Abdominal Compartment Syndrome in Surgical Patients

Background: The deleterious effects of intraabdominal hypertension and abdominal compartment syndrome, affect almost every system. Patients at risk are the critically ill, in whom it leads to alteredorgan perfusion and end organ dysfunction/failure. The five cases reported highlight the diagnostic and management challenges.Case Presentation: Five patients with variable degrees of multiple organ dysfunction/failure as evidenced by derangements in laboratory and clinical parameters are presented. Non-surgical interventions including insertion or repositioning of nasogastric tube, insertion of flatus tube, careful titration of IV fluid requirements and appropriate adjustments of ventilator setting were instituted. All five did not respond to initial management and decompressive laparotomy or re-opening of the abdomen was planned.Conclusion: Abdominal compartment syndrome can be prevented by regular measurement of intraabdominal pressure in patients at risk. Non-surgical means should precede decompressive laparotomy but timely surgical intervention is crucial.Key words: case series, Intra-abdominal pressure, Intra-abdominal hypertension, Abdominal compartment syndrome

Technique of Midline Abdominal Incision Closure Among Surgical Trainees

Background: Technique of anterior abdominal wall closure (AAWC) determines wound-related surgical complications. Residents in obstetrics and gynecology and surgery departments perform most midline abdominal wall closure; data is lacking on how it is being done. This study identifies abdominal wall closure techniques used. Methods: A descriptive study was carried out from October 2015 to May 2016. Results: 71 (35 surgical, 36 ObGyn) residents completed a self-administered questionnaire. Knowledge of midline abdominal closure was acquired from medical officers (58.6%) or consultants before residency (28.6%). Absorbable suture was preferred for clean wounds by 75% of residents; 70% used size 1 suture for fascial closure. Most residents (95.7%) closed fascia in clean wound by continuous suturing. Interrupted suturing was preferred in contaminated and dirty wounds. Half of the residents in both groups would close skin in contaminated wounds, while 16% of surgery and 9.4% ObGyn will close skin in dirty wounds. Conclusion: Inconsistencies exist in anterior abdominal wall closure between groups of residents despite presence of clear guidelines. It is important to harmonize training on AAWC at the tertiary hospital. Keywords: Abdominal closure, Midline incision, Wound complication

Documentation of pregnancy status before surgery in Kenya

Background: Performing surgical procedure on a pregnant woman may have major consequences for the fetus, patient, healthcare worker and institution. Assessment of pregnancy status in women of reproductive age when admitted to hospital is therefore an important safety practice. Documentation of likelihood of pregnancy among women admitted in the surgical units of Kenyatta National Hospital (KNH) is not known.Objective: To assess documentation of pregnancy status and possibility of pregnancy before surgery at KNH.Methods: This was a retrospective study involving all surgical units of female patients of reproductive age with various diagnoses and scheduled to undergo surgery between January 2011 and December 2016. Data collected included documentation of age, parity, last menstrual period, level of education, use of family planning, and pregnancy status confirmation using urine or serum beta human chorionic gonadotrophin (HCG) and ultrasound.Results: We analysed data from 331 patient records. All (100%) of the sampled records had age of the patient recorded, 43% had information on parity documented, 35% had last normal menstrual period recorded, and only 26% of the records showed information on use of family planning. 19 (5.7%) patients were confirmed to be pregnant using ultrasound and urine β-HCG.Conclusion: Although only a small proportion of women admitted in surgical units were pregnant, data on likelihood of pregnancy as deduced from information on age, last menstrual period and use of family planning were missing.Keywords: Pregnant, Fetus, Safety, Surgery, Anaesthesi

The magnitude and trend of artemether-lumefantrine stock-outs at public health facilities in Kenya

<p>Abstract</p> <p>Background</p> <p>Health facility stock-outs of artemether-lumefantrine (AL), the common first-line therapy for uncomplicated malaria across Africa, adversely affect effective malaria case-management. They have been previously reported on various scales in time and space, however the magnitude of the problem and trends over time are less clear. Here, 2010-2011 data are reported from public facilities in Kenya where alarming stock-outs were revealed in 2008.</p> <p>Methods</p> <p>Data were collected between January 2010 and June 2011 as part of 18 monthly cross-sectional surveys undertaken at nationally representative samples of public health facilities. The primary monitoring indicator was total stock-out of all four weight-specific AL packs. The secondary indicators were stock-outs of at least one AL pack and individual stock-outs for each AL pack. Monthly proportions and summary means of the proportions over the monitoring period were measured for each indicator. Stock-out trends were assessed using linear regression.</p> <p>Results</p> <p>The number of surveyed facilities across 18 time points ranged between 162 and 176 facilities. The stock-out means of the proportion of health facilities were 11.6% for total AL stock-out, 40.6% for stock-out of at least one AL pack, and between 20.5% and 27.4% for stock-outs of individual AL packs. Monthly decrease of the total AL stock-out was 0.005% (95% CI: -0.5 to +0.5; p = 0.983). Monthly decrease in the stock-out of at least one AL pack was 0.7% (95% CI: -1.5 to +0.3; p = 0.058) while stock-outs of individual AL packs decreased monthly between 0.2% for AL 24-pack and 0.7% for AL six-pack without statistical significance for any of the weight-specific packs.</p> <p>Conclusions</p> <p>Despite lower levels of AL stock-outs compared to the reports in 2008, the stock-outs at Kenyan facilities during 2010-2011 are still substantial and of particular worry for the most detrimental:- simultaneous absence of any AL pack. Only minor decrease was observed in the stock-outs of individual AL packs. Recently launched interventions to eliminate AL stock-outs in Kenya are fully justified.</p

