Cervical cancer management in a low resource setting: A 10-year review in a tertiary care hospital in Kenya.

Background: Cervical cancer is one of the leading causes of cancer mortality among women in Kenya due to late presentations, poor access to health care, and limited resources. Across many low- and middle-income countries infrastructure and human resources for cervical cancer management are currently insufficient to meet the high population needs therefore patients are not able to get appropriate treatment. Objective: This study aimed to describe the clinicopathological characteristics and the treatment profiles of cervical cancer cases seen at Moi Teaching and Referral Hospital (MTRH). Methods: This was a retrospective cross-sectional study conducted at MTRH involving the review of the electronic database and medical charts of 1541 patients with a histologically confirmed diagnosis of cervical cancer between January 2012 and December 2021. Results: Of the 1541 cases analyzed, 91% were squamous cell carcinomas, 8% were adenocarcinomas, and 1% were other histological types. Thirty-eight percent of the patients were HIV infected and less than 30% of the women had health insurance. A majority (75%) of the patients presented with advanced-stage disease (stage IIB-IV). Only 13.9% received chemoradiotherapy with curative intent; of which 33.8% received suboptimal treatment. Of the 13% who received surgical treatment, 45.3% required adjuvant therapy, of which only 27.5% received treatment. Over 40% of the women were lost to follow-up. Conclusion: Most of the patients with cervical cancer in Kenya present at advanced stages with only a third receiving the necessary treatment while the majority receive only palliative treatment or supportive care.

The every woman study™ low- and middle-income countries edition protocol: A multi-country observational study to assess opportunities and challenges to improving survival and quality of life for women with ovarian cancer.

BACKGROUND: Ovarian cancer is a challenging disease to diagnose and treat effectively with five-year survival rates below 50%. Previous patient experience research in high-income countries highlighted common challenges and opportunities to improve survival and quality of life for women affected by ovarian cancer. However, no comparable data exist for low-and middle-income countries, where 70% of women with the disease live. This study aims to address this evidence gap. METHODS: This is an observational multi-country study set in low- and middle-income countries. We aim to recruit over 2000 women diagnosed with ovarian cancer across multiple hospitals in 24 countries in Asia, Africa and South America. Country sample sizes have been calculated (n = 70-96 participants /country), taking account of varying national five-year disease prevalence rates. Women within five years of their diagnosis, who are in contact with participating hospitals, are invited to take part in the study. A questionnaire has been adapted from a tool previously used in high-income countries. It comprises 57 multiple choice and two open-ended questions designed to collect information on demographics, women's knowledge of ovarian cancer, route to diagnosis, access to treatments, surgery and genetic testing, support needs, the impact of the disease on women and their families, and their priorities for action. The questionnaire has been designed in English, translated into local languages and tested according to local ethics requirements. Questionnaires will be administered by a trained member of the clinical team. CONCLUSION: This study will inform further research, advocacy, and action in low- and middle-income countries based on tailored approaches to the national, regional and global challenges and opportunities. In addition, participating countries can choose to repeat the study to track progress and the protocol can be adapted for other countries and other diseases.

Epidemiological profile and clinico-pathological features of pediatric gynecological cancers at Moi Teaching & Referral Hospital, Kenya.

Background: The main pediatric (0-18 years) gynecologic cancers include stromal carcinomas (juvenile granulosa cell tumors and Sertoli-Leydig cell tumors), genital rhabdomyosarcomas and ovarian germ cell. Outcomes depend on time of diagnosis, stage, tumor type and treatment which can have long-term effects on the reproductive career of these patients. This study seeks to analyze the trends in clinical-pathologic presentation, treatment and outcomes in the cases seen at our facility. This is the first paper identifying these cancers published from sub-Saharan Africa. Method: Retrospective review of clinico-pathologic profiles and treatment outcomes of pediatric gynecologic oncology patients managed at MTRH between 2010 and 2020. Data was abstracted from gynecologic oncology database and medical charts. Results: Records of 40 patients were analyzed. Most, (92.5%, 37/40) of the patients were between 10 and 18 years. Ovarian germ cell tumors were the leading histological diagnosis in 72.5% (29/40) of the patients; with dysgerminomas being the commonest subtype seen in 12 of the 37 patients (32.4%). The patients received platinum-based chemotherapy in 70% of cases (28/40). There were 14 deaths among the 40 patients (35%). Conclusion: Surgery remains the main stay of treatment and fertility-sparing surgery with or without adjuvant platinum-based chemotherapy are the standard of care with excellent prognosis following early detection and treatment initiation. LMICs face several challenges in access to quality care and that affects survival of these patients. Due to its commonality, ovarian germ cell cancers warrant a high index of suspicion amongst primary care providers attending to adnexal masses in this age group.

