Laparoscopic surgery during the COVID-19 pandemic: detection of SARS-COV-2 in abdominal tissues, fluids, and surgical smoke.

BACKGROUND: There are still concerns over the safety of laparoscopic surgery in coronavirus disease 2019 (COVID-19) patients due to the potential risk of viral transmission through surgical smoke/laparoscopic pneumoperitoneum. METHODS: We performed a systematic review of currently available literature to determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in abdominal tissues or fluids and in surgical smoke. RESULTS: A total of 19 studies (15 case reports and 4 case series) comprising 29 COVID-19 patients were included. The viral RNA was positively identified in 11 patients (37.9%). The samples that tested positive include the peritoneal fluid, bile, ascitic fluid, peritoneal dialysate, duodenal wall, and appendix. Similar samples, together with the omentum and abdominal subcutaneous fat, tested negative in the other patients. Only one study investigated SARS-COV-2 RNA in surgical smoke generated during laparoscopy, reporting negative findings. CONCLUSIONS: There are conflicting results regarding the presence of SARS-COV-2 in abdominal tissues and fluids. No currently available evidence supports the hypothesis that SARS-COV-2 can be aerosolized and transmitted through surgical smoke. Larger studies are urgently needed to corroborate these findings.

Prevalence and pubo-umbilical index of pyramidalis muscle in a select Kenyan population.

PURPOSE: Pyramidalis is a lower anterior abdominal wall muscle that is considered vestigial and shows variations in prevalence and size. It's been utilized as an anatomical landmark and harvested for use in various surgical procedures. Despite knowledge of its clinical importance, data on the prevalence of pyramidalis remain absent from the Kenyan population with few studies globally reporting on its pubo-umbilical index. We therefore aimed to determine the prevalence and relative lengths (pubo-umbilical index) of pyramidalis muscle in a sample Kenyan population. MATERIALS AND METHODS: Fifty-two cadavers (41 males, 11 females) from the Department of Human Anatomy, University of Nairobi were used. Prevalence and length of the muscle (l) were established, and the distance between pubic symphysis and umbilicus (L) measured and used to calculate pubo-umbilical index (l/L ×100%). Independent and paired T tests were done, using SPSS® version 22. A p value of ≤ 0.05 was considered statistically significant at a 95% confidence interval. RESULTS: Pyramidalis was present in 84% (44) of cadavers; 83% (43) bilaterally, 2% (1) unilaterally, and 85.4% (35) in males, 81.8% (9) in females. Mean length in males and females was 71.8 ± 35 mm and 63.5 ± 37.5 mm, respectively. Mean pubo-umbilical index was 38% ± 18 (39 % ± 18 males, 35% ± 19 females). No statistically significant difference was found. CONCLUSION: Pyramidalis is a highly prevalent muscle in the Kenyan population and, hence, could be exploited for its clinical and surgical utilities. The muscle terminates largely within the 2nd quarter (25-50%) of the infra-umbilical linea alba measured from pubic symphysis. Its pubo-umbilical index would be useful to surgeons making midline infra-umbilical incisions and performing procedures involving the muscle.

Cancer is associated with coronavirus disease (COVID-19) severity and mortality: A pooled analysis.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is a rapidly escalating pandemic that has spread to many parts of the world. As such, there is urgent need to identify predictors of clinical severity in COVID-19 patients. This may be useful for early identification of patients who may require life-saving interventions. In this meta-analysis, we evaluated whether malignancies are associated with a significantly enhanced odds of COVID-19 severity and mortality. METHOD: A systematic search of literature was conducted between November 1, 2019, to May 26th, 2020 on PubMed and China National Knowledge Infrastructure (CNKI) to identify studies reporting data on cancers in patients with or without severe COVID-19 were included. The primary outcome of interest was the association between malignancies and COVID-19 severity, while the secondary outcome was the association between malignancies and COVID-19 mortality. Data were pooled into a meta-analysis to estimate pooled odds ratio (OR) with 95% confidence interval (95% CI) for either outcome. RESULTS: A total of 20 studies (n = 4549 patients) were included. Overall, malignancies were found to be associated with significantly increased odds of COVID-19 severity (OR = 2.17; 95% CI 1.47-3.196; p < 0.001) and mortality (OR = 2.39; 95% CI 1.18-4.85; p = 0.016). No heterogeneity was observed for both outcomes (Cochran's Q = 6.558, p = 0.922, I2 = 0% and Cochran's Q = 2.91, p = 0.71, I2 = 0% respectively). CONCLUSION: Malignancies were significantly associated with a 2-fold increase in the odds of developing severe COVID-19 disease, as well as mortality. Larger studies are needed to corroborate these findings. These patients should be closely monitored for any signs of unfavorable disease progression.

