Daycase trauma list: a safe and cost-effective service delivery.

INTRODUCTION: Daycase trauma surgery is an evolving and a novel approach. The aim of our study was to report our experience of daycase trauma surgery with a focus on safety, patient experience, complications and limitations. MATERIAL AND METHODS: Patients scheduled and operated on a daycase trauma list from January 2013 to December 2016 were included in the study. Age, sex, case mix, readmissions within 48 hours, complications, patient satisfaction, reasons for overnight stay and cost effectiveness were evaluated. RESULTS: A total of 229 procedures were carried out. The mean age of the patients was 44.3 years (range 16-85 years) . There were 128 men and 101 women, 178 upper-limb and 51 lower-limb cases. Only 2.6% of the patients had stayed overnight for pain control, physiotherapy and neurological observations; 94.5% of the patients were satisfied. The mean visual analogue scale score for satisfaction was 8.7. There were no admissions within 48 hours of discharge and one complication with failure of ankle fixation. The estimated cost saving was £65,562. CONCLUSION: We conclude that a daycase trauma service is safe, cost effective, and yields high patient satisfaction. It reduces the burden on hospital beds and a wide range of upper- and lower-limb cases can be performed as daycase trauma surgery with adequate planning and teamwork.

SEROPREVALENCE OF HAV, HBV, HCV, AND HEV AMONG ACUTE HEPATITIS PATIENTS AT KENYATTA NATIONAL HOSPITAL IN NAIROBI, KENYA.

BACKGROUND: Acute viral hepatitis is most frequently caused by the hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV). OBJECTIVES: To determine seroprevalence of HAV, HBV, HCV and HEV among patients with acute hepatitis in Nairobi, Kenya, elucidate various risk factors for hepatitis viral infection and determine the co-infection rates with these viruses in the acute hepatitis patients. DESIGN: Across sectional descriptive study. SETTING: Kenyatta National Hospital, from November 2007 to April 2008. SUBJECTS: One hundred patients were recruited by purposive sampling method and comprised of 57 males and 43 females. RESULTS: Among the enrolled patients, twenty three tested positive for one or more markers of acute viral hepatitis, that is, HAV, HBV, HCV and HEV. No markers were detected in 77patients, 2% tested positive for IgM anti-HAV 11% for IgM anti-HBc; 3% for HBsAg; 5% for HCV RNA and 7% for IgM anti-HEV.Various risk factors associated with acute viral hepatitis were identified; poor sanitation, source of water, occupation, place of residence, level of education, household size, drug abuse and sexual behaviours. Co-infection rate with hepatitis Viruses was at 4%, IgM anti-HAV and IgM anti-HEV 1% (n=1); IgM anti-HBc and IgM anti-HEV 1% (n=1); IgM anti-HBc and anti-HCV 2% (n=2). Three patients were positive for HBsAg; among this two were negative for IgM anti-HBc and this accounted for HBV carriage (2%). CONCLUSION: Hepatitis viruses'infections are commoncause of hepatitis among patients with acute hepatitis at Kenyatta National Hospital. Co-infection with these viruses was also identified among these patients.

Prevalence of hepatitis C virus and its genotypes among a cohort of drug users in Kenya.

BACKGROUND: Prevalence of hepatitis C virus and that of its main genotypes varies between the worlds geographic regions. The risk factors for infection with HCV include blood transfusion, tattoing and injecting drug use. OBJECTIVES: To examine the prevalence of HCV and determine its main genotypes among a cohort of drug users in Kenya. DESIGN: A laboratory based study. SETTING: Hepatitis research laboratory in the Centre for Virus Research at the Kenya Medical Research Institute, Nairobi. SUBJECTS: Three hundred and fourteen male and 19 female intravenous and non-intravenous drug users aged between 15-55 years. RESULTS: Seventy four (22.2%) out of 333 samples tested positive for anti-HCV. Sixty nine out of the 74 serum samples were assayed for HCV RNA and 38 (55.5%) were positive. The RNA positive samples were further subjected to sequencing and 19 (73%) of the samples were classified as genotype 1a, while seven (27%) samples were classified as genotype 4. Genotypes 2, 3, 5 and 6 were not identified in this study. CONCLUSIONS: These results demonstrate a high HCV infection prevalence among this cohort of drug users (22.2%) as compared to that of the general population, which is estimated to be 0.2-0.9%. The study also confirms the presence of at least two major genotypes among Kenyan drug users (genotypes 1 and 4).