Malaria Case-Management following Change of Policy to Universal Parasitological Diagnosis and Targeted Artemisinin-Based Combination Therapy in Kenya

BACKGROUND: The change of malaria case-management policy in Kenya to recommend universal parasitological diagnosis and targeted treatment with artemether-lumefantrine (AL) is supported with activities aiming by 2013 at universal coverage and adherence to the recommendations. We evaluated changes in health systems and case-management indicators between the baseline survey undertaken before implementation of the policy and the follow-up survey following the first year of the implementation activities. METHODS/FINDINGS: National, cross-sectional surveys using quality-of-care methods were undertaken at public facilities. Baseline and follow-up surveys respectively included 174 and 176 facilities, 224 and 237 health workers, and 2,405 and 1,456 febrile patients. Health systems indicators showed variable changes between surveys: AL stock-out (27% to 21%; p = 0.152); availability of diagnostics (55% to 58%; p = 0.600); training on the new policy (0 to 22%; p = 0.001); exposure to supervision (18% to 13%; p = 0.156) and access to guidelines (0 to 6%; p = 0.001). At all facilities, there was an increase among patients tested for malaria (24% vs 31%; p = 0.090) and those who were both tested and treated according to test result (16% to 22%; p = 0.048). At facilities with AL and malaria diagnostics, testing increased from 43% to 50% (p = 0.196) while patients who were both, tested and treated according to test result, increased from 28% to 36% (p = 0.114). Treatment adherence improved for test positive patients from 83% to 90% (p = 0.150) and for test negative patients from 47% to 56% (p = 0.227). No association was found between testing and exposure to training, supervision and guidelines, however, testing was significantly associated with facility ownership, type of testing, and patients' caseload, age and clinical presentation. CONCLUSIONS: Most of the case-management indicators have shown some improvement trends; however differences were smaller than expected, rarely statistically significant and still leaving a substantial gap towards optimistic targets. The quantitative and qualitative improvement of interventions will ultimately determine the success of the new policy

Improving accountability for equitable health and well-being in urban informal spaces: Moving from dominant to transformative approaches

This article critically reviews the literature on urban informality, inequity, health, well-being and accountability to identify key conceptual, methodological and empirical gaps in academic and policy discourses. We argue that critical attention to power dynamics is often a key missing element in these discourses and make the case for explicit attention to the operation of power throughout conceptualization, design and conduct of research in this space. We argue that: (a) urban informality reflects the exercise of power to confer and withhold advantage; (b) the dominant biomedical model of health poorly links embodied experiences and structural contexts; (c) existing models of accountability are inadequate in unequal, pluralistic governance and provision environments. We trace four conceptual and empirical directions for transformative approaches to power relations in urban health equity research

Six stormy years and the audacity to confront a challenging future: taking stock of the Kenyan Doctors’ Union

The Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) was formed in August 2011. Within the last six years, this union has galvanized the Kenyan doctors together, agitated for healthcare policy reforms and successfully negotiated and registered a Collective Bargaining Agreement (CBA). Though political will and the national citizens' psyche on matters pertaining to public healthcare remain a challenge, this union has made its foot prints on the Kenyan conversation space. KMPDU looks forward to engaging local, regional and international health stake holders to improve the state of the country's health care, key among these being to have a national commission handling all the human resources for health

Determination of ciprofloxacin in human plasma using high-performance liquid chromatography coupled with fluorescence detection: Application to a population pharmacokinetics study in children with severe malnutrition