Arterial Thrombosis in Coronavirus Disease 2019 Patients: A Rapid Systematic Review.

BACKGROUND: Emerging evidence suggests that severe form of coronavirus disease 2019 (COVID-19) is mediated, in part, by a hypercoagulable state characterized by micro- and macro-vascular thrombotic angiopathy. Although venous thrombotic events in COVID-19 patients have been well described, data on arterial thrombosis (AT) in these patients is still limited. We, therefore, conducted a rapid systematic review of current scientific literature to identify and consolidate evidence of AT in COVID-19 patients. METHODS: A systematic search of literature was conducted between November 1, 2019, and June 9, 2020, on PubMed and China National Knowledge Infrastructure to identify potentially eligible studies. RESULTS: A total of 27 studies (5 cohort, 5 case series, and 17 case reports) describing arterial thrombotic events in 90 COVID-19 patients were included. The pooled incidence of AT in severe/critically ill intensive care unit-admitted COVID-19 patients across the 5 cohort studies was 4.4% (95% confidence interval 2.8-6.4). Most of the patients were male, elderly, and had comorbidities. AT was symptomatic in >95% of these patients and involved multiple arteries in approximately 18% of patients. The anatomical distribution of arterial thrombotic events was wide, occurring in limb arteries (39%), cerebral arteries (24%), great vessels (aorta, common iliac, common carotid, and brachiocephalic trunk; 19%), coronary arteries (9%), and superior mesenteric artery (8%). The mortality rate in these patients is approximately 20%. CONCLUSIONS: AT occurs in approximately 4% of critically ill COVID-19 patients. It often presents symptomatically and can affect multiple arteries. Further investigation of the underlying mechanism of AT in COVID-19 would be needed to clarify possible therapeutic targets.

Coronavirus Disease 2019 (COVID-19) set to increase burden of atherosclerotic cardiovascular disease in Kenya.

The coronavirus disease 2019 (COVID-19), first reported in Kenya on March 13, 2020, is spreading rapidly. As of 30th June 2020, over 6,190 cases had been reported with a case fatality of 3.2%. Previous Coronavirus outbreaks have been associated with a significant burden of Cardiovascular disease. For COVID-19, however, there has been no direct reference to potential long-term cardiovascular effects, especially in Africa where atherosclerotic diseases are an emerging challenge. This article, therefore, aims at describing possible long-term effects on the burden of atherosclerotic disease among Kenyans. Available data indicate that COVID-19 and cardiovascular disease share pathomechanisms and risk factors which include ACE2 receptor invasion and renin-angiotensin system signaling, oxidative stress, systemic inflammation, and endothelial dysfunction. Further, SAR-COV-2 infection causes dyslipidemia, dysglycemia, kidney, and liver disease. These mechanisms and diseases constitute risk factors for the initiation, progression, and complications of atherosclerosis. In Kenya, the common risk factors for atherosclerotic cardiovascular disease, and COVID-19 comprising Hypertension, Diabetes Mellitus, Obesity, Cigarette Smoking, Respiratory Tract Infections, Pulmonary Thromboembolism, Chronic Obstructive Pulmonary Disease, and Renal disease are not uncommon and continue to increase. In essence, the prevalence of the common risk factors/comorbidities, between COVID-19 and CVD occurrence of ACE2 receptors on the endothelium, and hence pathomechanisms of SARS-COV-2 infection imply that COVID-19 may increase the burden of atherosclerotic disease in Kenya. All due care should be taken, to prevent and effectively manage the disease, to avert an imminent epidemic of atherosclerotic disease.

