IntroductionIleo-sigmoid knotting (ISK) is a rare cause of bowel obstruction in which the ileum twists around the sigmoid colon. It is associated with rapid bowel gangrene and a high mortality rate. Little has been published about this condition in Kenya. The objective was to determine the presentation, management, and outcome of patients with ISK.MethodsA seven year (January 2008-December 2014) retrospective chart review of patients managed for ISK at Tenwek Hospital in Bomet, Kenya.ResultsA total of 61 cases were identified, with a mean age of 35.8 years (range 2-68), and mean symptom duration of 1.6 days (range 3 hours-7 days). Gangrene was noted to involve both the ileum and colon in 45 patients, the ileum only in 9 patients, and the sigmoid colon only in one. Resection and primary anastomosis was carried out in most cases of gangrenous ileum (48/54, 89%) and gangrenous sigmoid colon (34/46, 74%), while resection and stoma was performed in 8 patients with gangrenous colon. Death occurred in 7 (11.5%) patients due to severe sepsis and multisystem organ failure. Morbidities were noted in 15 (24.6%) patients, including surgical site infection (8, 13.1%), respiratory insufficiency (4, 6.6%), fascial dehiscence (3, 4.9%) and anastomotic leak (2, 3.2%). The mean duration of hospitalization was 8.3 days (range 1-26).ConclusionIn this review, though retrospective in nature, ISK was noted to have high rates of bowel gangrene. In the appropriate setting, resection and primary anastomosis can be safely carried out in most cases of gangrenous colon.

We investigated whether engaging in cognitive activities is associated with mild cognitive impairment (MCI) in a cross-sectional study derived from an ongoing population-based study of normal cognitive aging and MCI in Olmsted County, Minnesota. A random sample of 1321 nondemented study participants ages 70 to 89 (n = 1124 cognitively normal persons and n = 197 subjects with MCI) was interviewed about the frequency of cognitive activities carried out in late life (within one year of the date of interview). were associated with decreased odds of having MCI. Social activities such as traveling were marginally significant [0.71 (0.51, 1.00); p = 0.050)]. Even though the point estimates for reading magazines, playing music, artistic activities, and group activities were associated with reduced odds of having MCI, none reached statistical significance. We could not expect to observe any difference between the two groups on the variable of reading newspapers since almost identical proportions of the two groups (97.4% of normals and 97.5% of the MCI group) were engaged in reading newspapers on a regular basis. [5][6][7] . However, little is known about the association between cognitive activities and the odds of having MCI. A convenience sample of a prospective cohort study involving community-dwelling elderly participants reported that baseline cognitive activities were associated with decreased risk of amnestic MCI 8 . There is a need to examine this question in a population-based setting using a larger sample. KeywordsWe examined whether engaging in cognitive activities is associated with MCI in a crosssectional study derived from an ongoing population-based study of normal cognitive aging and MCI in Olmsted County, Minnesota. Throughout this manuscript, one can interchangeably think of the phrase "cognitive activity" to be equivalent to "mental activity" or "intellectual activity". METHODS SETTINGThe detail of the design and conduct of the Mayo Clinic Study of Aging was reported elsewhere 9 . Briefly, it is an on-going population-based study of normal aging and MCI in Olmsted County, Minnesota. Elderly persons ages 70 to 89 on the prevalence date of October 1, 2004, were recruited by using a stratified random sampling from the target population of nearly 10,000 elderly individuals in Olmsted County, Minnesota. The sampling involved equal allocation of men and women in two age strata: 70 to 79 and 80 to 89 years old. During the first follow-up phase of the study, which took place between 2006 through 2008, we introduced a structured interview format to collect data on cognitive activities. 1,321 non-demented study participants completed the interview. At the time of the interview, neither the study participant nor the research personnel knew the case-control status of a participant. The classification of a study participant as having MCI or not was a downstream event to the collection of data on cognitive activities. The details of the classification process of MCI are discussed elsewhere in this paper. The...

Background Plasmodium falciparum malaria dominates throughout sub-Saharan Africa, but the prevalence of P. malariae, P. ovale spp., and P. vivax increasingly contribute to infection in countries which control malaria using P. falciparum-specific diagnostic and treatment strategies. Methods We performed qPCR on 2,987 dried blood spots from the 2015-2016 Malawi Demographic and Health Survey to identify the presence and distribution of non-falciparum infection. Bivariate models were used to determine species-specific associations with demographic and environmental risk factors. Results Non-falciparum infections had a broad spatial distribution. Weighted prevalence was 0.025 (SE: 0.004) for P. malariae, 0.097 (SE: 0.008) for P. ovale spp., and 0.001 (SE: 0.0005) for P. vivax. Most infections (85.6%) had low-density parasitemias ≤10 parasites/µL, and 66.7% of P. malariae, 34.6% of P. ovale spp., and 40.0% of P. vivax infections were co-infected with P. falciparum. Risk factors for P. malariae were like those known for P. falciparum, however, there were few risk factors recognized for P. ovale spp. and P. vivax, perhaps due to the potential for relapsing episodes. Conclusions The prevalence of any non-falciparum infection was 11.7%, with infections distributed across Malawi. Continued monitoring of Plasmodium spp. becomes critical as non-falciparum infections become important sources of ongoing transmission.

