Factors that influence advance directives completion amongst terminally ill patients at a tertiary hospital in Kenya.

BACKGROUND: An advance directive (AD) is a written or verbal document that legally stipulates a person's health care preference while they are competent to make decisions for themselves and is used to guide decisions on life-sustaining treatment in the event that they become incapacitated. AD can take the form of a living will, a limitation of care document, a do-not-resuscitate order, or an appointment of a surrogate by durable power of attorney. The completion rate of AD varies from region to region, and it is influenced by multiple factors. The objectives of this study were to determine the proportion of terminally ill patients with AD and to identify the factors that influence the completion of AD amongst terminally ill patients at a tertiary hospital in Kenya. METHODS: The study was a retrospective survey. All available records of terminally ill patients seen at Aga Khan University Hospital, Nairobi, between July 2010 and December 2015, and that met the inclusion criteria were included in the study. RESULTS: In total, 216 records of terminally ill patients were analyzed: 89 records were of patients that had AD and 127 records were of patients that did not have AD. The proportion of terminally ill patients that had completed AD was 41.2%. The factors that were associated with the completion of AD on bivariate analysis were history of ICU admission, history of endotracheal intubation, functional status of the patient, the medical specialty taking care of the patient, patient's caregiver discussing the AD with the patient, and a palliative specialist review. On multivariate regression analysis, discussion of AD with a caregiver and patient's functional impairment were the factors with statistically significant association with completion of AD. CONCLUSIONS: The proportion of terminally ill patients that had AD in their medical records was significant. However, most terminally ill patients did not have AD. Our data, perhaps the first on the subject in East Africa, suggest that most of the factors associated with AD completion mirrored those seen in other regions of the world. Discussion between patient and their physician and patient's functional impairment were the factors independently associated with completion of AD. Therefore, physicians need to be aware of the importance of discussions of AD with their patients.

Long-distance gene flow in Acacia senegal: Hope for disturbed and fragmented populations.

Even though pollen and seed dispersals are some of the important factors that determine tree species survival across landscapes, gene dispersal data of important tropical dryland tree species such as Acacia senegal that are undergoing various population disturbances remain scarce. Understanding patterns of gene dispersal in these ecosystems is important for conservation, landscape restoration and tree improvement. We investigated pollen and seed mediated gene flow in two A. senegal populations of contrasting state (less disturbed and heavily undisturbed) using nine microsatellites and 128 genotyping-by-sequencing single nucleotide polymorphism (SNPs) multilocus genotypes of two growth stages (juvenile and adult trees) and their spatial locations. We performed parentage assignments using likelihood approach and undertook spatial genetic structure (SGS) analyses for the two growth stages through correlation among kinship coefficients and geographical distances between pair of individuals. The SNPs showed higher resolving power and assignment rates than microsatellites; however, a combination of the two marker-types improved the assignment rate and provided robust parentage assessments. We found evidence of long-distance (up to 210 m) pollination events for both populations; however, the majority of seed dispersal was found closer to the putative maternal parent. On average, parentage analysis showed high amounts of pollen (40%) and seed (20%) immigration in both populations. Significant positive SGS was found only for the adult cohorts in the less disturbed population for distance classes 20 and 40 m, indicating historical short-distance seed dispersals. Our results suggest long-distance gene flow within the species and we recommend conservation of remnant and isolated populations or individual trees to promote genetic connectivity.

Population Structure and Migration Patterns of the Tsetse Fly Glossina fuscipes in Congo-Brazzaville.

Tsetse flies of the palpalis group, particularly Glossina fuscipes, are the main vectors of human African trypanosomiasis or sleeping sickness in Congo-Brazzaville. They transmit the deadly human parasite, Trypanosoma brucei gambiense and other trypanosomes that cause animal trypanosomiasis. Knowledge on diversity, population structure, population size, and gene flow is a prerequisite for designing effective tsetse control strategies. There is limited published information on these parameters including migration patterns of G. fuscipes in Congo-Brazzaville. We genotyped 288 samples of G. fuscipes from Bomassa (BMSA), Bouemba (BEMB), and Talangai (TLG) locations at 10 microsatellite loci and determined levels of genetic diversity, differentiation, structuring, and gene flow among populations. We observed high genetic diversity in all three localities. Mean expected heterozygosity was 0.77 ± 0.04, and mean allelic richness was 11.2 ± 1.35. Deficiency of heterozygosity was observed in all populations with positive and significant F IS values (0.077-0.149). Structure analysis revealed three clusters with genetic admixtures, evidence of closely related but potentially different taxa within G. fuscipes. Genetic differentiation indices were low but significant (F ST = 0.049, P < 0.05), indicating ongoing gene flow countered with a stronger force of drift. We recorded significant migration from all the three populations, suggesting exchange of genetic information between and among locations. Ne estimates revealed high and infinite population sizes in BEMB and TLG. These critical factors should be considered when planning area-wide tsetse control interventions in the country to prevent resurgence of tsetse from relict populations and/or reinvasion of cleared habitats.

Rangewide ploidy variation and evolution in Acacia senegal: a north-south divide?

Knowledge of rangewide variation in DNA content and ploidy level may be valuable in understanding the evolutionary history of a species. Recent studies of Acacia senegal report diploids and occasional tetraploids in the Sudano-Sahelian region of sub-Saharan Africa, but nothing is known about the overall extent of DNA ploidy variation within the species. In this study, we determine the DNA content and ploidy level of A. senegal across its native range, and explore whether the variation is related to its evolutionary and colonization history. We used propidium iodide flow cytometry (FCM) to estimate DNA content (2C value) and infer ploidy in 157 individuals from 54 populations on various tissues, using seeds, fresh leaves, dried leaves and twigs and herbarium specimens. The mean 2C DNA (pg ± s.d.) contents detected were 1.47 ± 0.09, 2.12 ± 0.02, 2.89 ± 0.12, and a single individual with 4.51 pg, corresponding to a polyploid series of diploid, triploid, tetraploid and hexaploid individuals. Diploids were confirmed by chromosome counts (2n = 2x = 26). Most populations (90.7 %) were of single ploidy level, while mixed ploidy populations (9.3 %) comprising mostly diploids (2x+3x, 2x+4x and 2x+6x) were restricted to the Sudano-Sahelian and Indian subcontinent regions, its northern range. The species is predominantly diploid, and no mixed ploidy populations were detected in east and southern Africa, its southern range. The geographic pattern of ploidy variation in conjunction with existing phylogeographic and phylogenetic data of the species suggests that polyploids have occurred multiple times in its evolutionary and recent colonization history, including contemporary ecological timescales. The successful use of external tissues of dried twigs in FCM is new, and presents the opportunity to study numerous other dryland woody species.