Predictors of Bacterial Vaginosis among Pregnant Women Attending Antenatal Clinic at Tertiary Care Hospital in Tanzania: A Cross Sectional Study.

BACKGROUND: Bacterial vaginosis (BV) is one of the most common genital tract infections in pregnancy associated with an increased risk of pregnancy losses, maternal and perinatal morbidity and mortality. Different social behavioural and obstetric factors can contribute to the development of BV. Determining the predictors of BV could be the best way of identifying women at high risk of developing the disease. METHODS: This was a cross-sectional study conducted between December 2017 and February 2018 to determine the prevalence and predictors of BV among pregnant women attending antenatal Clinic (ANC) at Muhimbili National Hospital (MNH), Tanzania. Participants were recruited using systematic random sampling. For each consented participant, a pretested questionnaire was filled, a pelvic examination was done and a sample was collected. BV was diagnosed using Nugent's score. Data was analysed using Statistical Package for Social Scientists (SPSS) version 23.0. Bivariate and multivariate logistic regression analysis was done to determine factors that were independently associated with BV. RESULTS: 178 (26.7%) pregnant women out of 667 were diagnosed positive for BV. In the bivariate analysis (Table 3), age (COR 1.71; 95% CI, 1.16-2.52), level of education (COR 4.08, 95% CI, 2.84-5.84), gravidity (COR, 1.52, 95% CI; 1.04-2.23), parity (COR 1.69, 95% CI; 1.18-2.42), vaginal douching (COR 2.89, 95% CI; 1.96-4.27), HIV status (COR 9.37, 95%CI; 4.12-21.28), history of STI (COR 2.49 95% CI; 1.46-4.25), LTSP (COR 2.76, 95% CI; 1.68-4.54) and age of first coitus (COR 3.19, 95% CI; 2.24-4.56) were significantly associated with BV. After adjusting for confounders in multivariate analysis, the following risk factors remained significantly associated with BV; age of 21-29 years (AOR, 2.22, 95%CI; 1.45-3.49), primary education level (AOR 3.97, 95% CI; 2.63-5.98), vaginal douching (AOR 3.68, 95% CI; 2.35-5.76), HIV status (AOR 6.44, 95% CI; 2.62-15.88), STI infection (AOR 2.34, 95% CI; 1.25-4.37), more than one LTSP (AOR 2.69, 95% CI; 1.53-4.74) and age of less than 18 years of first coitus (AOR 2.16, 95% CI; 1.42-3.30). CONCLUSION: The prevalence of BV in pregnant women was found to be high. Age of less than 30 years, primary education level and below, vaginal douching, HIV infection, STI, more than one lifetime sexual partners and early age of sexual debut were found to be significant predictors of BV. The high prevalence of BV in our population should necessitate policy makers to include screening and treatment of BV in the future policy of antenatal care package, as BV is associated with significant maternal and neonatal morbidity and mortality. Women should also be educated on harmful effects of certain behavioural practices such as vaginal douching that predispose to BV. In addition symptoms of BV such as abnormal vaginal discharge during pregnancy are inconsistent, under reported and often overlooked. Therefore, a high-risk approach can be used for screening and treatment of asymptomatic women.

Protection of mice against visceral leishmaniasis by immunization with promastigote antigen incorporated in liposomes.