Detection and identification of echovirus 7 from a child with gastro-enteritis.

BACKGROUND: Gastro-enteritis continues to be a significant cause of mortality in infants and young children in developing countries. Some previous studies have associated echoviruses with gastroenteritis. OBJECTIVE: To look for other viral agents causing gastro-enteritis in stool samples of infants and young children admitted with diarrhoea in an urban hospital in Kenya by electron microscopy. DESIGN: A cross sectional study. SETTING: Mbagathi District Hospital, Nairobi, Kenya. SUBJECTS: One hundred infants and young children admitted in the hospital due to gastro-enteritis and found to be negative for group A rotaviruses. RESULTS: We report a virus designated KE/CVR-99 which was recovered from the faeces of a one year old male child hospitalised for gastro-enteritis. Virus particles measuring 20-25 nm in diameter were detected by electron microscopy from the stool of the child hospitalised with gastro-enteritis. After injecting the viral particles intracerebrally in newborn suckling mice which were then observed daily for signs of illness, no sign of paralysis or any other form of illness was detected. Cytopathic effect was observed in rhabdomyosarcoma cells within six days of incubation whereas no cytopathic effect was observed in L-20 B cells. We identified the virus after typing against known anti-sera to a panel of enteroviruses. This virus was found to be Echovirus 7. CONCLUSION: This is the first case report of echovirus 7 in association with gastro-enteritis and detection by electron microscopy in Kenya.

Seroprevalence of hepatitis B markers in pregnant women in Kenya.

OBJECTIVE: To evaluate hepatitis B serological markers in pregnant women from various geographical sites in Kenya. DESIGN: A cross-sectional observational study of women attending antenatal clinics. SETTING: The Kenyatta National Hospital and eight hospitals from five provinces in Kenya. SUBJECTS: All women in their third trimester of pregnancy attending the antenatal clinic over the period June 2001 to June 2002. MAIN OUTCOME MEASURES: For each pregnant woman age and gestation were documented. Hepatitis serological markers were evaluated. RESULTS: A total of 2241 pregnant women were enrolled. Among them 205 women (9.3%) were positive for HbsAg and from these 18 (8.8%) were found to have HbeAg. Protective antibodies (anti-HbsAg) were detected in 669 (30.2%) of the women. There were notable significant regional differences for HbsAg rates. CONCLUSIONS: These results confirm the presence of high disease carrier rate and the corresponding previously reported low level of HbeAg suggesting questionable low rate of perinatal transmission but high rate of horizontal transmission.

Tuberculosis and oral Candida species surveillance in HIV infected individuals in Northern Kenya, and the implications on tuberculin skin test screening for DOPT-P.

OBJECTIVE: To determine the pattern of opportunistic infections such as TB and Candida species in HIV infected patients in Northern Kenya. DESIGN: Cross-sectional study. SETTING: Five health facilities in Moyale (n=224), Mandera (n=121) and Turkana Kakuma; (n=83), Lopiding; (n=94) districts during different periods in 2003. SUBJECTS: Five hundred and fifty two patients. RESULTS: In total 94 (18%) patients were found to be HIV positive (Moyale=42, Mandera=13, Turkana; Kakuma=8, Lopiding=31). Only 65 of 94 HIV positive patients provided saliva samples. Of these, 11 (17%) were TB smear positive and 19 (29.2%) were colonized by oral Candida species. The Candida isolates were as follows; Co-infection of Candida species and TB (n=4), C. albicans only (n=12), C. tropicalis only (n=1), C. albicans and C. glabarata (n=1) and C. albicans, C. glabarata and C. tropicalis. co-infection (n=1). CONCLUSION: The findings provides an important insight into the differences in mucosal susceptibility to bacteria (TB) infection and fungal (Candida species) colonization during HIV immunosuppression, based on collected blood, sputum and saliva specimens. Further studies are needed to elucidate the comparative transmission dynamics and pathogenetic mechanisms of these opportunistic infections-in different regions of Kenya. Such studies would improve the efficiency of directly observed preventive therapy programme (DOPT-P) whose implementation involves screening by tuberculin skin testing.

