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

Factors Influencing Choice of Inguinal Hernia Repair Technique

Background: Inguinal hernia repair surgery is one of the most frequently performed surgical procedures worldwide. This study sought to highlight factors that may influence decisions concerning inguinal hernia repair techniques.Methods: This descriptive crosssectional study was carried out in September 2014 among surgical trainees and surgeons.Data collected included: qualification of the operating doctor, level at which practical training on inguinal hernia repair occurred, awareness of the various inguinal hernia repair methods, inguinal hernia repair method(s) used for the past three (most recent) inguinal hernia operations and reasons for using that /those repair method(s).Results: Fifteen surgeons and sixty surgical trainees were recruited. Awareness levels and practical training were highest in the modified Bassini and Lichtenstein repair techniques. Experienced peers play a major role in training on the various repair techniques. The modified Bassini technique is preferred in emergency inguinal hernia repair; conversely, open mesh repair (Lichtenstein and PHS/plug) is preferred in elective cases. Reasons influencing choice of repair technique include training on the technique among others.Conclusion: Multiple factors affect the choice of inguinal hernia repair technique some of which are based on evidence while others are attributed to availability of resources and training (or lack thereof).Key words: Inguinal Hernia, Surgical Technique, Choice of Techniqu

Incidence and Early Outcome of Coagulopathy among Major Trauma Patients

Background: Despite improvement in many aspects of acute trauma care, uncontrolled bleeding is responsible for more than 50% of all trauma related deaths within the first two days of admission. Objective: This study sought to determine the incidence of coagulopathy among major trauma patients and their associated outcome. Methods: A prospective descriptive study carried at KNH among major trauma patients. Coagulation status was determined within 30 minutes of arrival. Outcomes assessed included length of hospital stay, transfusion requirement and mortality for 30 days. Fischer’s exact test was used to analyze categorical variables and Student T test used to analyze continuous variables. Results: Majority (85.7%) of the 140 patients recruited were male and, the mean age was 29.4 years (SD=12.0). Coagulopathy was present in 52.1% of the patients. The mean ISS on admission was 23.3 (SD=4.8), patients with coagulopathy had a higher ISS 22.2 (SD=5.2, p=0.018). The patients with coagulopathy stayed longer in hospital 12 days and their mortality was higher 21 (95.5%) p<0.001. Conclusion: Majority of trauma patients were coagulopathic. Initial assessment of coagulation status in trauma patients is useful in planning care and anticipating complications. Key words: Coagulopathy, Major trauma, Incidence, Outcomes, Low and middle income countrie

Base Deficit as an Indicator of Significant Blunt Abdominal Trauma

Background: Blunt abdominal trauma (BAT) is an important cause of morbidity and mortality among trauma patients. Base deficit (BD) has been proposed as an early available tool alongside focused assessment with sonography for trauma (FAST) in the screening of patients suspected to have BAT and also to help guide the selective use of CT scan. Objective: To determine the use of BD as an indicator of significant BAT. Methods: This was an observational study carried out at the Kenyatta National Hospital from February to May 2015. Patient with suspected BAT admitted into Accident & Emergency were enrolled. Data collected included clinical assessment, BD, FAST findings, CT-scan, and laparotomy were recorded. Data was analyzed using SPSS 17.0. Comparison of mean values of BD between different groups of patients (discharged from A&E, managed conservatively or operated) was performed using ANOVA. Results: Patients who had significant abdominal injury had sensitivity and specificity of 82.98% and 65.91 % respectively at BD of -4.15.The PPV and NPV were 56.52% and 87.88 % respectively. At this cut-off point, AUC was 0.863 (p=0.037). Conclusion: Due to high NPV, BD could rule out significant abdominal injuries but can also predict need for exploratory laparotomy when less than -6.85.Key words: Base deficit, Blunt abdominal trauma, Predictor

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

Can PSA Predict Bone Metastasis amongst Newly Diagnosed Prostate Cancer Patients?

Background: The decision as to when a bone scan is necessary in the staging of prostate cancer is controversial with different studies giving varying recommendations on the same subject. Objective: To determine the utility of total Prostate Specific Antigen in the prediction of bone metastases in newly diagnosed prostate cancer patients. Methods: This was a cross-sectional descriptive study carried out on newly diagnosed treatment naïve, prostate cancer patients over a period of five months. Patients who had an elevated prostate specific antigen of more than 10ng/ml, at least six core biopsies and bone scan examinations within one month of the PSA estimation were recruited. The bone scan results were then correlated with tPSA levels and Gleason scores from the histopathology report. Results: Of the 54 patients recruited, only 20% had positive bone scans. There was statistically significant association between bone scan results and Gleason scores (p value =< 0.001). The highest sensitivity and specificity was obtained at a PSA cut off of 100ng/ml, with area under curve of 0.7019. Conclusion: The results of this study show that PSA may be used in conjunction with Gleason scores as a predictor of the presence of bone metastases.Key words: Utility, PSA level, Bone scan, Bone metastasi

