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Background: Patients' satisfaction is an individual's positive assessment regarding a distinct dimension of healthcare and the perception about the quality of services offered in that health facility. Patients who are not satisfied with healthcare services in a certain health facility will bypass the facility and are unlikely to seek treatment in that facility. Objective: To determine satisfaction level of mothers with the free maternal services in selected Kenyan public health facilities after the implementation of the free maternal healthcare policy. Methods: Data was collected through a quantitative exit survey questionnaire. The respondents were mothers who had delivered in the health facilities and were waiting to leave the health facilities after discharge. The sample included 2,216 mothers in 77 public health facilities across 14 counties in Kenya under tier 3 and tier 4 categories. The number of respondents to be interviewed was proportionately arrived at based on each health facility's bed capacity. Results: The study established a satisfaction rate of 54.5% among the beneficiaries of the free maternal healthcare services in the country. Mothers benefiting from the free delivery services were satisfied with communication by the healthcare workers, staff availability in the delivery rooms, availability of staff in the wards, and drug and supplies availability (>56%) but unsatisfied with consultation time, cleanliness, and privacy in the wards (<56%). High education levels and lengthy stay in healthcare facilities were negatively associated with the satisfaction with the free delivery services (P < 0.05). Conclusion: There is a high satisfaction with the free maternal healthcare services in Kenya. However, the implementation of the free maternal healthcare policy was associated with low privacy, poor hygiene, and low consultation time in the health facilities. Therefore there is need to address these service gaps so as to attract more mothers to deliver in public health facilities.

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BACKGROUND: Kenya abolished delivery fees in all public health facilities through a presidential directive effective on June 1, 2013 with an aim of promoting health facility delivery service utilization and reducing pregnancy-related mortality in the country. This paper aims to provide a brief overview of this policy's effect on health facility delivery service utilization and maternal mortality ratio and neonatal mortality rate in Kenyan public health facilities. METHODS: A time series analysis was conducted on health facility delivery services utilization, maternal and neonatal mortality 2 years before and after the policy intervention in 77 health facilities across 14 counties in Kenya. RESULTS: A statistically significant increase in the number of facility-based deliveries was identified with no significant changes in the ratio of maternal mortality and the rate of neonatal mortality. CONCLUSION: The findings suggest that cost is a deterrent to health facility delivery service utilization in Kenya and thus free delivery services are an important strategy to promote utilization of health facility delivery services; however, there is a need to simultaneously address other factors that contribute to pregnancy-related and neonatal deaths.

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BACKGROUND: Cytomegalovirus (CMV) infection in susceptible patients is associated with serious morbidity and a high mortality. Transmission of cytomegalovirus infection through blood transfusion is markedly reduced by transfusion of CMV seronegative blood products, or by transfusion of leucodepleted blood products. OBJECTIVE: To determine the prevalence CMV IgG and IgM antibodies among blood donors at the National Blood Transfusion Services (NBTS), Nairobi. DESIGN: Cross-sectional descriptive study. SETTING: Four hundred participants were recruited from blood donors at the NBTS and testing was done at the Kenyatta National Hospital (KNH) immunology laboratories and the NBTC. MAIN OUTCOME MEASURES: Social demographic data and the CMV serologic status for the participants was determined and documented as being positive or negative for immunoglobulin G (IgG) and immunoglobulin M (IgM). The age, gender, marital status, education level and geographical area of residence of the participants were documented. Corresponding results of HIV, hepatitis B antigen, hepatitis C antibody from the patients were obtained from the NBTS. RESULTS: Majority of the blood donors recruited were male at 57.9%. Most blood donors were aged 16-20 years (42.5%) and only 17.2% were above 30 years of age. Unmarried blood donors, those with secondary school education and an income between Kshs 5000 (US $67) and KShs 50,000 (US$ 667) monthly were the majority at 78.5%, 54.8% and 66.1% respectively. Sexually active blood donors constituted 60.5% of the donors recruited. Positivity for transfusion transmissible infections (TTI) tested was 1.3%, 0.3%, 2.3% and 1.0% for human immunodeficiency virus (HIV), syphilis, hepatitis B and hepatitis C respectively. Anti- CMV IgG and IgM positivity was 97.0%, (95% CI 96.45-97.53%), and 3.6% (95% CI 1.7-5.2%), respectively. There was no statistical difference between different ages, marital status, salary, individual's sexuality in the prevalence of CMV antibodies. However females had a higher prevalence of CMV antibodies. CONCLUSION: There is a very high prevalence of cytomegalovirus antibodies among blood donors at the NBTS, with virtually all blood donors having been exposed to the virus. Since the CMV remains latent within leucocytes after infection inspite of the prescence of antibodies in seropositive individuals, leucoreduction of blood products is recommended before transfusion to seronegative susceptible patients. In Kenya, susceptible groups of patients include very low birthweight babies, patients with acquired immune deficiency syndrome (AIDS) due to human immunodeficiency virus infections (HIV) patients, patients on myelosuppressive cancer therapy and recipients of kidney transplants. Further studies are recomended to determine the prevalence of CMV antibodies in these patients in order to establish the magnitude of the demand for CMV safe blood.