Leishmanial antigens (LAg) were used as a vaccine against Leishmania donovani, the causative agent of visceral leishmaniasis. BALB/c mice, immunized intraperitoneally with 20 micrograms of the antigen in phosphate-buffered saline (PBS) or entrapped in liposomes, were infected intravenously with 2 x 10(7) L. donovani promastigotes. Mice immunized with PBS and empty liposomes showed similar levels of parasite burdens in the liver and spleen. Injection of the antigen alone or entrapped in liposomes, followed with infection, induced significant levels of protection against the disease. After 2 and 4 mo of infection, mice immunized with free antigen induced 7.4% and 50.7% reduction in the liver parasite burden, respectively, compared to control (PBS) mice. With antigen encapsulated in liposome, the liver parasite burden was further reduced by 30.4% and 73% at 2 and 4 mo by infection, respectively. Splenic parasite burden was very low at 2 mo of infection. At 4 mo, the parasite level was reduced by 54.2% with free antigen and 69.3% with antigen entrapped in liposomes. Whereas the protection induced by the free antigen is mainly cell mediated, stimulation of an antibody response together with a strong delayed-type hypersensitivity may be responsible for the better protection with liposomal antigen.

Isotype profiles of Leishmania donovani-infected BALB/c mice: preferential stimulation of IgG2a/b by liposome-associated promastigote antigens.

Leishmaniasis presents a complex spectrum of diseases and immunological manifestations depending upon both the species of the microorganism and the host it infects. BALB/c mice, which are homozygous for Lsh(s) on chromosome 1, are genetically susceptible to the visceralizing species of Leishmania. Infection of these mice with an Indian strain of Leishmania donovani showed a steady rise in the level of parasite burden in both the liver and the spleen to 24 wk. To investigate the immune responses determining the course of infection, we studied the relative levels of specific IgG, IgM, and IgA antibodies, and IgG isotypes, in the sera of diseased and protectively immunized mice at different periods of infection. IgG1 and IgG2a were stimulated in the control, infected, and immunized mice after parasite challenge. However, an early induction of IgG1 in the normal infected mice and stimulation of IgG2a and IgG2b isotypes prior to parasite challenge in liposome-antigen-immunized mice suggest that the elicitation of a particular subset of CD4+ T cells at the onset of disease may be responsible for either progression or resolution of infection.

Induction of partial protection against Leishmania donovani by promastigote antigens in negatively charged liposomes.

Negatively charged liposomes, proposed as potential vaccine adjuvants, have been extensively studied in association with various antigens. In the present study, we investigated the adjuvanicity of negatively charged liposomes to enhance the protective immunity of membrane antigens of Leishmania donovani promastigotes (LAg). In comparison to the control mice immunized with phosphate-buffered saline and empty liposomes, immunization with free LAg led to significant levels of protection against infection with virulent promastigotes. Encapsulation of LAg in liposomes also induced effective protection. However, the level of protection by LAg-liposome was not significantly different from that induced by free LAg. Investigation of the immune responses showed, in contrast to free LAg, that immunization with LAg-liposome elicited strong antibody responses. IgG isotype analysis revealed the presence of all 4 isotypes. However, the titer of IgG1 was significantly higher than IgG2a, IgG2b, and IgG3. Following infection, stimulation of IgG and IgG isotypes did not differ in the different immunization groups. Delayed-type hypersensitivity (DTH) analysis after immunization showed significant induction by LAg and LAg-liposomes, in comparison to controls. With infection, again, the level of DTH in all the groups became almost comparable. Stimulation of insufficient cellular response, as reflected by DTH and potentiation of IgG1 over IgG2a, IgG2b, and IgG3 suggest a dominance of Th2 response with this liposome-antigen formulation, resulting in weak protection against visceral leishmaniasis.

Leishmanicidal activity of stearylamine-bearing liposomes in vitro.

