Impact of Part-Time Private Practice on Medical Education in Kenya – A Personal Opinion

Traditional medical schools the world over are facing major challenges in educating physicians capable of responding to the continuously increasing health care needs of populations they serve1. The Kenyan situation is no different and the challenges are bigger considering the rampant poverty and the decline in what had been achieved in the health sector. In this country, effective healthcare, both promotive and curative, lies in the cooperation between a well-managed district hospital and health centers2. The district hospital, as the leader, plays a central role in promoting healthcare delivery. The failure of a district hospital will therefore lead to an unacceptable lowering of health standards and the collapse of preventive programs

Neonatal surgical emergencies at Moi Teaching and Referral Hospital in Eldoret -Kenya

Background: Success in the management of neonatal surgical emergencies depends on prompt diagnosis, adequate resuscitation, good nursing care, safe anaesthesia and competent surgery. Considering that centres for paediatric surgery are few in the developing world, an added requirement is application of the principles of neonatal transport, when neonates are transported to these centres from wherever they are born. These are the challenges that Moi Teaching & Referral Hospital (MTRH) faces in the provision of emergency service to neonates. The hospital serves the Western Kenya region with a population of about 15 million. This study was aimed at determining the pattern and the outcome of neonatal emergency surgery at MTRH.Methods: This was a retrospective descriptive study done at The Moi Teaching & Referral Hospital, Eldoret-Kenya. The study population included all neonates with emergencies managed by the paediatric surgical service between July 2003 and July 2006. Data was obtained from the theatre register and patients’ files.Results: Sixty nine neonates were operated between July 2003 and July 2006 but only 56 files were completed for analysis. Of the 56 neonates, 35 were male and 21 female (M: F ratio of 1.7:1). The median age of presentation was 3 days with a range of 1 – 22 days. Referrals represented 32 (60%). The leading three diagnoses were anorectal malformation 19 (34%) intestinal atresia 8 (14%) and anterior abdominal wall defects 7 (13%). 14 (25%) of the neonates had low birth weight. Application of principles of neonatal transport was poor. Inadequacy of fluid therapy was noted in 26 (45%) of the neonates. Challenges of providing parental nutrition were encountered in 11 (20%). Sepsis was the leading complication and major cause of mortality. Overall mortality was 18 (24%) but was 14 (44%) among the referrals.Conclusion: Morbidity and mortality was high in the management of neonates with surgical emergencies. Reversing the trend will require: early referral and presentation; overcoming the challenges of providing infrastructure that will enable good nursing care, and improving neonatal transport in the region

Non-traumatic abdominal surgical emergencies in children

Background: In developing countries, non-traumatic childhood abdominal surgical emergencies (NTCASE) are associated with high morbidity and mortality and include acquired diseases like acute appendicitis, intussusception and congenital abdominal anomalies such as gastroschisis. This study sought to identify the etiologies and outcomes of NTCASE at Moi Teaching and Referral Hospital (MTRH), Kenya.Methods: A prospective descriptive study that involved children below 18 years operated on for non-traumatic abdominal surgical emergencies between January 2015 and January 2016. Relevant data on clinical presentation, duration of onset of symptoms, investigations and intraoperative findings were entered into the data collection sheet. Daily follow-up was done until discharge or in-hospital death, and outcomes recorded.Results: A total of 140 patients were studied. Age of the patients ranged from 1 day to 17 years, with a mean of 3.0 (SD±2.9) years. Children below 2 years constituted 72.9% of the study participants. The male to female ratio was 2.1:1. The most common aetiologies were intussusception (17.9%) and gastroschisis (17.9%). The complication rate was 17.9% (n=25), average length of hospitalization 8.6±7.6 days, and in-hospital mortality 20%.Conclusion: The commonest aetiologies of NTCASE in MTRH are intussusception and gastroschisis. Mortality and morbidity rates are high. Factors co-related with mortality in patients with NTCASE are deranged potassium level, ASA classification grade 3 and 4, neonates, normal haemoglobin level, duration of illness presentation <24 hours, and development of complications.Keywords: Non-traumatic childhood abdominal surgical emergencies, Etiologies, Outcomes, Childre