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OBJECTIVES: To describe the clinical characteristics of Burkitt's lymphoma (BL) from three regions in Kenya at different altitudes with a view towards understanding the contribution of local environmental factors. DESIGN: Prospective cross-sectional study. SETTING: Kenyatta National Hospital and seven provincial hospitals in Kenya. METHOD: Histologically proven cases of Burkitt's lymphoma in patients less than 16 years of age were clinically examined and investigated. MAIN OUTCOME MEASURES: For every case the following parameters were documented: chief complaint(s); physical examination, specifically pallor, jaundice, oedema, lymphadenopathy, presence of masses, splenomegaly and hepatomegaly. Reports of evaluation of chest radiograph, abdominal ultrasound/scan, bone marrow aspiration, cerebral spinal fluid cytology, liver and kidney function tests, urinalysis, stool occult blood and full blood count results. Stage of disease was assigned A, B, C or D. Cases of BL from three provinces of Kenya with diverse geographical features were analysed: Central, Coast, and Western. RESULTS: This study documented 471 BL cases distributed as follows: Central 61 (males 39 and 22 females), M:F ratio 1.8:1; Coast 169 (111 males and 58 females), M:F ratio 1.9:1; and Western 241 (140 males and 101 females), M:F ratio 1.4:1. The major presenting complaints were: abdominal swelling--Central 36%, Coast 4% and Western 26%; swelling on the face--Central 31%, Coast 81% and Western 64%; and proptosis--Central 3%, Coast 1% and Western 9%. The mean duration of these complaints in weeks were Central 6.9, Coast 6.08, and Western 5.05. The initial physical finding was a tumour mass in 39%, 72% and 54% of cases for Central, Coast and Western respectively. Tumour stage at diagnosis was: stage A--Central 21%, Coast 43% and Western 34%; stage B--Central 10%, Coast 5% and Western 10%; stage C--Central 41%, Coast 34% and Western 30%; and stage D--Central 28%, Coast 17% and Western 26%. For the age and sex matched cases the results show that commonly involved sites were: abdomen--Central 35%, Coast 9% and Western 14%; jaw (mandible)--Central 24%, Coast 22% and Western 31%; maxilla--Central 6%, Coast 24% and Western 11%; and lymph nodes--Central 10%, Coast 4% and Western 8%. The disease stage was A--Central 33%, Coast 44% and Western 36%; stage B--Central 11%, Coast 10% and Western 27%; stage C--Central 39%, Coast 34% and Western 27%; and stage D--Central 21%, Coast 13% and Western 37%. CONCLUSION: This study shows that clinical features of childhood BL vary with geographical region. The variations are documented in proportion of jaw, maxilla, abdominal and lymph nodal sites involvement. The differences observed are potentially due to the local environmental factors within these provinces. BL cases from Western province had features, intermediate between endemic and sporadic. Coastal province BL cases were similar to endemic BL, while BL cases from Central province resembled more or less sporadic BL subtypes. Strategies to explain and investigate the local environmental factors associated with the observed differences may certainly contribute towards improved understanding and clinical management of BL.

