A comparative analysis of conventional Pap smear cytology, liquid based cytology and colposcopy clinical impression with colposcopy biopsy histology as gold standard in women undergoing colposcopy in Kenyatta National Hospital

Background: Cervical cancer is one of the most common female malignancies worldwide. Since the introduction of conventional Papanicolaou smear mortality from cervical cancer has reduced considerably. Despite its success, it has sensitivity of only 51% and false negative rate of 5-10%. Approved liquid based cytology (LBC) products by FDA claim a 65-percent increased detection rate of high grade squamous intraepithelial lesions (HGSIL) compared with conventional smears, as well as decreased unsatisfactory sample rates. Evidence shows that liquid based preparation is more sensitive and accurate for the detection of both squamous and glandular lesions of the cervix. Studies of the accuracy of liquid based preparations reports sensitivity of 61-66% and specificity of 82-91%. Objective of current study is to compare the performance of conventional Pap smear cytology, liquid based cytology and colposcopy clinical impression with colposcopic biopsy as the gold standard among women eligible for colposcopy in Kenyatta National Hospital, Kenya.Methods: This was a hospital-based comparative cross-sectional study. Convenient sampling over a period of 4 months was used to recruit clients referred to colposcopy clinic with abnormal Pap smear results.Results: A total of 73 patients referred with abnormal pap smears were recruited into the study. The mean age of the patients was 38 yrs (SD ±10). About 45% of the patients interviewed did not have knowledge of Pap smear testing. Both the results of referral Pap smear and repeat Pap smear were predominantly low grade squamous intraepithelial lesions (LGSIL) or HGSIL. With biopsy results being the gold standard, Liquid based cytology had a higher specificity of 75% when compared with conventional pap smears’ 11%.Conclusions: Even though colposcopy clinical impression has the highest agreement with colposcopy biopsy it’s a diagnostic and not a screening test, hence Liquid based cytology showed better performance as a screening test compared to conventional Pap smear. In general, there was good agreement for cytological results of repeat CPAP and LBC. We therefore recommend that for patients referred with abnormal pap smears requiring a repeat pap smear, liquid based cytology is used due to its higher specificity compared to conventional Pap smear

Quality of comprehensive emergency obstetric care through the lens of clinical documentation on admission to labour ward

Background: Clinical documentation gives a chronological order of procedures and activities that a patient is given during their management.Objective: To determine the level of quality of comprehensive emergency obstetric care, through the lens of clinical documentation of process indicators of selected emergency obstetric conditions that mostly cause maternal mortality on admission to labour wardDesign: Multi-site cross sectional survey.Setting: Twenty two Government Hospitals in Kenya with capacity to offer comprehensive emergency obstetric care.Subjects: Process variables were abstracted from patient’ case records with a diagnosis of normal vaginal delivery, obstetric haemorrhage, severe pre eclampsia/eclampsia and emergency cesarean section.Results: Availability of structure indicators were graded excellent and good except for long gloves, misoprostol, ergometrin and parenteral cefuroxime that were graded low. A total of 1,216 records were abstracted for process analysis. The median (IQR) for the: six variables of obstetric history was five (4-5); five variables of antenatal profile was four (1-5); five variables of vital signs documentation was three (2-4); five variables for obstetric exam was four (4-5); seven variables of vaginal examination one (0-2); ten variables for partograph was seven (2-9); five variables for obstetric hemorrhage was three (2-4) and eleven variables for severe pre-eclampsia/eclampsia was five (3-6). The median (IQR) from decision-to-operate to caesarean section was three (2-4) hours.Conclusion: Quality of emergency obstetric care based on documentation depicts inadequacy. There is an urgent need to objectively address the need for proper clinical documentation as an indicator of quality performance

Evaluation of nationwide referral pathways, investigation and treatment of suspected cauda equina syndrome in the United Kingdom.

Purpose: Cauda equina syndrome (CES) is a spinal emergency with clinical symptoms and signs that have low diagnostic accuracy. National guidelines in the United Kingdom (UK) state that all patients should undergo an MRI prior to referral to specialist spinal units and surgery should be performed at the earliest opportunity. We aimed to evaluate the current practice of investigating and treating suspected CES in the UK. Materials and Methods: A retrospective, multicentre observational study of the investigation and management of patients with suspected CES was conducted across the UK, including all patients referred to a spinal unit over 6 months between 1st October 2016 and 31st March 2017. Results: A total of 28 UK spinal units submitted data on 4441 referrals. Over half of referrals were made without any previous imaging (n = 2572, 57.9%). Of all referrals, 695 underwent surgical decompression (15.6%). The majority of referrals were made out-of-hours (n = 2229/3517, 63.4%). Patient location and pre-referral imaging were not associated with time intervals from symptom onset or presentation to decompression. Patients investigated outside of the spinal unit experienced longer time intervals from referral to undergoing the MRI scan. Conclusions: This is the largest known study of the investigation and management of suspected CES. We found that the majority of referrals were made without adequate investigations. Most patients were referred out-of-hours and many were transferred for an MRI without subsequently requiring surgery. Adherence to guidelines would reduce the number of referrals to spinal services by 72% and reduce the number of patient transfers by 79%