Patient Transfer Practices By Hospitals In Western Kenya

Background: Patients who are critically ill and those requiring emergency care are transported within and between hospitals on a regular basis seeking diagnostic or therapeutic services not available at the bed side or within the referring institution. The emergency of specialty systems often determines the ultimate destination of patients rather than proximity of facility and this has heightened the need for patient transfer. To achieve a favorable outcome, it is necessary to ensure that any transfer is carried out safely and effectively with minimum disruption of the continuum of care. Objectives: To determine the gap between existing knowledge of patient transfer principles and the practice by hospitals in Western Kenya referring patients to Moi Teaching and Referral Hospital (MTRH). Design: Cross-sectional descriptive study. Setting: Accident and emergency department at MTRH. Subjects: Patients transferred in over a period of six months for critical/emergency care. Results: Evaluation was done for 97 transfers during the six months period. Age ranged from four days old to 70 years with a median of 28 years. A wide spectrum of diseases were seen. However in order of frequency the leading five were; trauma and accidents, vascular disorders, infections; anaemia and malignancies. Of the infections, respiratory infections topped the list with pulmonary tuberculosis as the leading disease entity. Majority of patients 43 (44%) were referred within 24 hours of being seen at the primary hospital. Only 56% were transported by ambulance; appropriate escort(nurse) was provided in 60%; documentation was provided in 85%; monitoring enroute was done in 24%; warmth was provided in 62%, 27% were dehydrated requiring resuscitation; respiratory support was inadequate as only 14% (of those who required) had airway and 32% had oxygen provided; intravenous fluids were provided in 34% of those who required; nasogastric intubation was provided in 30% of those who required; urethral catheterisation was provided in 23% of those who required; 50% of those with long bone fractures were splinted and only 3% of those who required cervical spine stabilisation had cervical collar. Conclusion: There was significant failure by hospitals in Western Kenya in the application of principles of patient transfer while referring patients to MTRH

Burden And Pattern Of Cancer In Western Kenya

Background: Cancer regisries worldwide have evolved to provide useful information on the burden and diversity of the patterns of cancer, information that is vital for establishing appropriate programmes for disease management. Population based data on cancer in western Kenya as captured in the Eldoret cancer registry established in1999 is analysed and reported in this paper.Objective: To determine the burden and pattern of cancer in Western Kenya by use of data from the Eldoret cancer registry.Design: Retrospective study.Setting: The cancer registry located in the Department of Haematology at the Moi University, School of Medicine situated at the Moi Teaching and Referral Hospital, Eldoret, Kenya. The hospital has a catchment population of 13 to 15 million people forming about 40% of the Kenyan population.Results: A total of 5,366 patients were diagnosed to have cancer and attended to at the MTRH and other hospitals in Eldoret during the period between January 1999 and December 2006 giving an average of 671 cases per year. Among those treated 2,699 were males and 2,667 were females giving a M: F ratio of 1:1. About 21% of the patients had haematological malignancies with non-Hodgkins lymphoma being the most common.Another 79% of the patients had solid tumours with cancer of the oesophagus being the commonest. Cancer of the cervix and prostrate were the commonest among the females and males respectively. A general increase in the number of patients with Kaposis sarcoma associated with HIV/AIDS pandemic was observed.Conclusion: The burden of cancer is a significant health problem in western Kenya and there is need for the development of a comprehensive cancer care programme in the region to address the growing problem

Management and outcome of patients with Wilms’ Tumour (Nephroblastoma) at the Moi Teaching and Referral Hospital, Eldoret, Kenya

Background: Wilms’ tumour is a common malignant neoplasm of the kidney and is ranked among the top six solid tumours in children in Kenya. Despite its rapid growth and therefore debilitating effects on its victims, it is one tumour that has shown good response to combined modality approach to its treatment with encouraging possibilities of survival even in resource poor settings.Objective: To evaluate the management and outcome of patients with Wilms’ tumour attended to at Moi Teaching and Referral Hospital (MTRH) during the period between January 2000 and December 2007.Design: Retrospective Study.Setting: The Paediatric Oncology Service (Oncology unit in the Paediatric Ward, the Paediatric Surgical Ward and the Outpatient Oncology Clinic) at the Moi Teaching and Referral Hospital, Eldoret, Kenya.Results: Information of 45 patients diagnosed with Wilms’ tumour was analysed. Forty two (93%) of the patients were referrals from various health facilities in the region. Twenty three (51%) were male and 34 (76%) were aged less than 48 months. Twenty five (56%) had the left kidney affected, 19 (42%) the right kidney and one (2%) bilateral. All the 45 (100%) had an abdominal ultrasound done but none had exhaustive investigations done to stage the disease. Only eight (18%) of the patients had a medical insurance cover. Fourty one (91%) of the patients received specific cancer treatment with 28 (62%) getting combined modality treatment. Nineteen (42%) were lost to follow up. Thirty (67%), 21 (47%), 15 (33%) and 13 (29%) patients were alive six months, one year, two years and three years respectively from the time of diagnosis. 29% survived beyond three years of diagnosis .Conclusion: Staging of Wilms tumour fell short of the expected. Neo-adjuvant chemotherapy reduced morbidity and mortality of patients managed for Wilms’ tumour. Loss to follow up and cost of treatment had a negative impact on the outcome, a situation that requires to be improved

Human leukocyte antigen-DQA1*04:01 and rs2040406 variants are associated with elevated risk of childhood Burkitt lymphoma

