Legume seed system performance in sub-Saharan Africa: barriers, opportunities, and scaling options. A review

As a fundamental pillar of food security in sub-Saharan Africa (SSA), ensuring seed security is critical to empowering farmers in cultivating food and livestock feed, thereby fostering income generation from agricultural outputs. Among the crops cultivated by smallholders, legumes have the potential to deliver multifaceted benefits. Legumes are nutrient-dense and enhance soil health through their nitrogen-fixing qualities. However, in many instances, the development, release, and supply of improved legume varieties are insufficient to meet the needs of smallholder farmers in SSA. Here, we systematically reviewed the literature to (i) identify and categorize existing legume seed systems, (ii) map legume varieties available to smallholders, (iii) identify barriers hindering the adoption of various legume varieties, and (iv) identify potential strategies and opportunities for strengthening legume seed systems in SSA. Our results demonstrate the coexistence of formal and informal seed systems within legume seed supply chains in SSA, each employing unique seed distribution channels. Smallholders, however, are shown to predominantly depend on the informal seed system to source most legume seeds except for commercially available varieties. We also identified a diverse range of legume varieties available to smallholders in the region, with farmers having varying trait preferences based on crop type and gender. Notably, high yield and abiotic stress tolerance were the most preferred traits. The adoption of these varieties, however, is influenced by various factors, including lack of timely access to seeds in adequate quantities from the formal seed system, high seed costs, and limited information on new varieties. The reviewed literature highlighted that utilizing improved legume varieties had a positive effect on smallholders, leading to improved welfare, food security, dietary diversity, and income. We conclude that the effective scaling of legume systems in SSA is contingent upon the presence of supportive policy frameworks and well-established technical support structures.

Graphical Abstract

Packets of legume seeds within a legume germplasm and breeding program at the University of Zambia (Photo by Caitlin Breen, 2022).

Supplementary Information

The online version contains supplementary material available at 10.1007/s13593-024-00956-6.

Linkage mapping and genomic prediction of grain quality traits in tropical maize (Zea mays L.)

The suboptimal productivity of maize systems in sub-Saharan Africa (SSA) is a pressing issue, with far-reaching implications for food security, nutrition, and livelihood sustainability within the affected smallholder farming communities. Dissecting the genetic basis of grain protein, starch and oil content can increase our understanding of the governing genetic systems, improve the efficacy of future breeding schemes and optimize the end-use quality of tropical maize. Here, four bi-parental maize populations were evaluated in field trials in Kenya and genotyped with mid-density single nucleotide polymorphism (SNP) markers. Genotypic (G), environmental (E) and G×E variations were found to be significant for all grain quality traits. Broad sense heritabilities exhibited substantial variation (0.18-0.68). Linkage mapping identified multiple quantitative trait loci (QTLs) for the studied grain quality traits: 13, 7, 33, 8 and 2 QTLs for oil content, protein content, starch content, grain texture and kernel weight, respectively. The co-localization of QTLs identified in our research suggests the presence of shared genetic factors or pleiotropic effects, implying that specific genomic regions influence the expression of multiple grain quality traits simultaneously. Genomic prediction accuracies were moderate to high for the studied traits. Our findings highlight the polygenic nature of grain quality traits and demonstrate the potential of genomic selection to enhance genetic gains in maize breeding. Furthermore, the identified genomic regions and single nucleotide polymorphism markers can serve as the groundwork for investigating candidate genes that regulate grain quality traits in tropical maize. This, in turn, can facilitate the implementation of marker-assisted selection (MAS) in breeding programs focused on improving grain nutrient levels.

Pulmonary alveolar proteinosis diagnosis after re‑evaluation for chronic cough unresponsive to empirical antituberculosis therapy

This study extends the reports of PAP in SA, in this case a 29-year- old HIV-negative black African woman with no history of smoking. Patients with respiratory symptoms who are microbiologically negative for TB should be carefully evaluated for an alternative diagnosis.