Prevalence of Esophageal Adenocarcinoma

Background: There has been a marked increase of the prevalence of adenocarcinoma of the esophagus across the globe, with the risk factors including gastroesophageal reflux disease (GERD) and Barrett’s esophagus. It is not known whether the trend is similar locally. Objective: To describe the prevalence and clinicopathological characteristics of adenocarcinoma of the esophagus at Kenyatta National Hospital (KNH).Methods: This was a cross sectional descriptive study of patients presenting with dysphagia at the surgical outpatient unit and the Endoscopy Unit by consecutive sampling. The patients’ demographic and clinical data were obtained using a structured questionnaire. The findings at endoscopy including site of tumor and histopathological findings were recorded. The data was analyzed using SPSS version 22.0. The histological subtypes were presented as a proportion. Results: A total of 74 patients were recruited. The mean age at diagnosis of esophageal cancer was 57.7 years. The mean duration of symptomatology was 4.5 months, with 66.2% of the patients presenting with wasting at diagnosis. The prevalence of adenocarcinoma amongst esophageal tumors was 18.9%. Conclusion: There is increasing occurrence of adenocarcinoma, demonstrating a higher rate than a decade earlier. Further studies are needed to elucidate the risk factors locally.Key words: Prevalence, clinicopathological features, adenocarcinoma, Esophagu

Utility of World Society of Emergency Surgery Sepsis Severity Score in Predicting Outcomes of Intra-abdominal Infections

Background: Intra-abdominal infections are classified as simple or complicated. Many tools have been studied to predict risk factors and outcomes of patients with intra-abdominal infections. None of these tools has been adopted for patient care at the Kenyatta National Hospital (KNH), Kenya. Objective: To determine the utility of the World Society of Emergency Surgery (WSES) Sepsis Severity Score in predicting short-term outcomes of patients managed for complicated intra-abdominal infections. Methods: We conducted a hospital-based prospective cohort study. Patients aged 18 years and above with complicated intra-abdominal infections were recruited. Data were obtained on demographics, condition at admission, time to source control, origin of infection, immune suppressants and complications. IBM SPSS version 21.0 was used to obtain means and standard deviations while logistic regression was used for associations. Results: A sepsis severity score of 6.5, best predicted mortality having a sensitivity of 80% and a specificity of 20.9% were obtained. For each unit increase in the WSES scores, the odds of mortality were 2.1, organ dysfunction 2.2, CCU admission 2.1. Conclusion: Our sepsis severity score has demonstrated good performance in our adult population, and also ability to predict adverse outcomes other than mortality in patients managed for intra-abdominal sepsis. Keywords: WSES, Sepsis, Sepsis severity score, Intra-abdominal infection

Objective Structured Clinical Examination Tests: Comparison with Traditional Clinical Examinations in Surgery

Background: Examination methods change over time, and audits are useful for quality assurance and improvement. Objective: Comparison of traditional clinical test and objective structured clinical examination (OSCE) in a department of surgery. Methods: Examination records of results of the fifth year MBChB examinations for 2012–2013 (traditional) and 2014–2015 (OSCE) were analyzed. Using 50% as the pre-agreed pass mark, the pass rate for the clinical examinations in each year was calculated and these figures were subjected to t-test to determine any significant differences in each year and in type of clinical test. P value of <0.05 determined significant statistical differences in the test score. Results: We analyzed 1178 results; most (55.6%) did OSCE. The average clinical scores examinations were 59.7% for traditional vs 60.1% for OSCE examination; basic surgical skills were positively skewed. Conclusion: OSCE in the same setting of teaching and examiners may give more marks than the traditional clinical examination, but it is better at detecting areas of inadequacies for emphasis in teaching. Keywords: Clinical examination, Traditional, OSCE, Compariso

The Medical Education Environment at the University of Nairobi, Kenya: An Assessment with the DREEM Tool

Background: The supportive learning environment can enhance impartating of knowledge and skills. Objective: To assess the learning environment at the School of Medicine of the University of Nairobi using the Dundee Ready Educational Environment Measure(DREEM) tool. Methods: A cross-sectional survey carried in 2019 out among medical students during their clinical years to obtain their perceptions about the learning environment at the School of Medicine of the University of Nairobi. The DREEM tool was used for the survey. Data were entered and analyzed in SPSS version19. Comparisons were performed using analysis of variance (ANOVA). p≤0.05 was consideredstatistically significant. Results: We obtained 619 responses (77.4%) from 800 tools distributed. The total mean score of DREEM was 93.3/200. This is a 46.7%score overall indicating a poor perception of the learning environment. Year IV was the class with the poorest perception with a p<0.05. Conclusion: The DREEM score shows numerous problems, with perception of learning and social support being the areas requiring themost improvement. Although teachers are knowledgeable, students are wary of their ability to transfer knowledge and skills. Keywords: Learning environment, DREEM, Medical student