Screening for tuberculosis in pregnancy: do we need more than a symptom screen? Experience from western Kenya.

OBJECTIVES: 1) To explore the utility of tuberculosis (TB) symptom screening for symptoms of ≥2 weeks' duration in a routine setting, and 2) to compare differences in TB diagnosis between human immunodeficiency virus (HIV) infected and non-HIV-infected pregnant women in western Kenya. DESIGN: Comparative cross-sectional study among pregnant women with known HIV status screened for TB from 2010 to 2012, in Eldoret, western Kenya. RESULTS: Of 2983 participants, respectively 34 (1%), 1488 (50.5%) and 1461 (49.5%) had unknown, positive and negative HIV status. The median age was respectively 30 years (interquartile range [IQR] 26-35) and 26 years (IQR 24-31) in HIV-infected and non-infected participants. A positive symptom screen was found in respectively 8% (119/1488) and 5% (67/1461) of the HIV-infected and non-infected women. The median CD4 count at enrolment was 377 cells/µl (IQR 244-530) for HIV-infected women. One non-HIV-infected patient was sputum-positive. For HIV-infected women, TB was presumptively treated in 1% (16/1488) based on clinical symptoms and chest X-ray. Cumulatively, anti-tuberculosis treatment was offered to 0.6% (17/2949) of the participants. CONCLUSION: This study does not seem to demonstrate the utility of TB symptom screening questionnaires in a routine setting among pregnant women, either HIV-infected or non-infected, in western Kenya.

Symptom screen: diagnostic usefulness in detecting pulmonary tuberculosis in HIV-infected pregnant women in Kenya.

OBJECTIVE: To determine the diagnostic usefulness of tuberculosis (TB) symptom screening to detect active pulmonary TB among human immunodeficiency virus (HIV) infected pregnant women in two PMTCT (prevention of mother-to-child transmission) clinics in western Kenya that are supported by the United States Agency for International Development-Academic Model Providing Access to Healthcare partnership. DESIGN: Cross-sectional study. Participants were interviewed for TB symptoms with a standardized questionnaire (cough >2 weeks, fever, night sweats, weight loss or failure to gain weight). Those with cough submitted sputum specimens for smear microscopy for acid-fast bacilli and mycobacterial culture. Women at >14 weeks gestation underwent shielded chest radiography (CXR). RESULTS: Of 187 HIV-infected women, 38 (20%) were symptom screen-positive. Of these, 21 had a cough for >2 weeks, but all had negative sputum smears and mycobacterial cultures. CXRs were performed in 26 symptomatic women: three were suggestive of TB (1 miliary, 1 infiltrates and 1 cavitary). Of 149 women with a negative symptom screen, 100 had a CXR and seven had a CXR suggestive of TB (1 cavitary, 2 miliary and 4 infiltrates). CONCLUSION: This study did not support the utility of isolated symptom screening in identification of TB disease in our PMTCT setting. CXR was useful in identification of TB suspects in both symptomatic and asymptomatic women.

Cardiotocography and perinatal outcome in women with and without meconium stained liquor.

BACKGROUND: There is little evidence linking meconium stained liquor to poor perinatal outcome and clear amniotic fluid is frequently considered a reassuring sign during labour. OBJECTIVE: To determine whether there are any differences in cardiotocography (CTG) tracings and perinatal outcomes in women with meconium stained compared with those with clear liquor in labour. DESIGN: A prospective cohort study. SETTING: The Aga Khan University Hospital, Nairobi. SUBJECTS: Seventy seven women presenting in labour were studied. Thirty six had meconium stained liquor and 41 had clear liquor. MAIN OUTCOME MEASURES: Initial and intrapartum CTG was done. Perinatal and maternal outcomes determined were birth weights, Apgar scores, admission due to foetal indications and puerperal sepsis. CTG interpretation was based on RCOG/NICE guidelines-2001. SPSS 12.0.1 was used for all analyses. RESULTS: Variable decelerations were the most common foetal heart rate patterns. In the initial CTG, suspicious (RR 1.033, 95% CI: 0.515 - 2.073), and pathologic (RR 1.490, 95% CI: 0.928-2.393) patterns were increased in the meconium stained group. In the intrapartum CTG, pathologic pattern was increased in women with meconium stain liquor (RR 1.096, 95% CI: 0.650-1.847). Apgar score of <7 was likely if the initial base line rate was abnormal (RR 1.357, 95% CI: 0.139 -1.009, irrespective of the state of liquor. Meconium staining of liquor was associated with Caesarean delivery (RR = 1.357, 95% CI: 1.010-1.823; P-value 0.042). There was no significant difference in the mean birth weights of the infants born to women in both groups (3359.72 grams and 3260.24 grams respectively, P = 0.282). One minute Apgar score in both groups was not significantly (RR 0.390, 95% CI:0.131-1.1611). CONCLUSION: The suspicious and pathologic tracings were increased in the meconium stained liquor group. There was no significant difference in the Apgar scores in both groups of women. Meconium staining of liquor was significantly associated with Caesarean delivery.

Bone metabolism in healthy ambulatory control premenopausal women and in epileptics on anti-convulsant drugs.