Vulvo-perianal giant condylomata accuminata (Buschke Lowenstein Tumor) in a HIV-infected woman: a case report

Giant condylomata accuminata also known as Buschke Lowenstein Tumor (BLT) is a benign extensive cauliflower like lesion that is commonly found in the genital area. Its etiology is human pappiloma virus. It occurs more in men than women with a ratio of 2.7:1. Immunosuppresssion with HIV is the main risk factor but it has also been associated with pregnancy, diabetes, chronic steroid use and organ  transplants. It is debilitating with extensive psychosocial maladjustments and has 50% potential for  malignant transformation. The study was undertaken at Kenyatta National Hospital Gynecological ward. A 37 year old Para 2+0, HIV-infected woman on Highly Active Antiretroviral Therapy (HAART) for the past eight years, presented with a seven year history of progressive vulval growths and a five year history of per vaginal discharge and pruritus. The growths were insidious in onset and progressive but with no associated pain. The discharge was yellow, watery, copious and not foul smelling. There was no history of dyspareunia or post coital bleeding. She had been treated with various creams and antibiotics with no improvement. The physical examination revealed extensive cauliflower vulvo-vaginal and perianal warts with confluence in the mons pubis and labia majora  bilaterally. The lesions appeared flat and brownish- black, and of variable diameter ranging from 0.5cm to 3cm. The lesions were not friable and did not bleed upon touch. Due to the extensive nature of the lesions, a decision to undertake simple vulvectomy was made. The patient was consented for the surgery, wide excision was done with successful primary closure of wound site. Histopathology results confirmed giant condylomata acuminata, with no malignant changes noted and free margins. The wound healed by primary intention within one week of surgery. At one year follow up, the patient was still on HAART, no recurrence of the vulval lesions and a Pap smear cytology report was normal. She was advised on condom use, adherence to HAART and on the  importance of sustained follow up. We concluded that HIV-infected women on HAART are at risk for BLT, a severe disease associated with malignant transformation, vulvo-perineal examination should be scheduled into routine follow up for early diagnosis and treatment

Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya

Objectives: 1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ⩾2 weeks’ duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya. Design: Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya. Results: Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26–35) and 26 years (IQR 24–31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/μl (IQR 244–530) for HIV-infected women. One non-HIV-infected patient was sputump ositive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants. Conclusion: This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya

Total protein, albumin and low-molecular-weight protein excretion in HIV-positive patients

<p>Abstract</p> <p>Background</p> <p>Chronic kidney disease is common in HIV positive patients and renal tubular dysfunction has been reported in those receiving combination antiretroviral therapy (cART). Tenofovir (TFV) in particular has been linked to severe renal tubular disease as well as proximal tubular dysfunction. Markedly elevated urinary concentrations of retinal-binding protein (RBP) have been reported in patients with severe renal tubular disease, and low-molecular-weight proteins (LMWP) such as RBP may be useful in clinical practice to assess renal tubular function in patients receiving TFV. We analysed 3 LMWP as well as protein and albumin in the urine of a sample of HIV positive patients.</p> <p>Methods</p> <p>In a cross-sectional fashion, total protein, albumin, RBP, cystatin C, and neutrophil gelatinase-associated lipocalin (NGAL) were quantified in random urine samples of 317 HIV positive outpatients and expressed as the ratio-to-creatinine (RBPCR, CCR and NGALCR). Exposure to cART was categorised as none, cART without TFV, and cART containing TFV and a non-nucleoside reverse-transcriptase-inhibitor (TFV/NNRTI) or TFV and a protease-inhibitor (TFV/PI).</p> <p>Results</p> <p>Proteinuria was present in 10.4 % and microalbuminuria in 16.7 % of patients. Albumin accounted for approximately 10 % of total urinary protein. RBPCR was within the reference range in 95 % of patients while NGALCR was elevated in 67 % of patients. No overall differences in urine protein, albumin, and LMWP levels were observed among patients stratified by cART exposure, although a greater proportion of patients exposed to TFV/PI had RBPCR >38.8 μg/mmol (343 μg/g) (p = 0.003). In multivariate analyses, black ethnicity (OR 0.43, 95 % CI 0.24, 0.77) and eGFR <75 mL/min/1.73 m² (OR 3.54, 95 % CI 1.61, 7.80) were independently associated with upper quartile (UQ) RBPCR. RBPCR correlated well to CCR (r² = 0.71), but not to NGALCR, PCR or ACR.</p> <p>Conclusions</p> <p>In HIV positive patients, proteinuria was predominantly of tubular origin and microalbuminuria was common. RBPCR in patients without overt renal tubular disease was generally within the reference range, including those receiving TFV. RBP therefore appears a promising biomarker for monitoring renal tubular function in patients receiving TFV and for distinguishing patients with normal tubular function or mild tubular dysfunction from those with severe renal tubular disease or Fanconi syndrome.</p