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Background Cancer is the third leading cause of mortality in Kenya, accounting for 7% of annual deaths. The Kenyan Ministry of Health (MOH) is committed to reducing cancer mortality, as evidenced by policies such as the National Cancer Control Strategy (2011-2016). There are many Kenyan and international organizations devoted to this task; however, coordination is lacking among stakeholders, resulting in inefficient and overlapping expenditure of resources. Methods The MOH and the NCI Center for Global Health collaboratively executed a two day workshop to improve coordination among government, NGO, and private organizations. Over 80 stakeholders participated from leading cancer research and control institutions in Kenya and the international sphere. Findings Actionable recommendations include: establishment of a nationally representative population-based cancer registry; enhanced training for community health workers, nurses, researchers, pathologists, and oncology specialists; a reconfigured referral process, including leveraging of existing resources to improve access to cancer care; and coordinated community outreach and education. The MOH is in the process of forming a Technical Working Group (TWG) and has elected a Board of Directors for the newly established Kenyan National Cancer Institute (KNCI), with both entities committed to advancing the cancer control work of the MOH. Interpretation This stakeholder meeting enhanced in-country networks, identified priority needs and developed actionable proposals for coordinated improvement of cancer research and control. Active, persistent follow-up by the TWG, KNCI, and other partners will be needed to turn proposals into reality and ensure that partners' investments are integrated into larger cancer control efforts prioritized by MOH.

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IntroductionIntestinal obstruction (IO) occurs when there is impedance to the flow of intestinal contents due to a congenital or acquired pathology, and is a common paediatric surgical emergency. This study aimed to assess the pattern and outcome of paediatric IO in western Kenya.MethodsA retrospective review of all recorded cases of mechanical IO in patients aged 15 years or below admitted at Tenwek Hospital between January 2009 and December 2013.ResultsThe cohort included a total of 217 children (130 boys and 87 girls). The mean age was 6.7 years (range: newborn-15 years), with most (65, 30%) cases aged 1-3 years. Vomiting (161, 74.2%), abdominal pain (152, 70%), abdominal tenderness (113, 52.1%), constipation (111, 51.2%), and abdominal distension (104, 47.9%) were the predominant signs and symptoms. The most common causes of IO were ascariasis (96, 44.2%), adhesions (34, 15.7%), and intussusception (30, 13.8%). Intussusception was the leading cause of IO in children aged ≤ 1 year, ascariasis in children aged 1-5 and 6-10 years, and adhesions in children aged 11-15 years. Operative management was undertaken in 120 (55.3%) cases with 39 (32.5%) of these having gangrenous bowel. The overall mortality rate was 5%.ConclusionThe most common causes of mechanical bowel obstruction in this series were ascariasis, adhesions, and intussusception. Ascariasis remains a significant cause of paediatric IO in this region, thus public education, improved sanitation and deworming campaigns may be helpful in reducing the worm burden.

Malawi has the highest invasive cervical cancer (ICC) mortality rate worldwide, and ICC is the leading cause of cancer death among women. In 2004, Malawi adopted visual inspection with acetic acid (VIA) and ablative treatment with cryotherapy.However, screening coverage has remained low (<30%) and few women (<50%) who require ablative treatment receive it. Additional barriers include long distances to health facilities and challenges with maintaining gas supplies. Thermal ablation is a safe and effective alternative to cryotherapy. We assessed the safety and uptake of community-based ICC screening with VIA and same-day treatment using a handheld thermocoagulator (HTU) in rural Malawi. We held educational talks alongside community leaders and conducted VIA screening in nonclinic community settings to nonpregnant women aged 25 to 49 years without history of hysterectomy or genital cancer/precancer. Eligible women received same-day thermal ablation and HIV testing/counseling. We collected cervical biopsies before treatment and followed up women at Weeks 6 and 12, with repeat biopsy at Week 12. Between July and August 2017, 408 (88%) of 463 eligible women underwent VIA. Overall, 7% (n = 30) of women had a positive VIA, of whom 93% (n = 28) underwent same-day thermal ablation. Among the 30 VIA-positive women, 5 had cervical intraepithelial neoplasia (CIN) 1, 4 had CIN 2/3 and 21 had benign histologic findings. Abnormal vaginal discharge (60%) and light vaginal bleeding (52%) were the most reported adverse events. There was high uptake of the community-based ICC screening in the study population and treatment was safe in this setting. Similar strategies that minimize false-positive results are urgently needed in Malawi. K E Y W O R D S community-based screening, invasive cervical cancer, screen-and-treat, thermal ablation, VIA 1 | INTRODUCTION Cervical cancer is the fourth most common cancer among women worldwide. In 2018, invasive cervical cancer (ICC) caused 311 000 deaths with Abbreviations: CAB, Community Advisory Board; CIN, cervical intraepithelial neoplasia; HPV, human papillomavirus; HTU, handheld thermocoagulation; ICC, invasive cervical cancer;