The Spectrum of Paediatric Congenital Heart Disease at The Kenyatta National Hospital: Implications for Surgical Care

BackgroundCongenital Heart Disease (CHD) is a significant cause of morbidity and mortality amongst infants and children globally. Complex heart lesions are more costly to manage than simple lesions. Geographical differencesin the spectrum of CHD have been reported; knowledge of the spectrum of CHD provides a foundation for the rational allocation of health care resources. We undertook a study to determine if the CHD spectrum inKenya differs from that encountered elsewhere in the globe.MethodsA five year retrospective study was carried out at the Kenyatta National Hospital, Nairobi between January 1st 2000 and December 31st 2004. The frequency of selected CHD lesions was examined and compared with that reported from other parts of the world.ResultsTwo hundred and fourteen patients were studied. The mean age at confirmation of diagnosis by echocardiography was 18.6 months. The frequency of ventricular septal defects, atrial septal defects, patent ductus arteriosus, tetralogy of Fallot and transposition of the great arteries, were 18.7%, 4.7%, 10.7%, 8.4%, 6.5% and 4.2% respectively.ConclusionThe spectrum of CHD encountered in Kenya may contain more complex lesions than the spectrum found in developed regions of the world. Health resource allocation formulae applied to developed nations may not optimize the care of patients with CHD in developing nations. This may have important implications for health care resource allocation towards CHD in Kenya

Surgical Apgar Score predicts postoperative complications in traumatic brain injury

Background: Predicting complications in neurotrauma patients by using an effective scoring system can reduce morbidity and mortality while facilitating objective clinical decision making during recovery. Compared to existing morbidity and mortality predictive scores, the Surgical Apgar Score (SAS) is simple and effective. We carried out this study to determine the utility of SAS in predicting postoperative complications in neurotrauma patients.Methods: A prospective study was carried out at the Kenyatta National Hospital. The SAS was derived using intra-operative lowest mean arterial pressure, lowest heart rate and total blood loss for each patient. Major complications were determined during the thirty day post operative period.Results: Two hundred and one patients were reviewed. One hundred and sixteen (56%) of the patients developed major complications. The mean SAS for patients without complications was 7.04 while for patients with complications was 4.80. SAS was found to have a strong correlation with occurrence of major complication during the 30 day post surgery period.Conclusion: The SAS is useful in predicting complications and mortality following surgery in patients with traumatic brain injury. The score is recommended in triaging post operative patients and as a guide for patient referral.Keywords: Surgical Apgar Score (SAS), Traumatic Brain Injury, Complication

Variant anatomy of the right portal vein in a black Kenyan population

Surface mapping of the liver before invasive procedures depends on a proper understanding of its segmental vasculature. The right portal vein ramification and lengths show marked variations and these mostly involve its right posterior sectoral branch. Their incidence is variable among populations and altogether undocumented among Africans. One hundred livers obtained during autopsies and dissections at the Department of Human anatomy, University of Nairobi, were used in this study. Gross dissection was done to reveal and determine the branching pattern of the right portal vein and the origin of the right posterior sector branch. The lengths of the right portal vein were also measured and recorded. When present, the right portal vein terminated by bifurcation in 61% of the cases, trifurcated in 20.8% and quadrifircated in 18.2%. Its length was between 0.5cm and 4cm. The right posterior sector vein was given off the main portal vein in 34 cases, the common left portal vein trunk in 15 cases, and the right portal vein in 42 cases. In 9 cases, it was not observed at the porta hepatis. We report significant different incidences of the variant anatomy of the right portal vein compared to those found in previous studies and this should be borne in mind when doing surgical interventions.Keywords: Segmentectomy, transjugular, Surface mapping, Bifurcatio

The Effect of Provider Density on Lung Cancer Survival Among Blacks and Whites in the United States