Discovery of genomic regions associated with grain yield and agronomic traits in Bi-parental populations of maize (Zea mays. L) Under optimum and low nitrogen conditions

Low soil nitrogen levels, compounded by the high costs associated with nitrogen supplementation through fertilizers, significantly contribute to food insecurity, malnutrition, and rural poverty in maize-dependent smallholder communities of sub-Saharan Africa (SSA). The discovery of genomic regions associated with low nitrogen tolerance in maize can enhance selection efficiency and facilitate the development of improved varieties. To elucidate the genetic architecture of grain yield (GY) and its associated traits (anthesis-silking interval (ASI), anthesis date (AD), plant height (PH), ear position (EPO), and ear height (EH)) under different soil nitrogen regimes, four F3 maize populations were evaluated in Kenya and Zimbabwe. GY and all the traits evaluated showed significant genotypic variance and moderate heritability under both optimum and low nitrogen stress conditions. A total of 91 quantitative trait loci (QTL) related to GY (11) and other secondary traits (AD (26), PH (19), EH (24), EPO (7) and ASI (4)) were detected. Under low soil nitrogen conditions, PH and ASI had the highest number of QTLs. Furthermore, some common QTLs were identified between secondary traits under both nitrogen regimes. These QTLs are of significant value for further validation and possible rapid introgression into maize populations using marker-assisted selection. Identification of many QTL with minor effects indicates genomic selection (GS) is more appropriate for their improvement. Genomic prediction within each population revealed low to moderately high accuracy under optimum and low soil N stress management. However, the accuracies were higher for GY, PH and EH under optimum compared to low soil N stress. Our findings indicate that genetic gain can be improved in maize breeding for low N stress tolerance by using GS.

A South African central hospital's experience with malignant colorectal obstruction

BACKGROUND

The spectrum and outcome of colorectal cancer (CRC) presenting with obstruction is not well studied in low- to middle-income countries (LMIC) and could have implications for health policy. This study aimed to address this deficit in an LMIC setting.

METHODS

A retrospective analysis was conducted of patients with large bowel obstruction, during the period 2000-2019 from the prospective Inkosi Albert Luthuli Central Hospital (IALCH) CRC registry data. Data analysed included the site of CRC, tumour differentiation, management of patients with obstructive CRC, resection margins post resection, oncological management and reasons for failure to receive oncological therapy. Patient follow-up and recurrence were recorded.

RESULTS

Malignant obstruction from CRC occurred in 510 patients (20% of the CRC registry). Median age at presentation was 57 years (IQR 48-67). One hundred and seventy-six (34.5%) and 135 (26.5%) had stage III and IV disease respectively. Moderately differentiated cancer was seen in 335 (65.6%). Management was resection (370; 72.5%), diverting colostomy (123; 24.1%) and stent insertion (55; 10.8%). Twenty-one patients (5.7%) had positive resection margins. Recurrence occurred in 34 patients (6.7%), all of whom had initially undergone resection, giving a recurrence rate of 9.8% in those receiving surgery. Median disease-free interval for patients developing recurrence was 21 months (IQR 12-32).

CONCLUSION

One in five patients with CRC presented with obstruction. These patients were younger than in high incomecountry (HIC) series. Over 70% underwent resection. Stomas were used twice as frequently as stents to relieve the obstruction, a finding that is the reverse of that in HICs.

Genome-wide association studies of grain yield and quality traits under optimum and low-nitrogen stress in tropical maize (Zea mays L.)

