Redisplacement Rates after Reduction and Cast Immobilization of Isolated Distal Radial Fractures

Background The maintenance of satisfactory alignment in distal radial fractures following closed reduction and casting of the forearm is challenging. Redisplacement rates of between 2 and 91% have been described, mostly for Western populations and for fractures involving both the forearm bones. The local scenario is unexplored. Objective This study sought to determine the rate of redisplacement in isolated closed distal radial fractures in children aged 6-15 years and the factors contributing to the redisplacement. Setting The Kenyatta National Hospital, a teaching and referral hospital in Kenya. Patients and Methods This was a prospective study carried out between June 2005 and February2006. Patients were recruited from casualty, where the fracture was reduced and casted. Immediate check x-rays were taken to ascertain satisfactory alignment. At follow up the fractures were evaluated for redisplacement in the fracture clinic in the second and fourth weeks with further check x-rays. Redisplacement was regarded as the presence of dorsal or volar- angulation of greater than 200. The data was collected and entered into statistical package for social sciences (SPSS) 12.0 version. Comparison of the binomial outcomes of the factors determining the redisplacement of the distal radial fractures was carried out using Fischer’s exact test. P valu

Typhoid Ileal Perforation: A Review of a Rural District Hospital Experience

Background: Enteric fever is endemic in developing countries and frequently complicates with ileal perforation. Surgical intervention forthe perforation is the usual treatment but attendant rate of postoperativecomplications high. It is unclear what the spec- trum of enteric fever perforations is in rural hospital practice in Kenya, where the diagnosis most often in intraoperative.Objective: To describe the surgical experience of typhoid perforationsat a rural district hospital in Kenya.Patient and Methods: This was a retrospective chart review of patients who underwent laparotomies for peritonitis at the Kapenguria District Hospital in Kenya between April 2007 and October 2009. Data abstracted from patient files included demographics, presenting symptom, duration of symptoms, investigations (Widal and/or stool culture), operative management, complications, length of stay, and death. Widal test was indicative when titer was 1:160 for “O” antigen or above. Antimesenteric longitudinal perforation was assumed to be a complication of enteric fever. The data were analyzed using SPSS version 16.0.The results are presented in frequency tables, bar charts and pie charts.Results: Of the 50 files retrieved with diagnosis of peritonitis, 21(42%) were found at operation to have had ileal perforations. Of these 15(71.5%) had resection and primary anastomosis, 2(9.5%) had refreshening and anastomosis (simple anastomosis) and 4 (19%) hadileostomy. Male to female ratio was 4:1, majority were aged 6-15 years(38.1%). Wound infection was 8(38.1%), enterocutaneous fistulae were7(33.3%), while 7(33.3%) required second laparotomy and 4(19%)were referred due to complications which could not be managed atthis level. Mortality was 3(14.3%) and average length of stay was17days.Conclusion: Morbidity and mortality arising from typhoid ileal perforationis high in this environment making it a major challenge in a resource poor environment. Prevention by use of protocols is highly recommende

Safety of thyroidectomy at a rural district hospital in Kenya

The clinical outcome of thyroidectomy may be influenced by among other things, the experience of the surgeon performing the procedure. Furthermore, auditing of any surgical procedure helps in monitoring the safety of the procedure in the hands of the operator. Objective This study is an audit of outcome of thyroidectomy performed by the author within the first 18 months of qualification from a local residency program. It aims to record the outcomes as baseline to facilitate future personal and institutional trends of thyroid disease, prevalent in the area. Setting Kapenguria District hospital in Kenya. The author was posted to this facility immediately after completion of surgical residency at the University of Nairobi. Design This was a retrospective audit from April 2007 to September 2008 Patients The patients who underwent thyroidectomy by the author from April 2007 to September 2008. The period was divided into three separate six month blocks of time (A-April to September 2007, B-October 2007 to March 2009, and C- April to September 2008. Main outcome measures Complications and length of stay. Results Thirty nine patients underwent thyroidectomy during this period. The most common type of goiter was multinodular goiter (69.2%, 27) while the most common type of surgery was total thyroidectomy (35.9%, 14). The number of days in hospital did not differ across the periods- 1.92 for period A, 1.75 for B and 1.07 for C. Two complications occurred during period A and were associated with total thyroidectomy Conclusion Subtotal and total thyroidectomy can be safely performed by general surgeons qualifying from our local training institutions. Institutional audits are important to document future improvements in outcomes

Management of Type 2 Diabetes in African Americans: Increasing Knowledge Using a Culturally Tailored Diabetes Education Program