Burkitt lymphoma (BL) is responsible for many childhood cancers in sub-Saharan Africa, where it is linked to recurrent or chronic infection by Epstein-Barr virus or Plasmodium falciparum. However, whether human leukocyte antigen (HLA) polymorphisms, which regulate immune response, are associated with BL has not been well investigated, which limits our understanding of BL etiology. Here we investigate this association among 4,645 children aged 0-15 years, 800 with BL, enrolled in Uganda, Tanzania, Kenya, and Malawi. HLA alleles are imputed with accuracy >90% for HLA class I and 85-89% for class II alleles. BL risk is elevated with HLA-DQA1*04:01 (adjusted odds ratio [OR] = 1.61, 95% confidence interval [CI] = 1.32-1.97, P = 3.71 × 10-6), with rs2040406(G) in HLA-DQA1 region (OR = 1.43, 95% CI = 1.26-1.63, P = 4.62 × 10-8), and with amino acid Gln at position 53 versus other variants in HLA-DQA1 (OR = 1.36, P = 2.06 × 10-6). The associations with HLA-DQA1*04:01 (OR = 1.29, P = 0.03) and rs2040406(G) (OR = 1.68, P = 0.019) persist in mutually adjusted models. The higher risk rs2040406(G) variant for BL is associated with decreased HLA-DQB1 expression in eQTLs in EBV transformed lymphocytes. Our results support the role of HLA variation in the etiology of BL and suggest that a promising area of research might be understanding the link between HLA variation and EBV control

Mosaic chromosomal alterations in peripheral blood leukocytes of children in sub-Saharan Africa

In high-income countries, mosaic chromosomal alterations in peripheral blood leukocytes are associated with an elevated risk of adverse health outcomes, including hematologic malignancies. We investigate mosaic chromosomal alterations in sub-Saharan Africa among 931 children with Burkitt lymphoma, an aggressive lymphoma commonly characterized by immunoglobulin-MYC chromosomal rearrangements, 3822 Burkitt lymphoma-free children, and 674 cancer-free men from Ghana. We find autosomal and X chromosome mosaic chromosomal alterations in 3.4% and 1.7% of Burkitt lymphoma-free children, and 8.4% and 3.7% of children with Burkitt lymphoma (P-values = 5.7×10-11 and 3.74×10-2, respectively). Autosomal mosaic chromosomal alterations are detected in 14.0% of Ghanaian men and increase with age. Mosaic chromosomal alterations in Burkitt lymphoma cases include gains on chromosomes 1q and 8, the latter spanning MYC, while mosaic chromosomal alterations in Burkitt lymphoma-free children include copy-neutral loss of heterozygosity on chromosomes 10, 14, and 16. Our results highlight mosaic chromosomal alterations in sub-Saharan African populations as a promising area of research

Neonatal Surgical Emergencies at Moi Teaching and Referral Hospital in Eldoret -Kenya.

Background: Success in the management of neonatal surgical emergencies depends on prompt diagnosis, adequate resuscitation, good nursing care, safe anaesthesia and competent surgery. Considering that centres for paediatric surgery are few in the developing world, an added requirement is application of the principles of neonatal transport, when neonates are transported to these centres from wherever they are born. These are the challenges that Moi Teaching & Referral Hospital (MTRH) faces in the provision of emergency service to neonates. The hospital serves the Western Kenya region with a population of about 15 million. This study was aimed at determining the pattern and the outcome of neonatal emergency surgery at MTRH. Methods: This was a retrospective descriptive study done at The Moi Teaching & Referral Hospital, Eldoret-Kenya. The study population included all neonates with emergencies managed by the paediatric surgical service between July 2003 and July 2006. Data was obtained from the theatre register and patients’ files. Results: Sixty nine neonates were operated between July 2003 and July 2006 but only 56 files were completed for analysis. Of the 56 neonates, 35 were male and 21 female (M: F ratio of 1.7:1). The median age of presentation was 3 days with a range of 1 – 22 days. Referrals represented 32 (60%). The leading three diagnoses were anorectal malformation 19 (34%) intestinal atresia 8 (14%) and anterior abdominal wall defects 7 (13%). 14 (25%) of the neonates had low birth weight. Application of principles of neonatal transport was poor. Inadequacy of fluid therapy was noted in 26 (45%) of the neonates. Challenges of providing parental nutrition were encountered in 11 (20%). Sepsis was the leading complication and major cause of mortality. Overall mortality was 18 (24%) but was 14 (44%) among the referrals. Conclusion: Morbidity and mortality was high in the management of neonates with surgical emergencies. Reversing the trend will require: early referral and presentation; overcoming the challenges of providing infrastructure that will enable good nursing care, and improving neonatal transport in the region