Genome-wide association study (GWAS) demonstrated that multiple genomic regions influence grain quality traits under nitrogen-starved soils. Using genomic prediction, genetic gains can be improved through selection for grain quality traits. Soils in sub-Saharan Africa are nitrogen deficient due to low fertilizer use and inadequate soil fertility management practices. This has resulted in a significant yield gap for the major staple crop maize, which is undermining nutritional security and livelihood sustainability across the region. Dissecting the genetic basis of grain protein, starch and oil content under nitrogen-starved soils can increase our understanding of the governing genetic systems and improve the efficacy of future breeding schemes. An association mapping panel of 410 inbred lines and four bi-parental populations were evaluated in field trials in Kenya and South Africa under optimum and low nitrogen conditions and genotyped with 259,798 SNP markers. Genetic correlations demonstrated that these populations may be utilized to select higher performing lines under low nitrogen stress. Furthermore, genotypic, environmental and GxE variations in nitrogen-starved soils were found to be significant for oil content. Broad sense heritabilities ranged from moderate (0.18) to high (0.86). Under low nitrogen stress, GWAS identified 42 SNPs linked to grain quality traits. These significant SNPs were associated with 51 putative candidate genes. Linkage mapping identified multiple QTLs for the grain quality traits. Under low nitrogen conditions, average prediction accuracies across the studied genotypes were higher for oil content (0.78) and lower for grain yield (0.08). Our findings indicate that grain quality traits are polygenic and that using genomic selection in maize breeding can improve genetic gain. Furthermore, the identified genomic regions and SNP markers can be utilized for selection to improve maize grain quality traits.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

COVID-19 in Sub-Saharan Africa: A Multi-Institutional Survey of the Impact of the Global Pandemic on Cancer Care Resources

Purpose/Objective(s)

The COVID-19 pandemic has direct and indirect impact on patients with cancer. Low- and middle-income regions, especially sub-Saharan Africa, are especially vulnerable to a negative impact on cancer resources and outcomes. We report the initial indirect impact of COVID-19 on cancer care in the sub-Saharan Africa region approximately 14 months into the pandemic.

Materials/Methods

At the start of the pandemic, we created a consortium of African and North American cancer centers and NGOs for the distribution of factual and timely information and data on COVID-19 and cancer care. A survey was distributed to consortium members and other colleagues from the sub-Saharan Africa region to understand the impact of COVID-19 in cancer care resources. Survey respondents represent cancer experts from 8 centers in Ghana, Nigeria, Kenya, Ethiopia, South Africa, Rwanda, and Zimbabwe.

Results

All sites report SARS-COv-2 transmission amongst cancer patients and staff. A total of 48 staff developed COVID-19 infection with one site reporting a single death. Additionally, 62.5% of sites report loss of oncology physician or nursing staff due to redeployment for COVID-19 care resulting in minimal (20%), moderate (60%), or other (20%) impact on cancer care. All 8 sites report a government mandated lockdown with a median duration of 2.3 months (IQR .9-4.2 months). Impact of the lockdown on cancer care was reported as none (12.5%), minimal (12.5%), moderate (50%) and severe (25%). Additionally, we surveyed the impact of COVID-19 on resources in radiation, medical and surgical oncology services. A total of 25% of responders reported decreases in radiation resources while 37.5% reported changes in medical and surgical oncology resources. For radiation oncology, the most common impact was access to CT imaging for 3D-conformal planning (25%), access to brachytherapy (12.5%), and medical physics support (12.5%). For medical oncology, the most frequent impact was access to chemotherapy (37.5%) and blood products (12.5%), and loss of oncology ward space (12.5%). The most frequent impact for surgical oncology was access to operating rooms (37.5%), ventilators (12.5%), anesthesia (25%), blood products (25%), and other supply chain issues (25%). Of centers who reported impact on cancer care, severity of impact was none (50%) and moderate (50%) for radiation oncology; mild (25%) and moderate (75%) for medical oncology; and moderate (75%) and severe (25%) for surgical oncology.

Conclusion

Our survey identified diffuse impact of COVID-19 on all facets of cancer care across sub-Saharan Africa. Based on physician assessment of impact, the discipline of surgical oncology may be impacted the greatest. Additional studies measuring the impact of COVID-19 on cancer outcomes are ongoing.