Seroprevalence of hepatitis B and C in maintenance dialysis in a public hospital in a developing country.

BACKGROUND: Patients with end-stage renal disease (ESRD) on maintenance dialysis are predisposed to hepatitis B virus (HBV) infection for a number of reasons. In a similar way, the prevalence of anti-hepatitis C virus (HCV) antibodies among patients on chronic haemodialysis and peritoneal dialysis is consistently higher than in healthy populations. There are few published data on these diseases in patients undergoing maintenance dialysis in sub-Saharan Africa. OBJECTIVE: To determine the seroprevalence of HBV and HCV in patients on maintenance dialysis. SETTING: Renal Unit, Kenyatta National Hospital, the largest public referral and teaching hospital in Kenya. DESIGN: Cross-sectional descriptive study. STUDY POPULATION: All 100 patients on maintenance dialysis during the 9-month study period were evaluated. METHOD: The following information was obtained from all the patients: socio-demographic data, date of diagnosis of ESRD and commencement of dialysis, and number of blood transfusions. Additionally, a history suggestive of hepatitis in spouses was looked for and physical examination for tattoos and other scars was carried out. Laboratory investigations included urea, electrolytes and serum creatinine, liver enzymes, hepatitis B surface antigen (HBsAg), immunoglobulin M anti-hepatitis B core antibody (IgM anti-HBc), hepatitis B e antigen (HBeAg) and anti-HCV antibodies. Student's t-test was used to assess the significance of the data collected. RESULTS: The results were expressed as mean (+/- SD). Fifty-seven males and 43 females were studied. Mean age was 44.3 +/- 14.6 years. Ten patients (10%) had elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) (> 40 U/l for both). HBsAg was found in 8 patients (8%), IgM anti-HBc in 2%, and HBeAg in none. Anti-HCV antibody was found in 5%. Six of the HBsAg-positive patients were on haemodialysis, the other 2 on continuous ambulatory peritoneal dialysis (CAPD). There was no coexistence of HBV and HCV markers. Longer duration of dialysis and the number of blood transfusions were associated with an increased seroprevalence of HBV and HCV. CONCLUSION: There is a low seroprevalence of HBV and HCV in our dialysis population. This should not lead to complaisance in screening for these potentially lethal complications.

CD4T lymphocyte subsets and disease manifestation in children with and without HIV born to HIV-1 infected mothers.

OBJECTIVE: To understand the natural history of HIV-1 infection in children in terms of evolution of childhood clinical manifestations versus the immune status, we prospectively studied children with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 for two years between March 1998 and March 2000. DESIGN: A prospective cohort study. SETTING: An institutional children's home. SUBJECTS: Fifty nine children (26 males and 33 females) with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 and adopted in institutional children home. METHODS: HIV-1 status of children under nine months was confirmed by polymerase chain reaction(PCR). ELISA for HIV-1 antibody in serum/plasma was used to confirm HIV-infection status for children aged < or = 18 months. Children were visited every three months between March and June 2000. At every visit blood was collected for total white cell count, haemoglobin and CD4+ and CD8+ T cell counts. The institutional doctor routinely examined children and treated all ailments. Clinical data were recorded. MEASURES: HIV-DNA, anti-HIV antibodies, total white blood count, total T cell counts, CD4 and CD8 T cell subset counts, frequency of childhood manifestations of infection. RESULTS: The children were aged between 4.5 and 13 years. The baseline haematological and immunological profiles (mean, mode) were: HIV-1 sero-converters (WBC 7151,7150; HB 11.6, 12.0; CD4+ 686, 795; CD8+ 2168, 1507) and HIV-1 de-seroconverters (mean, mode) were: (WBC 8386, 7150; HB 11.7, 12.8; CD4+ 735, 795; CD8+ 2168, 1507). The commonest causes of illnesses among the HIV-1 children were URTI (85.3%), TB(56.1 %), pneumonia (56.2%), tonsillitis (34.1%), parotiditis (28%) and acute otitis media (25%). The distribution of clinical manifestations was similar between the two categories of children, except URTI, whose prevalence was significantly increased among HIV-1 infected children (p-value=0.006). Among the HIV-1 infected children, only TB, parotiditis, and acute otitis media (AOM) were significantly associated with decreased CD4+ T cell count (p<0.05) resulting from HIV infection. CONCLUSIONS: HIV infection in children predisposes them to common childhood infections that can be used as markers of immune decline. TB, AOM, URTI may be early indicators of suspicion that would enable selective screening for HIV infection in children.