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OBJECTIVES: To determine the effectiveness of an oral combination chemotherapy regimen administered to patients with AIDS-associated Hodgkin's disease. DESIGN: Prospective, pilot phase II clinical trial. SETTING: Consecutive patient recruitment occurred at two medical centers in the United States: Albany Medical Center, Albany, New York, where patients were recruited prior to December 31, 1996 (pre-HAART era); and University Hospitals of Cleveland, Cleveland, Ohio, where patients were recruited after January 1, 1997 (HAART era). INTERVENTION: Oral chemotherapy consisted of lomustine (100 mg/m2 day I for cycle one and odd cycles thereafter); etoposide (200 mg/m2 days 1 through 3); and cyclophosphamide and procarbazine (each 100 mg/m2 days 22 through 31). Cycles were repeated every six weeks. Colony-stimulating factor support (G-CSF in all instances) was allowed. MAIN OUTCOME MEASURES: Clinical demographic variables, peripheral blood counts, serum chemistries, CD4 lymphocyte count, histopathological subtype of Hodgkin's disease were identified for all patients, who were staged according to Ann Arbor criteria. DATA ANALYSIS: Common Toxicity Criteria were utilized to assess safety; response was assessed using ECOG criteria; and survival was analyzed by Kaplan-Meier methods and difference of survival between pre-HAART and HARART era was compared using log-rank test. RESULTS: Eleven patients (six in pre-HAART era), all but one male, with a median age of 36 years, excellent performance status and advanced International Prognostic Score were treated. Myelosuppression was the major side effect and there were minimal other grade 3 or greater toxicity all of which were promptly reversible. An overall objective response rate of 82% (with 18% complete responses) and median survival duration of 24 months (range 2.5 +/- 68) were observed. Survival was markedly improved in patients treated in the HAART era (median not reached versus 7.25 months, p = 0.034). CONCLUSIONS: This feasibility study demonstrates acceptable tolerance and excellent clinical activity of oral combination chemotherapy in patients with AIDS-associated Hodgkin's disease. Improved survival is observed in combination with HAART therapy. Dose-modification of this regimen would be suitable to evaluate in the resource constrained setting and larger confirmatory studies are encouraged.

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BACKGROUND: Strategies to circumvent or lessen the myelotoxicity associated with combination chemotherapy may improve the overall outcome of the management of patients particularly in resource poor settings. OBJECTIVES: To develop effective non-myelotoxic therapies for Burkitt's Lymphoma (BL) and AIDS-related non-Hodgkin's lymphoma. DATA SOURCES: Publications, original and review articles, conference abstracts searched mainly on Pubmed indexed for medline. DATA EXTRACTION: A systematic review of the clinical problem of combination chemotherapy. Identification of clinical strategies that circumvent or lessen the myelotoxicity of combination cytotoxic chemotherapy. Length of survival, lack of clinically significant (> grade 3) myelosuppression and weight loss were used as markers of myelotoxicity. DATA SYNTHESIS: Review of published experience with some of these strategies including dose-modification of multi-agent chemotherapy; rationale for targeted therapies, and the preclinical development of a mouse model exploring the role of metronomic scheduling substantiate pragmatism and feasibility of these approaches. CONCLUSION: Myelotoxic death rates using multi-agent induction chemotherapy approach 25% for endemic Burkitt's lymphoma and range between 20% to 60% for AIDS-related malignancy. This is mostly explained by the paucity of supportive care compounded by wasting and inanition attributable to advanced cancer and HIV infection making patients more susceptible to myelosuppressive side effects of cytotoxic chemotherapy. Investigations and alternative approaches that lessen or circumvent myelotoxicity of traditional cytotoxic chemotherapy for the management of Burkitt's lymphoma and AIDS-related non-Hodgkin's lymphoma in the resource-constrained setting are warranted. Pertinent pre-clinical and clinical data are emerging to support the need for abrograting the myelosuppressive effects of traditional cytotoxic chemotherapy. This can be achieved by developing targeted anti-viral and other strategies, such as the use of bryostatin 1 and vincristine, and by developing a preclinical mouse model to frame the clinical rationale for a pilot trial of metronomic therapy for the treatment of Burkitt's and AIDS-related lymphoma. Implementation of these investigational approaches must be encouraged as viable anti-cancer therapeutic strategies particularly in the resource-constrained settings.