The use of South African botanical species for the control of blood sugar

ETHNOPHARMACOLOGICAL RELEVANCE

Diabetes mellitus (DM) is one of the most prevalent diseases globally and is of considerable concern to global health. Approximately 425 million people are estimated to have DM globally and this is predicted to increase to >642 million by 2040. Whilst the prevalence of DM in South Africa is slightly lower than the global average, it is expected to rise rapidly in future years as more South Africans adopt a high calorie "westernised" diet. Traditional medicines offer an alternative for the development of new medicines to treat DM and the usage of South African plants is relatively well documented.

AIM OF THE STUDY

To critically review the literature on the anti-diabetic properties of South African plants and to document plant species used for the treatment of DM. Thereafter, a thorough examination of the related research will highlight where research is lacking in the field.

MATERIALS AND METHODS

A review of published ethnobotanical books, reviews and primary scientific studies was undertaken to identify plants used to treat DM in traditional South African healing systems and to identify gaps in the published research. The study was non-biased, without taxonomic preference and included both native and introduced species. To be included, species must be recorded in the pharmacopeia of at least one South African ethnic group for the treatment of DM.

RESULTS

One hundred and thirty-seven species are recorded as therapies for DM, with leaves and roots most commonly used. The activity of only 43 of these species have been verified by rigorous testing, and relatively few studies have examined the mechanism of action.

CONCLUSION

Despite relatively extensive ethnobotanical records and a diverse flora, the anti-diabetic properties of South African medicinal plants is relatively poorly explored. The efficacy of most plants used traditionally to treat DM are yet to be verified and few mechanistic studies are available. Further research is required in this field.

Silicosis and pulmonary tuberculosis in deceased female South African miners

BACKGROUND

Implementation of South Africa's 2002 Mining Charter increased women's participation in underground mining. However, occupational lung diseases (OLDs) in female gold miners have not been studied.

AIMS

To compare autopsy-diagnosed pulmonary silicosis, lymph gland silicosis (a precursor of pulmonary silicosis) and active pulmonary tuberculosis (PTB) in South African gold miners.

METHODS

The law allows for autopsies on miners for OLD compensation. Information is stored on the Pathology Automation (PATHAUT) database. We selected records of deceased miners who had worked only in gold mines, started employment from 2002, and were autopsied between 2005 and 2015. Using descriptive statistics, we compared demographic and employment characteristics, and disease proportions by sex.

RESULTS

The study comprised 847 gold miners: 68 women and 779 men. There were no statistically significant differences in proportions of autopsy-diagnosed pulmonary silicosis [3 (4%) in women and 54 (7%) in men], lymph gland silicosis [11 (16%) and 171 (22%)] or PTB [29 (43%) and 254 (33%)]. Age and employment duration in women and men with disease were similar. Most miners with pulmonary silicosis had started employment from 2003 [315 (77%)] and worked for under 10 years.

CONCLUSION

It is important to report research findings by sex. Proportions of silicosis and PTB were comparable in women and men, suggesting similar exposures. Silicosis detection after short employment indicates inadequate dust control, particularly as most entered the industry after implementation of interventions to control silica dust in 2003.

Rapidly increasing body mass index among children, adolescents and young adults in a transitioning population, South Africa, 2008-15

Background

There is a global epidemic of overweight and obesity; however, this rate of increase is even greater in some low- and middle-income countries (LMIC). South Africa (SA) is undergoing rapid socioeconomic and demographic changes that have triggered a rapid nutrition transition. The paper focuses on the recent rate of change of body mass index (BMI) among children, adolescents and young adults, further stratified by key sociodemographic factors.

Methods

We analysed mean BMI of 28 247 individuals (including children) from 7301 households by age and year, from anthropometric data from four national cross-sectional (repeated panel) surveys using non-linear fitted curves and associated 95% confidence intervals.

Results

From 2008 to 2015, there was rapid rise in mean BMI in the 6-25 age band, with the highest risk (3-4+ BMI unit increase) among children aged 8-10 years. The increase was largely among females in urban areas and of middle-high socioeconomic standing. Prominent gains were also observed in certain rural areas, with extensive geographical heterogeneity across the country.