KEMRI Hep-cell II hepatitis B surface antigen screening kit.

BACKGROUND: Kenya is a high hepatitis B virus (HBV) endemic zone. Prevention of HBV transmission by transfusing safe blood is necessary. Kits for screening hepatitis B surface antigen (HBsAg) are usually imported and are expensive. Hence it has been difficult to screen donated and patient blood samples all over Kenya. OBJECTIVE: To produce a HBsAg screening kit locally in order to be able to screen donated and patient blood samples all over Kenya. DESIGN: A laboratory based study. SETTING: Centre for Virus Research (CVR), Kenya Medical Research Institute (KEMRI), Nairobi. METHOD: Purified HBsAg from plasma of carriers obtained from National Public Health Laboratories Services (NPHLS) was used to minimise guinea pigs to produce antihepatitis B (anti HBs) antibody. The anti HBs was then used to sensitise sheep red blood cells (SRBC). The final product was freeze dried (lyophilised) and its sensitivity and specificity was compared with other commercial kits. RESULTS: The sensitivity and specificity of KEMRI Hep-cell II was found to be 98% and 99%, respectively. The kit was found to be stable and potent for one year whether kept 4 degrees C, 37 degrees C or room temperature. CONCLUSION: KEMRI Hep-cell II was successfully produced locally. The sensitivity and specificity were comparable to other commercial kits. The kit was stable and potent for one year between temperature of 4 degrees C and 37 degrees C. The kit required only simple apparatus to carry out the test hence it can be used anywhere in Kenya. It was also cheap and affordable.

PIP: Kenya is a high hepatitis B virus endemic zone, and prevention of viral transmission by transfusing safe blood is necessary. However, kits for screening hepatitis B surface antigen (HBsAg) are usually imported and are expensive; hence, it has been difficult to screen donated and patient blood samples all over the country. This laboratory-based study, conducted at the Kenya Medical Research Institute (KEMRI), produced a HBsAg screening kit locally in order to be able to screen donated and patient blood samples throughout Kenya. Purified HBsAg from plasma carriers obtained from the National Public Health Laboratories Services was used to induce guinea pigs to produce anti-hepatitis B antibody (anti-HBs). The anti-HBs was then used to sensitize sheep red blood cells. The final product was freeze dried (lyophilized) and its sensitivity and specificity was compared with other commercial kits. The KEMRI Hep-cell II had 98% and 99% sensitivity and specificity, respectively, in comparison with other commercial kits. The kit was found to be stable and potent for 1 year at temperatures of 4 degrees Celsius, 37 degrees Celsius, or at room temperature. The KEMRI Hep-cell II kit is cheap and affordable and requires a simple apparatus to carry out the test; hence, it can be used anywhere in Kenya.

Human plasma derived hepatitis B vaccine: Kenyan experience.

OBJECTIVE: To determine the efficacy and safety of hepaccine B. DESIGN: Vaccination on first-come-first-served basis. SETTING: Kenya Medical Research Institute (KEMRI) staff and families at Nairobi, Kenya. PARTICIPANTS: A total of 107 vaccinees aged 0-10 years and 10 years and above. MAIN OUTCOME: Antibody to hepatitis B surface antigen (anti HBs) checked one month after the third dose of the vaccine. RESULTS: Ninety seven per cent of the vaccinees developed antiHBs. Side effects were few in the form of soreness at site of injection and headache. CONCLUSION: Hepaccine B produced good immune response in vaccinees with minimal side effects.

Colonoscopic findings in Kenyan African patients.

