaluations. Operative outcomes were assessed during the intraoperative, perioperative, and postoperative periods. During procedures, patients were continually monitored and details recorded (http://www.mghglobalhealth.org). ESM-Ketamine providers were supervised by surgeons who were ultimately responsible for patient safety. No intraoperative adverse events occurred other than the ones reported in the manuscript. To ensure data accuracy, & Thomas F. Burke tfburke@mgh.harvard.edu

Intraoperative awareness and experience with a ketamine-based anaesthesia package to support emergency and essential surgery when no anaesthetist is available

Introduction Five of the 7.2 billion people on earth have limited access to emergency and essential surgical procedures. The lack of safe, affordable and timely anaesthesia services are primary barriers to universal surgical coverage. The objective of this study was to assess intraoperative awareness when the ‘Every Second Matters for Emergency and Essential Surgery – Ketamine’ (ESM-Ketamine) package was used to support emergency and essential surgeries and painful procedures in rural Kenya when no anaesthetist was available. Methods Forty-seven consecutive adult patients that underwent an operative procedure under ESM-Ketamine at Sagam Community Hospital in Luanda, Kenya were enrolled. Participants underwent two semi-structured interviews that explored the patient’s experience with ESM-Ketamine both after the operative procedure and four to six weeks after surgery. Results Forty-seven participants completed the first interview and 37 (78.7%) the second interview. Thirty-seven (78.7%) cases were procedural sedations and ten were (21.3%) emergency surgeries. Intraoperative awareness occurred in nine (24.3%) participants who underwent procedural sedation and two (20%) who underwent emergency surgery. Twenty-six (55.3%) participants reported dreams during the procedure. Thirty-two (86.5%) participants considered their experience positive, and 35 (95%) would recommend a procedure supported by ketamine to a friend. Discussion Most patients whose painful procedures and emergency operations were supported by the ESM-Ketamine package when no anaesthetist was available reported favourable experiences.