Conclusions

We have demonstrated a major deviation from the current understanding of patterns of BMI increase, with a rate of increase substantially greater in the developing world context compared with the global pattern. This population-wide effect will have major consequences for national development as the epidemic of related non-communicable disease unfolds, and will overtax the national health care budget. Our refined understanding highlights that risks are further compounded for certain groups/places, and emphasizes that urgent geographical and population-targeted interventions are necessary. These interventions could include a sugar tax, clearer food labelling, revised school feeding programmes and mandatory bans on unhealthy food marketing to children.The scenario unfolding in South Africa will likely be followed in other LMICs.

Childhood Cancers in Zimbabwe: A 10 year review of the Zimbabwe National Cancer Registry data

OBJECTIVE

To document the pattern of cancer in children (0-14 years) registered in the Zimbabwe National Cancer Registry from 2000-2009.

DESIGN

Retrospective descriptive analysis.

METHODS

Analysis of data from the Zimbabwe National Cancer Registry for the period 2000-2009.

SETTING

The Zimbabwe National Cancer Registry.

RESULTS

Childhood Cancer constituted 3.8% of all malignancies recorded at the cancer registry during the study period. The common cancers were: Wilm's Tumour 286 (16.2%), Kaposi Sarcoma 277 (15.7%), Retinoblastoma 231 (13.1%), Non- Hodgkins lymphoma 182 (10.3%), leukemia 158 (8.9%), brain and nervous tissue 107 (6.1%), connective tissue 105 (5.9%), bone 97 (5.5%), Hodgkins lymphoma 57 (3.2%), Non-melanoma skin 33 (1.9%). All the other remaining cancers were 233 (13.2%). Burkits lymphoma constituted only 2% of all cancers. The noted pattern of cancers in this study were compared to patterns from other countries and similarities and differences are discussed.

CONCLUSION

This study showed high incidence rates of Nephroblastoma, Retinoblastoma and Kaposi sarcoma. In contrast to high income countries leukemia and brain tumours are more prevalent in older age group. Compared to other countries in Africa, Burkits lymphoma was rare. Further research is required to identify factors that influence relative frequencies in childhood cancers in Zimbabwe. Findings from this study provide baseline data for future studies.

Presentation patterns of invasive cancer of the cervix: results from Parirenyatwa Oncology and Radiotherapy Centre, Harare, Zimbabwe 1998-2010

MAIN OBJECTIVE

The study sought to identify the presentation patterns of invasive uterine cancer of the cervix (CaCx) in Zimbabwe in terms of histology, stage of the disease, ages of patients and socio-economic status.

DESIGN

Retrospective study from 1998 to 2010.

SUBJECTS

All patients who registered for the first time with invasive CaCx over a systematically selected sample period of four years (1998, 2002, 2006 & 2010).

SETTING

The main referral Radiotherapy and Oncology centre in Harare the capital city of Zimbabwe.

RESULTS

Majority of patients (91.75%) presented with squamous cell carcinoma, 5.5% presented with adenocarcinomas and 2.75% presented with other types of histology. Late presentation was noted with the majority of the patients (89%) presenting with stage IIB and above. The common ages of patients at presentation were between 40 to 60 years. The majority of the patients (59.5%) were of low socio-economic status.

CONCLUSION

In the developed countries CaCx is reducing in frequency, presentation tends to be early, treatment effective and there is decreasing mortality rate from this disease. However in developing countries the situation is not as positive and the disease remains a major concern. This is shown by the presentation pattern of patients with invasive CaCx in Zimbabwe. The patients are shown to present with late stage disease of the squamous cell type, primarily in the age ranges of 40 to 60 years and with the majority of the patients belonging to the low socio-economic status group.