OBJECTIVE: To determine the types and prevalence of colonic diseases in Kenyan African patients referred for colonoscopy with lower gastrointestinal tract symptoms. DESIGN: A cross sectional survey conducted over a two year period. SETTING: Major private hospitals in Nairobi. PATIENTS: Two hundred forty seven consecutive patients of both sexes and all ages referred for colonoscopy between January 1996 and December 1997. Only Kenyans of African origin were included. Patients were referred from all over the country though the majority of cases were from Nairobi and its surrounding districts. RESULTS: The major indications for colonoscopy were lower abdominal pain (35.6%), non-bloody diarrhoea (22.3%), constipation (21.4%) and rectal bleeding (19.8%). Nearly 53% of patients colonoscoped had abnormal mucosal findings, with the main abnormalities being: proctocolitis (20.2%), colorectal cancers (12.1%), haemorrhoids (7.3%), colorectal polyps (6.5%) and diverticulosis (5.3%). The main histological diagnosis among patients whose colonic biopsy were done included normal colonic mucosa (29%), non-specific colitis (28.5%), adenocarcinoma (18.2%), benign colonic polyp (9.7%) and ulcerative colitis (7.3%). There was one case of Crohn's colitis and five cases (3%) of infective colitis. CONCLUSION: The study shows that the African colon has a number of pathological lesions contrary to previous reported literature.

Study of hepatoma from all provincial hospitals in Kenya

Hepatocellular carcinoma is common in Kenya occurring at an earlier age than in Europe. It is the third commonest solid tumour among males at the Kenyatta National Hospital. Hepatitis B virus seems to be playing a very important role in the causation of HCC. A study done at the KNH in 1985 showed that hepatitis B surface antigen (HBsAg) was positive in 85of HCC patients. Some of these cases had integrated HBV-DNA in the liver; whereas others had free HBV-DNA. We undertook to screen patients with possible HCC clinically and ultrasonographically in all teh provincial hospitals in Kenya and taat KHN. These patients had blodded samples taken for HBV markers; hepatitis C virus (HCV)) antibodies and allllphafetopreotein (AFP). A few of teh patients had histological confirmation of the HCC. A total of 137 cases of HCC were screened; with a mean age of 45.7 years (range 7-86 years). The prevalence of HBsAg in HCC was found to be 39.4 per cent and the prevalence of anti-HCV Ab was found to be 2.9 per cent. AFP was positive in 51.8 per cent of HCC cases with 38 per cent of cases having levels greater than 200 ng/ml. Most of the HCC cases were diffuse (48 per cent) or multiple (32.7 per cent) and only solitary in 9.2 per cent of the cases. Even the solitary tumours were large with an average size of 41.3 pmm. HBV plays an important role in the causation of HCC in our setup whereas HCV does not seem to be as important. AFP is an important indicator of HCC and combined with ultrasound; it can be used for early diagnosis of HCC in high risk groups; that is; HBsAg positive individuals

Viral hepatitis.

The list of hepatitis viruses is increasing over the years. Now the viruses range from A to G. Hepatitis A virus is a short incubation RNA virus which is transmitted oro-faecally. It does not cause chronic illness but may be fatal in a few cases especially in pregnancy. It can now be prevented by vaccination. Hepatitis B virus is a long incubation DNA virus which is transmitted mainly through blood and blood products. It causes chronic illness and can lead to liver cancer in some cases. It can be prevented by vaccination and WHO is now recommending global vaccination of all infants irrespective of endemicity of hepatitis B virus. Hepatitis C virus is an RNA virus which used to be known as parenterally transmitted non A non-B virus. It leads to chronic illness and can lead to liver cancer. It is now responsible for most cases of post transfusion hepatitis in Europe, North America and Asia. Hepatitis Delta virus is a defective virus which requires hepatitis B virus for its existence. Thus it affects only those who have hepatitis B virus. Hepatitis E virus used to be known as the enterically transmitted non-A non-B virus. It is transmitted oro-faecally and seems not to lead to chronic illness. It is endemic in some areas like Middle East and parts of Africa. Hepatitis G virus is just being described. More information about it will soon be available.