Article published in Journal of Chromatography BClinical pharmacokinetic studies of ciprofloxacin require accurate and precise measurement of plasma drug concentrations. We describe a rapid, selective and sensitive HPLC method coupled with fluorescence detection for determination of ciprofloxacin in human plasma. Internal standard (IS; sarafloxacin) was added to plasma aliquots (200uL) prior to protein precipitation with acetonitrile. Ciprofloxacin and IS were eluted on a Synergi Max-RP analytical column (150mm×4.6mm i.d., 5um particle size) maintained at 40 ◦C. The mobile phase comprised a mixture of aqueous orthophosphoric acid (0.025 M)/methanol/acetonitrile (75/13/12%, v/v/v); the pH was adjusted to 3.0 with triethylamine. A fluorescence detector (excitation/emission wavelength of 278/450 nm) was used. Retention times for ciprofloxacin and IS were approximately 3.6 and 7.0 min, respectively. Calibration curves of ciprofloxacin were linear over the concentration range of 0.02–4ug/mL, with correlation coefficients (r2)≥0.998. Intraand inter-assay relative standard deviations (SD) were <8.0% and accuracy values ranged from 93% to 105% for quality control samples (0.2, 1.8 and 3.6ug/mL). The mean (SD) extraction recoveries for ciprofloxacin from spiked plasma at 0.08, 1.8 and 3.6ug/mL were 72.8±12.5% (n = 5), 83.5±5.2% and 77.7±2.0%, respectively (n = 8 in both cases). The recovery for IS was 94.5±7.9% (n = 15). The limits of detection and quantification were 10 ng/mL and 20 ng/mL, respectively. Ciprofloxacin was stable in plasma for at least one month when stored at −15 ◦C to −25 ◦C and −70 ◦C to −90 ◦C. This method was successfully applied to measure plasma ciprofloxacin concentrations in a population pharmacokinetics study of ciprofloxacin in malnourished children.Clinical pharmacokinetic studies of ciprofloxacin require accurate and precise measurement of plasma drug concentrations. We describe a rapid, selective and sensitive HPLC method coupled with fluorescence detection for determination of ciprofloxacin in human plasma. Internal standard (IS; sarafloxacin) was added to plasma aliquots (200uL) prior to protein precipitation with acetonitrile. Ciprofloxacin and IS were eluted on a Synergi Max-RP analytical column (150mm×4.6mm i.d., 5um particle size) maintained at 40 ◦C. The mobile phase comprised a mixture of aqueous orthophosphoric acid (0.025 M)/methanol/acetonitrile (75/13/12%, v/v/v); the pH was adjusted to 3.0 with triethylamine. A fluorescence detector (excitation/emission wavelength of 278/450 nm) was used. Retention times for ciprofloxacin and IS were approximately 3.6 and 7.0 min, respectively. Calibration curves of ciprofloxacin were linear over the concentration range of 0.02–4ug/mL, with correlation coefficients (r2)≥0.998. Intraand inter-assay relative standard deviations (SD) were <8.0% and accuracy values ranged from 93% to 105% for quality control samples (0.2, 1.8 and 3.6ug/mL). The mean (SD) extraction recoveries for ciprofloxacin from spiked plasma at 0.08, 1.8 and 3.6ug/mL were 72.8±12.5% (n = 5), 83.5±5.2% and 77.7±2.0%, respectively (n = 8 in both cases). The recovery for IS was 94.5±7.9% (n = 15). The limits of detection and quantification were 10 ng/mL and 20 ng/mL, respectively. Ciprofloxacin was stable in plasma for at least one month when stored at −15 ◦C to −25 ◦C and −70 ◦C to −90 ◦C. This method was successfully applied to measure plasma ciprofloxacin concentrations in a population pharmacokinetics study of ciprofloxacin in malnourished children

Major Improvements in the Quality of Malaria Case-Management under the “Test and Treat” Policy in Kenya

A Journal article by Dr. Gabriel Okello, a faculty in the Chandaria School of Business in USIU-AfricaBackground: Monitoring implementation of the "test and treat" case-management policy for malaria is an important component of all malaria control programmes in Africa. Unfortunately, routine information systems are commonly deficient to provide necessary information. Using health facility surveys we monitored health systems readiness and malaria case-management practices prior to and following implementation of the 2010 "test and treat" policy in Kenya. Methods/findings: Between 2010 and 2013 six national, cross-sectional, health facility surveys were undertaken. The number of facilities assessed ranged between 172 and 176, health workers interviewed between 216 and 237 and outpatient consultations for febrile patients evaluated between 1,208 and 2,408 across six surveys. Comparing baseline and the last survey results, all readiness indicators showed significant (p<0.005) improvements: availability of parasitological diagnosis (55.2% to 90.7%); RDT availability (7.5% to 69.8%); total artemether-lumefantrine (AL) stock-out (27.2% to 7.0%); stock-out of one or more AL packs (59.5% to 21.6%); training coverage (0 to 50.2%); guidelines access (0 to 58.1%) and supervision (17.9% to 30.8%). Testing increased by 34.0% (23.9% to 57.9%; p<0.001) while testing and treatment according to test result increased by 34.2% (15.7% to 49.9%; p<0.001). Treatment adherence for test positive patients improved from 83.3% to 90.3% (p = 0.138) and for test negative patients from 47.9% to 83.4% (p<0.001). Significant testing and treatment improvements were observed in children and adults. There was no difference in practices with respect to the type and result of malaria test (RDT vs microscopy). Of eight dosing, dispensing and counseling tasks, improvements were observed for four tasks. Overall AL use for febrile patients decreased from 63.5% to 35.6% (p<0.001). Conclusions: Major improvements in the implementation of "test and treat" policy were observed in Kenya. Some gaps towards universal targets still remained. Other countries facing similar needs and challenges may consider health facility surveys to monitor malaria case-management