Palliative radiation therapy practice for advanced esophageal carcinoma in Africa

While numerous surveys of pattern of practices of palliative radiotherapy (RT) in advanced esophageal cancers have been published in developed countries, there is no such survey in African countries. During and after a regional training course by the International Atomic Energy Agency (IAEA) in palliative cancer care, a questionnaire was distributed to African RT centers to gather information about infrastructure and human resources available, and the pattern of practice of palliative RT for esophageal cancers. Twenty-four of the 35 centers (60%) completed the questionnaire. Twenty out of 23 (87%) centers treat patients with esophageal cancer presenting with dysphagia using external beam RT (16 centers external beam RT alone and 4 centers also use brachytherapy as a boost). Twelve (60%) centers prescribe RT doses of 30 Gy in 10 fractions and 2 centers 20 Gy in 5 fractions. Eighteen centers (78%) have low dose rate (LDR) brachytherapy, and 9 (39%) centers have high dose rate (HDR) brachytherapy. One center only used HDR brachytherapy alone to a dose of 16 Gy in 2 fractions over 8 days. RT remains a major component of treatment of patients with esophageal cancers in African countries. Still, there is a great variety among centers in both indications for RT and its characteristics for a treatment indication.

Cholangiocarcinoma presenting in an adolescent with vertically acquired HIV infection

An adolescent with long-standing HIV infection who was severely immunosuppressed during HIV diagnosis developed cholangiocarcinoma 1.5 years after starting antiretroviral therapy.

Antimicrobial resistence of Shigella species isolated during 2004 and 2005 from selected sites in Zimbabwe

OBJECTIVE

To determine the predominant serotype and antibiotic sensitivity pattern of Shigella isolates during 2004 and 2005 in Zimbabwe.

DESIGN

Cross sectional study.

SETTING

National Microbiology Reference Laboratory (NMRL), Harare, Zimbabwe.

SAMPLE

259 clinical isolates of Shigella species isolated during 2004 and 2005 in Zimbabwe were studied. These samples had been referred to the NMRL for further testing.

MAIN OUTCOME MEASURES

Serotype and antibiotic sensitivity pattern of Shigella species.

RESULTS

Of the 259 clinical isolates of Shigella tested the following species were serotyped; 141 (54.4%) were S. flexneri; 70 (27%) S. sonnei; 38 (14.7%) S. dysenteriae and 10 (3.9%) S. boydii. About 4% of all Shigella isolates tested showed full sensitivity to commonly used antibiotics, 20.8% were resistant to one antibiotic only while 75.3% were resistant to at least two antibiotics. The most common resistance among Shigella species was to cotrimoxazole (89%), tetracycline (73%), ampicillin (49%) and chloramphenicol (41%). High susceptibility among Shigella species was observed to nalidixic acid (86%), ciprofloxacin (99%) and ceftazidine (99%).

CONCLUSION

There was a low drug resistance of Shigella species to nalidixic acid, a drug of choice in Zimbabwe, except among Shigella dysenteriae type 1 strains. Continuous monitoring of the susceptibility patterns of Shigella species is important in order to detect the emergence of drug resistance and to update guidelines for antibiotic treatment in shigellosis.

The perceived impact of downsizing and organisational transformation on survivors

Change is a way of life and the ability to manage change is a key factor in organisational survival and effectiveness. This article evaluates the ‘survivor syndrome’ and assesses the impact of the process of downsizing and transformation on communication, trust, survivor commitment and loyalty, morale and career advancement opportunities. The study was conducted using a stratified random sample of 361 employees/survivors in a branch of a motor manufacturer that had undergone major transformation. Data was collected using a self-developed questionnaire and analysed using descriptive and inferential statistics. The study generates a framework/model of critical change implementation factors and recommendations that will enable change managers to sense, adjust, respond and implement change timeously so as to gain strategic and competitive advantage. Opsomming Verandering is ’n lewenswyse en die vermoë om te verander is ’n kernaspek in organisasieverandering en -oorlewing. In hierdie artikel word die ‘oorlewingsindroom’ beoordeel en word die impak van die afskalingsproses en transformasie op kommunikasie, vertroue, ‘oorlewende’ toewyding en lojaliteit, moraal en loopbaanvorderingsgeleenthede takseer. Die studie is uitgevoer, met die gebruik van ’n gestratifiseerde ewekansige steekproef van 361 werknemers/’oorlewendes’ in ’n afdeling van ’n motorvervaardiger wat ingrypende transformasie ondergaan het. Data is ingesamel by wyse van ’n selfontwikkelde vraelys en ontleed aan die hand van beskrywende en inferensiële statistiek. Die studie het ’n raamwerk/model van kritieke veranderingsimplementeringsfaktore en aanbevelings gegenereer wat veranderingsbestuurders in staat sal stel om die gewaarwording, aanpassing, reaksie en implementering van verandering tydig te doen sodat strategiese en mededingingsvoordeel behaal kan word.