Acute Kidney Injury is Associated with Worse Prognosis In COVID-19 Patients: A Systematic Review and Meta-analysis.

BACKGROUND: The association between acute kidney injury (AKI) and outcome of coronavirus disease 2019 (COVID-19) has not yet been conclusively established. Therefore, we conducted a meta-analysis of recent scientific literature to assess whether AKI may be associated with worse prognosis and increased mortality in COVID-19 patients. METHODS: A systematic search of literature was conducted between 1st November 2019 and 15th May 2020 on Medline (PubMed interface) and China National Knowledge Infrastructure (CNKI) to identify potentially eligible studies. Cohort or case-control studies reporting data on AKI in patients with or without severe COVID-19 were included. Studies were divided into separate cohorts for analysis based on two endpoints (severity [severe vs non-severe] and mortality [non-survivors vs survivors]). Data were pooled into a meta-analysis to estimate pooled odds ratio (OR) with 95% confidence interval (95% CI) for either outcome. RESULTS: A total of 15 studies (n= 5,832 patients) were included in the analysis. Overall, AKI was found to be associated with significantly increased odds of COVID-19 severity (OR= 18.5; 95% CI 8.99-38.08) and mortality (OR= 23.9; 95% CI 18.84-30.31). No heterogeneity was observed for both outcomes (Cochran's Q= 6.21, p=0.52, I2=0% and Cochran's Q= 4.56, p=0.47, I2=0% respectively). -Conclusion: According to current data, AKI seems to be associated with worse prognosis in COVID-19 -patients. -Further investigation of the underlying mechanism of renal disease in COVID-19 would be needed to clarify possible therapeutic targets. AKI could be used as a clinical characteristic in severity classification and risk -stratification.

Morphometric Dimensions of the Calcaneus.

Calcaneal morphometric dimensions influence surgical treatment plans after injury. These dimensions display population heterogeneity, and there is a paucity of data in the setting of our hospital in Kenya. Further, estimation of calcaneal dimensions during reconstruction in comminuted fractures can be difficult. This cross-sectional study therefore aims to determine equations for estimation of these dimensions as well as provide local data. Sixty-four bilateral calcanei of adult indigenous Kenyans were obtained from the National Museum of Kenya and measured for maximum anteroposterior length, maximum height, cuboidal facet height, body height, and load arm length. The data were coded into SPSS software, and means were calculated. Paired t tests, independent t tests, and Pearson correlation tests were done, and linear regression model equations were developed. Data are presented using tables. In millimeters, the mean right and left values, respectively, were as follows: maximum anteroposterior length, 36.1063 and 35.3047; maximum height, 68.958 and 68.266; cuboidal facet height, 27.815 and 27.841; body height, 47.94 and 48.98; and load arm length, 18.83 and 17.93. Paired and independent t tests did not reveal statistically significant difference between the variables based on side or sex. Pearson correlational tests between the maximum length on each side and other variables revealed strong positive correlations, apart from the maximum width and load arm length on both sides. All correlational R2 values were statistically significant, apart from that of the maximum width bilaterally. The calcaneus in our setting also showed markedly reduced values compared with other populations. These findings, and the proposed equations we developed, may be considered in local calcaneal reconstruction.

Computed Tomography Scan Assessment of the Anatomy of the Pterygomaxillary Junction and Its Relevance in Le Fort I Osteotomy.