Liposomes consisting of stearylamine (SA) and egg yolk phosphatidylcholine (PC) were studied for their cytotoxic activity against freshly transformed promastigotes and intracellular amastigotes of Leishmania donovani, the causative agent of visceral leishmaniasis. More than 99% of the parasites of strain AG83 were killed within 60 min by treatment with 22 mol% SA-PC liposomes (132 microg/ml total lipids). This was further confirmed by incubating the liposome-treated promastigotes at 22 C for 96 hr. The killing activity of the liposomes progressively decreased with lowering lipid concentration. However, weak cytotoxic activity was still detected at 6.6 microg/ml lipids. Leishmanicidal activity of the liposomes became stronger with increasing SA content but was reduced with the incorporation of cholesterol in the liposomes. A similar cytotoxic effect was observed on other Indian strains of L. donovani, for example PKDL and DD8, as well as on species such as Leishmania donovani S1, Leishmania donovani infantum, Leishmania tropica, Leishmania amazonensis, and Leishmania mexicana. However, freshly transformed promastigotes appeared to be more susceptible than the ones subcultured. The strong leishmanicidal activity of SA-PC liposomes was also demonstrated toward intracellular L. donovani amastigotes. The SA-bearing vesicles could effectively inhibit the growth and multiplication of the parasites within the macrophages. The cytolytic activity of these liposomes on leishmanial parasites and low toxicity on host macrophages may, thus, find application in the therapy of leishmaniasis.

Regulated expression of CXCR4 constitutive active mutants revealed the up-modulated chemotaxis and up-regulation of genes crucial for CXCR4 mediated homing and engraftment of hematopoietic stem/progenitor cells.

SDF-1/CXCR4 axis plays a principle role in the homing and engraftment of hematopoietic stem/progenitor cells (HSPCs), a process that defines cells ability to reach and seed recipient bone marrow niche following their intravenous infusion. However, the proper functioning of CXCR4 downstream signaling depends upon consistent optimal expression of both SDF-1 ligand and its receptor CXCR4, which in turn is variable and regulated by several factors. The constitutive active mutants of CXCR4 (N119A and N119S) being able to induce autonomous downstream signaling, overcome the limitation of ligand-receptor interaction for induction of CXCR4 signaling. Therefore, we intended to explore their potential in Chemotaxis; a key cellular process which crucially regulates cells homing to bone marrow. In present study, Tet-on inducible gene expression vector system was used for doxycycline inducible regulated transgene expression of CXCR4 active mutants in hematopoietic stem progenitor cell line K-562. Both of these mutants revealed significantly enhanced Chemotaxis to SDF-1 gradient as compared to wild type. Furthermore, gene expression profiling of these genetically engineered cells as assessed by microarray analysis revealed the up-regulation of group of genes that are known to play a crucial role in CXCR4 mediated cells homing and engraftment. Hence, this study suggest the potential prospects of CXCR4 active mutants in research and development aimed to improve the efficiency of cells in the mechanism of homing and engraftment process.

Adjuvanticity and protective immunity elicited by Leishmania donovani antigens encapsulated in positively charged liposomes.

In the search for a leishmaniasis vaccine, extensive studies of cutaneous leishmaniasis have been carried out. Investigations in this regard with the visceral form are limited. As an initial step in the identification of the protective molecules, leishmanial antigens extracted from the membranes of Leishmania donovani promastigotes, alone or in association with liposomes, were evaluated for their immunogenicity and ability to elicit a protective immune response against challenge infection. Intraperitoneal immunization of hamsters and BALB/c mice with the leishmanial antigens conferred protection against infection with the virulent promastigotes. Encapsulation in positively charged liposomes significantly enhanced the protective efficacy of these antigens. The splenic parasite burden of hamsters was reduced by 97% after 6 months of infection. BALB/c mice exhibited 87 and 81.3% protection in the liver and spleen, respectively, after 4 months of infection. These protected animals elicited profound delayed-type hypersensitivity and increased levels of Leishmania-specific immunoglobulin G (IgG) antibodies. Protection in mice also coincided with elevated levels of IgM and IgA antibodies, which decreased with disease progression in the control-infected animals. Although both IgG1 and IgG2a antibodies were present in the sera of infected mice, IgG1 appeared to be the predominant isotype, suggesting a preferential induction of the Th2 type of immune response over that of Th1. Effective stimulation of all the IgG isotypes, particularly IgG2a, after immunization with liposome encapsulated antigens seems to be responsible for the significant levels of resistance against the disease. Taken together, these data indicate a potential for the liposomal antigens as a vaccine which could trigger both humoral and cell-mediated immune responses.