Factors associated with tumour stage at presentation in invasive cervical cancer

OBJECTIVE

The main objective of the study was to determine the demographic, social, clinical, laboratory and histologic factors associated with late stage presentation in cervical cancer.

DESIGN

A cross sectional study.

SETTING

Government tertiary referral institutions, Harare, Zimbabwe

STUDY POPULATION

One hundred consecutive cases of histology proven cervical cancer that presented for treatment between November 2001 and April 2002.

MAIN OUTCOME MEASURES

The patients were categorized as early invasive cancer (stage I and II) and late invasive cancer (stage III and IV).

RESULTS

The median age of the patients was 48 years (Q1=39 and Q3= 60). Eighty percent presented with late stage disease. Squamous cell carcinoma was the commonest histology (96%) with adenocarcinoma constituting only 4% of all tumours. Poorly differentiated tumour histology and no history of prior cervical cancer screening were found to be significantly associated with late tumour stage at presentation. The odds of presenting with late stage disease in women with a poorly differentiated tumour were 12.97 (95% CI 2.03 to 82.55; p = .007), whilst the odds of late stage presentation in the absence of a history of screening were 11.13 (95% CI 1.33 to 93.21; p = .026).

CONCLUSIONS

Intrinsic tumour characteristics were the most important in this population in determining late stage at diagnosis and the value of screening was also highlighted by the results. The odds ratios had wide 95% confidence intervals, thus limiting their usefulness as point estimates.

Radical radiotherapy for carcinoma of the cervix--the Zimbabwean experience

OBJECTIVE

Carcinoma of the cervix accounts for over 30% of all female malignancies in Zimbabwe. Patients treated with radiotherapy tend to have advanced disease. This study examines some presentation patterns, radiotherapy treatment parameters, outcomes of treatment and identifies some prognostic factors in this set up.

DESIGN

Retrospective study.

SETTING/SUBJECTS

The study was undertaken on all patients (273) who presented to the Parirenyatwa Hospital Radiotherapy Centre (RTC) between November 1990 and December 1991 with a diagnosis of cervical carcinoma. Of these patients 93 were suitable for radical treatment and they were studied.

MAIN OUTCOME MEASURES

Complete remission rates in relation to total dose given and stage of disease, incidence of acute complications, local recurrence and development of metastases.

RESULTS

Of the 93 patients studied 72 (77.4%) were Stages I and II and 21 (22.6%) were stage III. Fifty nine percent of the patients gave a history of three to eight months symptom duration and 21.5% symptom duration longer one year. The mean length of follow up time was 13.4 months. The overall complete remission (CR) rate 49%. Ninety seven percent of patients achieving a CR had received 70 Gy or more as total dose to Point A. Patients with both pelvic wall and lower one third vaginal involvement (Stage A + B) did more poorly than other Stage III patients. Acute complications were mainly mild and seen in patients whose overall treatment time was under seven weeks. Most recurrences and metastases occurred within one year of completion of treatment.

CONCLUSION

It is only a minority of patients (34.1%) that present to the Radiotherapy Centre with cervical carcinoma who are suitable for radical treatment. These are patients who become aware of their symptoms early. Treatment achieves a good complete remission rate. Follow up of treated patients is poor. The sub group of patients with Stage III A + B must be recognised for their poorer response compared to other patients with Stage III disease.