Knowledge of the morphometry and types of pterygomaxillary junction (PMJ) during Le-Fort I osteotomy is an important consideration in the reduction of intraoperative complications. The PMJ is known to display population variations and with the recent increase in these surgical interventions in Kenya, a detailed description of the PMJ is warranted. Computed tomography scan images of PMJ obtained from 63 patients were analyzed at the level of the posterior nasal spine to assess types and the morphometry of the PMJ. A fissure type of PMJ was present in 65.9% (83/126 sides) while a synostosis type was present in 34.1% (43/126). Bilateral fissures were found in 58.73% (37/63), bilateral synostosis in 26.98% (17/63), and an asymmetric PMJ in 15.25% (9/63). The average height, width, and thickness of the PMJ were 17.45 ±â€Š5.26 mm, 10.24 ±â€Š1.97 mm, and 6.40 ±â€Š1.97 mm respectively. Males had a significantly greater height (P = 0.003) and width (P = 0.000). The average width was greater in cases with a synostosis as compared with those with a fissure (P = 0.019). Average distance of greater palatine canal was 40.41 ±â€Š2.28 mm and 7.19 ±â€Š2.20 mm from the piriform rim and the pterygoid fossa respectively. The PMJ among Kenyans is characterized by a higher occurrence of synostosis, greater height, and thickness compared with previous findings from other populations. The results of this study can be helpful for surgeons in selecting the most appropriate techniques to achieve successful pterygomaxillary disjunction and minimize avoid attendant complications such as vascular and nerve injuries.

Pattern of stroke in a rural Kenyan hospital.

Background: The pattern of stroke in rural population differs from that in urban ones. Although there are many studies on this condition in sub-Saharan Africa, few studies about stroke pattern in a Kenyan rural area exist.. This study therefore aims at describing the characteristics of stroke in a rural Kenyan hospital. Patients and Methods: The study was conducted on 227 consecutive patients admitted with a World Health Organization (WHO) diagnosis of stroke in Kangundo Hospital, a level IV facility in Machakos, Eastern Kenya, between April 2015 and September 2016. The sub-type and anatomical distribution of stroke as well as the age, gender of the patients were recorded prospectively. Diagnosis was made through physical neurological examination and confirmed by Computerized Tomography (CT) scan imaging. Only those with complete bio-data, past medical and social history, clinical and physical findings of the patients and imaging results were included. The data were entered into a pre-formatted questionnaire, analysed for means, standard deviations and frequencies, and are presented in tables and bar charts. Results: Out of 3200 medical admissions, 227 (7.09%) had a confirmed diagnosis of stroke. Ischaemic stroke was more common (67.4%) than haemorrhagic stroke (32.6%). It affected mainly the anterior circulation, especially the middle cerebral artery (39%). The mean age of patients was 68.8 years, (Range 32-96). It was more common in females (62%) than in males (38%). Hypertension was the most common (74%) risk factor followed by alcohol abuse (63%), tobacco smoking (48%) and diabetes mellitus (42%). Conclusion: Ischaemic stroke was the more common major cause of morbidity in the rural hospital studied in Kenya. It occurred most commonly among elderly females, with the most frequent comorbidities being hypertension. In addition, modifiable lifestyle factors like alcohol abuse and cigarette smoking contributed to the prevalence; hence we recommend the control of blood pressure and glucose as well as lifestyle modification to reduce the scourge in our studied population.

Variant termination of the left coronary artery: pentafurcation is not uncommon

Variant termination of the left coronary artery is important in interpreting effects of its occlusion, and in guiding cardiac surgery and intervention procedures. It also constitutes a geometric risk factor for atherosclerosis. These features show ethnic variations, but data from African populations are scarce. This study therefore aimed at describing the variant patterns of termination of the left coronary artery in an indigenous Kenyan population. Left coronary arteries of 208 formalin-fixed hearts were studied by dissection at the Department of Human Anatomy, University of Nairobi. The number of terminal branches was recorded. Images of representative patterns were taken using a high resolution camera. Frequencies were calculated. Results are presented using tables and macrographs. Single left coronary arteries from the left aortic sinus were present in all the 208 hearts studied. The most frequent termination pattern was bifurcation (54.8%), followed by trifurcation (32.2%), quadrifurcation (9.6%) and pentafurcation (3.4%). Over 45% of left coronary arteries have variant patterns of termination. Pentafurcation is not uncommon. This calls for extra caution during interventional coronary artery angiography, instrumentation and surgery. Preoperative angiographic evaluation is recommended

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