IntroductionLung cancer mortality rates may vary with access to specialty providers and local resources. We sought to examine the effect of access to care, using density of lung cancer care providers, on lung cancer mortality among blacks and whites in the United States.MethodsWe examined U.S. county-level data for age-adjusted lung cancer mortality rates from 2003 to 2007. Our primary independent variable was per capita number of thoracic oncologic providers, adjusting for county-level smoking rates, socioeconomic status, and other geographic factors. Data were obtained from 2009 Area Resource File, National Center for Health Statistics, and the County Health Rankings Project.ResultsProviders of lung cancer care were unevenly distributed among the U.S. counties. For example, 41.4% of the U.S. population reside in counties with less than four thoracic surgeons per 100,000 people, 23.4% in counties with 4 to 15 surgeons per 100,000 people, and 35.3% in counties with more than 15 surgeons per 100,000 people. Geographically, 4.3% of whites compared with 11.2% of blacks lived in high lung cancer mortality zones. Lung cancer mortality did not vary by density of thoracic surgeons or oncology services; however, higher primary care provider density was associated with lung cancer mortality reduction of 4.1 per 100,000 for whites.ConclusionVariation in provider density for thoracic oncology in the United States was not associated with a difference in lung cancer mortality. Lower mortality associated with higher primary care provider density suggests that equitable access to primary care may lead to reduced cancer disparities

Neonatal Ebstein’s Anomaly: Surgical Decision Making

Ebstein’s Anomaly (EA) is a rare form of congenital heart disease. Surgical decision-making in neonates is controversial. In developing countries, neonates with Ebstein’s anomaly requiring surgical intervention rarely present to health institutions capable of providing intervention. We present a 2.2 kg term female neonate who presented with Ebstein’s anomaly. Data was obtained retrospectively from clinical case notes. We describe our surgical decision-making process and outcome in relation to prevailing thought regarding the management of this condition and we make a recommendation on what we consider to be the best surgical option for these patients.Key words: Ebstein's anomaly, Neonatal, Treatmen

The Diagnostic Utility of Induced Sputum Microscopy and Culture in Childhood Pneumonia.

BACKGROUND.: Sputum microscopy and culture are commonly used for diagnosing the cause of pneumonia in adults but are rarely performed in children due to difficulties in obtaining specimens. Induced sputum is occasionally used to investigate lower respiratory infections in children but has not been widely used in pneumonia etiology studies. METHODS.: We evaluated the diagnostic utility of induced sputum microscopy and culture in patients enrolled in the Pneumonia Etiology Research for Child Health (PERCH) study, a large study of community-acquired pneumonia in children aged 1-59 months. Comparisons were made between induced sputum samples from hospitalized children with radiographically confirmed pneumonia and children categorized as nonpneumonia (due to the absence of prespecified clinical and laboratory signs and absence of infiltrate on chest radiograph). RESULTS.: One induced sputum sample was available for analysis from 3772 (89.1%) of 4232 suspected pneumonia cases enrolled in PERCH. Of these, sputum from 2608 (69.1%) met the quality criterion of <10 squamous epithelial cells per low-power field, and 1162 (44.6%) had radiographic pneumonia. Induced sputum microscopy and culture results were not associated with radiographic pneumonia, regardless of prior antibiotic use, stratification by specific bacteria, or interpretative criteria used. CONCLUSIONS.: The findings of this study do not support the culture of induced sputum specimens as a diagnostic tool for pneumonia in young children as part of routine clinical practice

Safety of Induced Sputum Collection in Children Hospitalized With Severe or Very Severe Pneumonia.

BACKGROUND.: Induced sputum (IS) may provide diagnostic information about the etiology of pneumonia. The safety of this procedure across a heterogeneous population with severe pneumonia in low- and middle-income countries has not been described. METHODS.: IS specimens were obtained as part a 7-country study of the etiology of severe and very severe pneumonia in hospitalized children <5 years of age. Rigorous clinical monitoring was done before, during, and after the procedure to record oxygen requirement, oxygen saturation, respiratory rate, consciousness level, and other evidence of clinical deterioration. Criteria for IS contraindications were predefined and serious adverse events (SAEs) were reported to ethics committees and a central safety monitor. RESULTS.: A total of 4653 IS procedures were done among 3802 children. Thirteen SAEs were reported in relation to collection of IS, or 0.34% of children with at least 1 IS specimen collected (95% confidence interval, 0.15%-0.53%). A drop in oxygen saturation that required supplemental oxygen was the most common SAE. One child died after feeding was reinitiated 2 hours after undergoing sputum induction; this death was categorized as "possibly related" to the procedure. CONCLUSIONS.: The overall frequency of SAEs was very low, and the nature of most SAEs was manageable, demonstrating a low-risk safety profile for IS collection even among severely ill children in low-income-country settings. Healthcare providers should monitor oxygen saturation and requirements during and after IS collection, and assess patients prior to reinitiating feeding after the IS procedure, to ensure patient safety