Antileishmanial activities of stearylamine-bearing liposomes.

Here we report the activity of liposomes comprising egg phosphatidylcholine (PC) and stearylamine (SA) against Leishmania donovani parasites. Both promastigotes and intracellular amastigotes in vitro and in vivo were susceptible to SA-PC liposomes. A single dose of 55 mg of SA-PC liposomes/animal could significantly reduce the hepatic parasite burden by 85 and 68% against recent and established experimental visceral leishmaniasis, respectively, suggesting their strong therapeutic potential.

Differential decline in Leishmania membrane antigen-specific immunoglobulin G (IgG), IgM, IgE, and IgG subclass antibodies in Indian kala-azar patients after chemotherapy.

Pathogenesis in kala-azar is associated with depressed cellular immunity and significant elevation of antileishmanial antibodies. Since these antibodies are present even after cure, analysis of the parasite-specific isotypes and immunoglobulin G (IgG) subclasses in kala-azar patients may shed new light on the immune responses during progression and resolution of infection. Using leishmanial membrane antigenic extracts, we investigated the relative levels of specific IgG, IgM, IgA, IgE, and IgG subclasses in Indian kala-azar patient sera during disease, drug resistance, and cure. Acute-phase sera showed strong stimulation of IgG, followed by IgE and IgM and lastly by IgA antibodies. IgG subclass analysis revealed expression of all of the subclasses, with a predominance of IgG1 during disease. Following sodium stibogluconate (SAG) resistance, the levels of IgG, IgM, IgE, and IgG4 remained constant, while there was a decrease in the titers of IgG2 and IgG3. In contrast, a significant (2.2-fold) increase in IgG1 was observed in these individuals. Cure, in both SAG-responsive and unresponsive patients, correlated with a decline in the levels of IgG, IgM, IgE, and all of the IgG subclasses. The stimulation of IgG1 and the persistence, most importantly, of IgE and IgG4 following drug resistance, along with a decline in IgE, IgG4, and IgG1 with cure, demonstrate the potential of these isotypes as possible markers for monitoring effective treatment in kala-azar.

Immunoglobulin subclass distribution and diagnostic value of Leishmania donovani antigen-specific immunoglobulin G3 in Indian kala-azar patients.

Visceral leishmaniasis, or kala-azar, a fatal tropical disease, remains problematic, as early diagnosis is difficult and treatment often results in drug resistance and relapse. We have developed a sensitive enzyme-linked immunosorbent assay (ELISA), using leishmanial membrane antigenic extracts (LAg) to detect specific antibody responses in 25 untreated Indian visceral leishmaniasis patients. To investigate the pathogenetic significance of isotype markers in kala-azar, relative levels of specific immunoglobulin G (IgG), IgM, IgA, IgE, and IgG subclasses were analyzed under clinically established diseased conditions. Since LAg showed higher sensitivity for specific IgG than lysate, the immunoglobulin isotype responses were evaluated, with LAg as antigen. Compared to 60 controls, which included patients with malaria, tuberculosis, leprosy, and typhoid and healthy subjects, visceral leishmaniasis patients showed significantly higher IgG (100% sensitivity, 85% specificity), IgM (48% sensitivity, 100% specificity), and IgE (44% sensitivity, 98.3% specificity) responses. Low levels of IgA in visceral leishmaniasis patients contrasted with a 13-fold-higher reactivity in sera from patients with leprosy. Among IgG subclasses, IgG1, -3, and -4 responses were significantly higher in visceral leishmaniasis patients than in the controls. IgG2 response, however, was significantly higher (twofold) in leprosy than even visceral leishmaniasis patients. The rank orders for sensitivity (IgG = IgG1 = IgG3 = IgG4 > IgG2 > IgM > IgE > IgA) and specificity (IgM = IgG3 > IgE > IgG4 > IgG2 > IgG > IgG1 > IgA) for LAg-specific antibody responses suggest the potentiality of IgG3 as a diagnostic marker for visceral leishmaniasis.