Background: African Americans are disproportionately affected by type 2 Diabetes Mellitus (T2DM). Efforts to improve health outcomes related to diabetes and reduce associated complications have focused on self-management. Purpose: This Doctor of Nursing Practice (DNP) project focuses on implementing a culturally tailored diabetes education program with the goal of increasing participants’ knowledge and management of their disease. Methods: This quality improvement project was implemented at a community health center in Dorchester, Massachusetts, with African American adults age 18 years and older. The culturally tailored educational sessions were conducted biweekly for a total of six sessions; each session lasted approximately 90 minutes. The American Association of Diabetes Educators (AADE) guidelines was used to develop the education curriculum. The session topics included an overview of diabetes, nutrition and healthy eating, physical activity, and stress management. A survey and diabetes knowledge questionnaire was administered at the first and the last group session. Results: Fourteen African Americans with T2DM, ages 42-67 years old, participated in the culturally tailored educational intervention. Ten participants completed the minimum of four sessions to be included in data analysis for this project. The results indicate that knowledge on self-management of diabetes increased, with 60% of the participants having \u3e50% rate of improvement between the pre and post-test scores. Conclusion: The culturally tailored education demonstrated effectiveness in increasing knowledge of diabetes among African American adults. Diet, exercise, and stress management are considered necessary components in the management of diabetes and have been found to positively affect knowledge and self-monitoring of diabetes

40 years of surgical education in Kenya; what does the future hold?

Surgical education structure and systems worldwide have changed gradually to incorporate not only the traditional competencies of medical knowledge, patient care and technical skills but other non-technical skills of communication, systems based practice and professionalism. Until recently, it was anticipated that these non-technical skills were learnt in the same apprenticeship manner as the other surgical skills were achieved. However, great efforts are presently being expended to incorporate these non-technical skills into curricula, with the same level of evaluation and feedback as the other more traditional skills. Even at the leadership levels of surgical communities and surgical societies, professionalism is now recognized as a priority skill for surgeons worldwide. The implementation of this new skill will likely increase trust between surgeon and patient and hopefully improve the standards of patient care and safety. In Kenya, there have been suggestions of mistrust including increased litigation and adverse media reports on doctor’s conduct. These suggest that we have an opportune moment to consider changing the system to return trust in the healing profession. This paper discusses why the Kenyan surgical society and other medical professional bodies should seize the opportunity to ensure the standards of training in Kenya incorporate professionalism in order to ensure better improved skill set for the present medical graduates.Keywords: Medical Education, Non Technical Skills, Professionalis

Skills upgrading for newly qualified surgeon: Is the district hospital in Kenya suitable?

Background: Surgical training in many settings involves acquisition of both knowledge and skill in an environment of adequate caseloads and dedicated supervision. With adequate surgical activity in these settings, the trainee’s confidence is boosted to the point of independence. This skill acquisition is a continuous process, especially so for those who qualify from an exit training program like the one at the University of Nairobi (UON). The continuity is maintained for two years after the masters in surgery program under an experienced surgeon leading to registration by the medical board. This seems to have changed with the posting of newly qualified surgeons to the district hospitals, which has meant a transition from trainee to service provider in the absence of supervision. Objective: This study sought to document the caseload and type of surgical pathologies in the district hospital, the morbidities/mortality for cases operated on at the district, the proportion of the cases referred to higher level surgical centres and the reasons for referrals. Setting: The Kapenguria District Hospital (KDH) in the Rift Valley province of Kenya. Methodology: Records of all surgical patients attended to at the KDH between April 2007 and September 2007 were reviewed. Information collected included the nature of surgical pathology, investigations ordered and where these were done, surgical treatment offered, referrals, post-operative Complications and lengths of stay. All operations were performed or supervised by the author. Data were entered onto an SPSS 12.0 software program and analyzed for summary data. Results: Two hundred and ninety patients were evaluated. The main surgical pathologies were general trauma, goitres and herniae. There were 29 (10%) referrals to higher level facilities mainly due to lack of surgical instruments. Most investigations requested could not be done at KDH. The morbidity and mortality rate for the group of surgical patients was 12.4% and 4.1% respectively. Hospital stay averaged 3.46 days. Conclusion: The district hospital presents a potential setting for acquisition of surgical skills with its variety of surgical pathology and reasonable outcome data. However, the low volumes, lack of investigative capacity and surgical instruments compounded by absence of supervision, dictates that improvements in the system must be effected before the district hospital can be an ideal environment for the immediate post-residency training