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BACKGROUND: The quality of life of cancer patients is likely to be influenced by psychological reactions of the cancer patients yet there are no documented issues related to quality of life in cancer patients in Kenyan hospitals. OBJECTIVE: To investigate issues which affect the quality of life in male cancer patients. DESIGN: Prospective cross sectional study. SETTING: Kenyatta National Hospital, Nairobi, Kenya. METHODS AND SUBJECTS: Cancer patients above 12 years of age were interviewed during the course of their stay in the hospital, specifically to gather information on; semi structured questions and a modified Beck's 24 item depression inventory with a view to solicit for their reaction on issues which pertains to quality of life. MAIN OUTCOME MEASURES: Age group, level of education, tribe, geographical place (province) of birth, chief complains, main concerns, views on doctors, contact with psychiatrist and psychologist, the anatomic site of cancer, treatment given and responses on modified Beck's depression inventory. RESULTS: Forty two patients were studied, their age range 13-72 years, mean 43.2 and peak 13-26 years. Forty seven per cent of cases had no formal education. The cancers were gastrointestinal tract 33%, blood and lymphoid tissue (26%), bone and muscle (11.9%), skin (9.4%) and genitourinary tract (4.8%). Treatment given was chemotherapy, radiotherapy and surgery. Ninety three per cent were unable to cope. Chief complaints were pain, inability to work, feeling miserable and concerns were families, health and work retardation. Modified Beck's depression score was 20%, with major issues being; work retardation, insomnia, weight loss, and anorexia. Most affected were, age group 27-35 years (and least 13-26 years), uneducated, living in Nairobi (city), having carcinomas, treatment with combined surgery and radiotherapy. Low education level and residence in Nairobi coped poorly. Radiation therapy group appeared to cope better than other modalities. CONCLUSION: The issues affecting the quality of life of male cancer patients stated were pain, inability to work, poor coping with cancer and psychological reactions of work retardation, insomnia, weight loss, fatigability and depression. Gambling, suicidal ideas and social withdrawal were minimal. Other concerns were families, health and work.

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OBJECTIVE: To identify autotransfusion strategies and their basis in elective surgery patients. DESIGN: A cross sectional prospective study. SETTING: General surgery and orthopaedic wards, Kenyatta National Hospital, Nairobi. SUBJECTS: Adult patients of both sexes planned for elective surgery. MAIN OUTCOME MEASURE: Forevery patient, the following were enquired about and documented: age in years, sex, ethnicity, religion, occupation and educational standard. Blood values of haemoglobin, platelet counts, total and differential white cell counts, urea, electrolytes and liver function tests were assayed. Others were the number of units of blood donated before the operation, the type of surgery performed, time taken from diagnosis to performing the operation and whether the blood was transfused preoperatively, intraoperatively and postoperatively. RESULTS: A total of sixty three cases constituting five per cent of all surgical patients admitted during the period of study were evaluated. Of these 53 (84%) were males and ten (16%) females. The age range was 15 to 65 years with a peak at 45-49 years. There were more Christians (90%) than Muslims (10%). In all, 32 (51.6%) had primary school education, 23 (36.5%) secondary school education, seven (11.3%) no formal education and one (1.6%) had attained college level. Employment pattern showed 50% were civil servants, 30% were self employed and 20% were unemployed. The duration of disease ranged from 1-24 weeks with two peaks at two weeks and six weeks. Orthopaedic cases constituted 78.7% and general surgery 21.3%. Preoperative haemoglobin ranged from 13.5-14.2 g/dl. Transfusions were given intraoperatively to 41 (66.1%) and to 12 (33.9%) postoperatively. Mean duration of hospitalisation was 13 days (range 5 to 21 days). 98.4% deposited only one unit while 1.6% deposited four units of blood. Only one patient required additional transfusion from homologous donors. CONCLUSION: The strategies and basis for autotransfusion have been demonstrated among a majority of adult patients requiring orthopaedic procedures. Major determinants are shown to be baseline blood count profiles and time to operation.

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Granulocytic sarcoma (GS) is a rare extramedullary solid tumour composed of malignant immature cells of the granulocytic series. It may herald, accompany or signal acute myeloid leukaemia (AML) or chronic granulocytic leukaemia (CGL). GS may also occur in patients with myelodysplastic syndromes (MDS) where it is a sign of imminent disease progression. Three cases of GS are presented; the first one involving the pancreas and preceding AML, the second case affecting uterine cervix in stable phase CGL and the third case is GS of the breast accompanying AML. Any site of the body may be involved by the GS, and morbidity depends on the local organ/tissue affected in addition to the attending primary leukaemia or MDS. Treatment of GS involves surgery, radiotherapy and chemotherapy. The objective of this communication is to enhance awareness in personnel providing health care. Further, early diagnosis and treatment affects overall outcome.

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Forty two children with aplastic anaemia were seen at Kenyatta National Hospital, Nairobi, over a period of 8 years (1980-1988). These have been analysed with respect to sex, age and area of geographical origin. The overall male:female ratio is 1:1 with a preponderance of Kikuyu patients. Repeated transfusions was the commonest presenting feature and rapid onset was associated with poor prognosis. Exposure to herbicides/pesticides and other agrochemicals is implicated in the aetiopathogenesis of childhood aplastic anaemia in Kenya.

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