Detection of HBV-DNA and HCV-RNA viral sequences by polymerase chain reaction in selected Kenyan samples and the relationship to HBV seromarkers.

We undertook a study on selected samples from patients who had presented with viral hepatitis and conditions of the liver (liver cirrhosis, chronic hepatitis and hepatocellular carcinoma). Diagnosis, screening and confirmation for viral hepatitis was done using a battery of techniques: ultrasound, conventional serological methods (Hepatitis B surface Antigen [HBsAg] - Reverse Passive Haemagglutination [RPHA], Hepatitis B core Antibody [HBcAb] - Passive Haemagglutination [PHA], Alpha-feto Protein - RPHA), Hepatitis B e Antigen/Antibody [HBeAg/Ab] - Radioimmunoassay [RIA], Hepatitis C antibody [HCV-Ab] - Enzyme Immunosorbent Assay [EIA]. Due to the high specificity and sensitivity of the Polymerase Chain Reaction technique [PCR] in detecting the viral genomes, it was used to establish the presence of the HBV-DNA and HCV-RNA to correlate the serological diagnosis of their respective seromarkers. A total of 39 serum samples were tested comprising 11 blood donors, 8 chronic liver disease patients and 20 hepatocellular carcinoma cases. 4/19 (21%) HCV-antibody (C-l) reactive samples were found to be positive for HCV-RNA by PCR. 14 of the 19 (73.7%) including the 4 HCV-RNA positive cases tested positive for HBcAb. 6 of 11 (55%) HBsAg positive cases also tested positive for HBV-DNA by PCR, In 8 of 20 (40%) hepatocellular carcinoma cases, no aetiological role could be assigned to hepatitis B or C as only HBcAb was demonstrated in those cases.

The prevalence of hepatitis C virus antibodies in renal patients, blood donors and patients with chronic liver disease in Kenya.

We tested serum samples from four categories of patients with nephrological problems (nephrotic syndrome, stable chronic renal failure, haemodialysis patients and renal transplant recipients), patients with chronic liver disease and volunteer blood donors for the presence of antibody to hepatitis C virus (HCV). Screening was done by second-generation enzyme linked immunosorbent assay (ELISA) and confirmation with second-generation recombinant immunoblot assay (RIBA). Of all the renal patients, only 6.3% of the transplant patients tested positive for anti-HCV, while in patients with chronic liver disease anti-HCV was detected in 2.6% of the patients with chronic hepatitis and in none with liver cirrhosis or hepatocellular carcinoma. This finding of low prevalence in these patient groups was not in keeping with findings in studies done elsewhere. Our anti-HCV prevalence of 0.9% in blood donors was comparable to that found in Europe, USA and Taiwan. We recommend that the low prevalence of anti-HCV in some of our high risk groups should not lead to complacence and hence further studies are necessary to evaluate the infectivity of anti-HCV positive patients and the potential for cross infection.

Efficacy of hepatitis B vaccine in a rural community in Muranga, Kenya.

One hundred and seventy four high risk cases were vaccinated at Muranga district in Kenya. The plasma derived HB vaccine was used in 61 cases (group 1) and recombinant HB vaccine was used in 113 cases (group 2). Fifty five cases (90.2%) in group 1 and 112 (99.1%) cases in group 2 seroconverted. Anti-HBc seroconversion occurred in one case during the study period. Significant anti-HBs seroconversion were obtained both for plasma derived HB vaccine and recombinant HB vaccine. In infants, there was statistically significant difference between the geometrical mean of anti HBs titres in group 1 and that in group 2. The recombinant vaccine was more effective than the plasma derived vaccine.

Famotidine in the management of gastro-oesophageal reflux.

Famotidine has been used for the treatment of peptic ulcers and Zollinger Ellison syndrome and is also useful in reflux and erosive oesophagitis. To evaluate the effects of Famotidine 20 mg given twice daily in the symptomatic relief of gastro-oesophageal reflux disease with normal oesophagus or mild endoscopic oesophagitis, patients were followed over a period of six weeks. 70% of the patients had complete day-time heartburn relief during the study and 75% had complete night-time heartburn relief during the study. Famotidine was found to be safe and there were no serious clinical or laboratory adverse experiences.