Role of calcium and AMP kinase in the regulation of mitochondrial biogenesis and GLUT4 levels in muscle

Contractile activity induces mitochondrial biogenesis and increases glucose transport capacity in muscle. There has been much research on the mechanisms responsible for these adaptations. The present paper reviews the evidence, which indicates that the decrease in the levels of high-energy phosphates, leading to activation of AMP kinase (AMPK), and the increase in cytosolic Ca(2+), which activates Ca(2+)/calmodulin-dependent protein kinase (CAMK), are signals that initiate these adaptative responses. Although the events downstream of AMPK and CAMK have not been well characterized, these events lead to activation of various transcription factors, including: nuclear respiratory factors (NRF) 1 and 2, which cause increased expression of proteins of the respiratory chain; PPAR-alpha, which up regulates the levels of enzymes of beta oxidation; mitochondrial transcription factor A, which activates expression of the mitochondrial genome; myocyte-enhancing factor 2A, the transcription factor that regulates GLUT4 expression. The well-orchestrated expression of the multitude of proteins involved in these adaptations is mediated by the rapid activation of PPAR gamma co-activator (PGC) 1, a protein that binds to various transcription factors to maximize transcriptional activity. Activating AMPK using 5-aminoimidizole-4-carboxamide-1-beta-D-riboside (AICAR) and increasing cytoplasmic Ca(2+) using caffeine, W7 or ionomycin in L6 myotubes increases the concentration of mitochondrial enzymes and GLUT4 and enhances the binding of NRF-1 and NRF-2 to DNA. AICAR and Ca-releasing agents also increase the levels of PGC-1, mitochondrial transcription factor A and myocyte-enhancing factors 2A and 2D. These results are similar to the responses seen in muscle during the adaptation to endurance exercise and show that L6 myotubes are a suitable model for studying the mechanisms by which exercise causes the adaptive responses in muscle mitochondria and glucose transport

Exposure in emergency general surgery in a time-based residency program: A call for review

Objective: This paper aimed to characterize the resident exposure to acute general surgical conditions during a three-months rotation in a general surgical unit. Setting: The Department of Surgery, University of Nairobi and Kenyatta National Referral and Teaching Hospital in Nairobi. MethodS: Four residents (in their first to third post-basic science year) were evaluated during a 12-week General Surgery rotation. Details assessed included number and variety of admission diagnoses logged by each resident, number and nature of surgical operations performed independently by each resident and with consultant support, and the resident involvement in the continuity of care. The experiences were compared across the residents. Results: One hundred and forty five patients were admitted. The number of admissions per resident varied between 30 and 41. Fifty-eight patients had surgery. Operative experience where the resident was the principal surgeon ranged from 11 cases to 23 cases per resident. A second resident assisted in 8 out of the fiftyeight cases operated on and consultant support was infrequent. Conclusion: The operative experience was variable for the general surgical residents. Exposure could be improved by a policy of resident assistance at emergency surgery. The infrequent consultant support may invalidate formative assessment of resident competence

Alvarado vs Lintula Scoring Systems in Acute Appendicitis

Background: Timely and correct diagnosis of acute appendicitis reduces complications and avoids unnecessary surgeries. Scoring systems are used as adjuncts to aid in diagnosis.Methods: This was a prospective observational study carried out at Kenyatta National Hospital, from November 2014 to April 2015. Demographic, clinical and laboratory data was collected from consenting patients. The gold standard of diagnosis was histopathology. Data analysis was done using SPSS. The receiver operating characteristics, sensitivity, specificity, positive predictive values and negative predictive values of both scoring systems were then calculated for each of the scoring systems and compared between the two.Results: Majority of patients presented with right iliac fossa pain and underwent appendectomy. The sensitivity of the Lintula and Alvarado scoring systems were 60.8% and 84.3% respectively, while the specificity was 60% and 35% respectively. The PPV of the Lintula was 79.5% while that of the Alvarado 76.8%.Conclusion: The Lintula system compares well with the Alvarado system for diagnosis of acute appendicitis and can therefore be employed in situations where laboratory facilities may be limited.Key words: Acute Appendicitis, Scoring systems, Lintula, Alvarad

Abdominal cocoon: A case report

An abdominal cocoon is an uncommon condition in which there is a total or partial encapsulation of the small bowel by fibrous membrane. A preoperative diagnosis is seldom made. Awareness of this rare surgical entity may prevent delay in treatment and avoid unnecessary procedures. We report on a patient in whom diagnosis of an abdominal cocoon was made intraoperatively and review the relevant literature