BACKGROUND: Long term anti-epileptic drug use causes multiple abnormalities in calcium and bone metabolism that have been documented in both institutionalised and ambulatory patients. OBJECTIVE: To assess bone metabolism in ambulatory females of reproductive age, on antiepileptic drugs. DESIGN: Cross sectional comparative study. SUBJECTS: Ambulatory females in reproductive age group with epilepsy and on regular follow up were compared to healthy females of similar ages not on any treatment. RESULTS: The mean duration of treatment for epilepsy was eight years (+/- 6.3). Majority of the patients were on enzyme inducing drugs like phenobarbital, phenytoin, carbamazepine and valproate, either alone or in combination with non-enzyme inducers like lamotrigine (98.2%). There was a significantly lower mean serum calcium and a higher alkaline phosphatase level among the patients (P = 0.002 and 0.0001 respectively) than among the comparators. The urinary marker of bone loss (mean urine calcium excretion) was also significantly raised among the patients (P=0.003). The mean lumbar BMDT-score results were not significantly different in the two groups. CONCLUSIONS: Long-term anti-epileptic drug use significantly affects biochemical parameters of bone metabolism. These effects on bone biochemistry markers were not reflected in lumbar spine BMD in this study.

Quality of record keeping in the intrapartum period at the Provincial General Hospital, Kakamega, Kenya.

OBJECTIVE: To assess the quality of recording critical events in the intrapartum period in Kakamega Provincial General Hospital (PGHK). DESIGN: Retrospective comparative study. SETTING: Provincial General Hospital, Kakamega, the referral hospital for Western Province, Kenya. PARTICIPANTS: Two hundred women admitted at the labour ward during the six-month period between 1st September 2000 and 28th February 2001 were compared to two hundred women admitted between 1st July 2001 and 31st December 2001. INTERVENTION: The Safe Motherhood Demonstration Project (SMDP) was introduced in four districts of Western Province, Kenya, in which PGHK is located. It included on job training in Safe Motherhood which emphasised, among others, collection and utilisation of maternal health care services data. MAIN OUTCOME MEASURES: Comprehensiveness of recording of biodata, history taking and examination findings were assessed for women in labour before and during the implementation of the SMDP. The proportion of cases in labour managed by use of partograph and its appropriate use were also determined. RESULTS: Retrieval rate of patients' notes was 86.9% and 89.6% before and during SMDP respectively. Information on sociodemographic characteristics, history taking, general and obstetric examination had a near universal recording in both groups but data on alcohol consumption, smoking, menarche, previous pregnancies and contraceptive use was poorly recorded. There was a significant improvement in recording of diagnosis and plan of management during the SMDP (p = 0.037). The partograph was used in only 11% of patients before SMDP as compared to 85% during SMDP (p = 0.000). Record on foetal condition and progress of labour were significantly improved during the SMDP (p = 0.000). Records on summary of labour likewise significantly improved during the SMDP (p = 0.02). CONCLUSION: The quality of record keeping in the intrapartum period at the PGHK greatly improved during the implementation of the SMDP. It would be worthwhile to assess the sustainability of quality of intrapartum records and care a year or so after the SMDP ended.

Socio-demographic characteristics of patients admitted with gynaecological emergency conditions at the provincial general hospital, Kakamega, Kenya.

OBJECTIVE: To determine the magnitude of gynaecological emergencies and the socio demographic characteristics of patients admitted at Provincial General Hospital Kakamega (PGHK). DESIGN: Retrospective cross-sectional study. SETTING: Provincial General Hospital Kakamega, the referral hospital for Western Province, Kenya. SUBJECTS: Four hundred patients admitted at the gynaecological wards during the period 1st January 2002 to 31st December 2002. RESULTS: In this study 80% of gynaecological patients admitted at PGH Kakamega were of an emergency nature with 45% being teenagers. The mean age was 17 +/- 3 (mean +/- SD). The majority had primary level of education or below (69%), unemployed (87%) and were rural residents (71%). Patients with abortion formed about 43% of the study group while those with inflammatory disease, pelvic abscess and ectopic pregnancy formed about 24%, 10% and 8% respectively. CONCLUSION: Most gynaecological admissions in PGH Kakamega are of acute nature, with abortion being the most common diagnosis. Hence, trained staff, equipment, supplies and drugs for management of acute gynaecological conditions should be available in hospitals in Western Kenya.

A survey of knowledge of family planning (FP) methods among Kenyan medical doctors: secondary data analysis.

PIP: This survey, conducted between October 1989 and March 1990, to determine the knowledge, attitude, practice, and provision of family planning of a sample of 376 Kenyan medical doctors, reports on the aspects of knowledge of family planning (FP) methods. Kenyan medical doctors had low-to-average knowledge of the association between oral contraceptives (OCs) and the risk of various medical conditions and the mechanism of action of steroidal contraceptives. Their knowledge of the effectiveness of various program methods was average to high. There was a linear relationship between monthly income and knowledge of effectiveness of OCs, according to which physicians earning more had less knowledge than their colleagues who earned less (Z = 2.318, p = 0.02). A stepwise unconditional logistic regression model showed that two variables, department where most work is performed and sex, are significantly associated with better knowledge. Use of these operational variables for assessing medical doctors' knowledge of FP methods gave a better resolution of the extent and perhaps the quality of counseling and advice they provided to their FP clients. At the same time, the need for update courses in FP for medical doctors is unquestionable and long overdue.^ieng

A survey of attitude of Kenyan medical doctors on family planning (FP): secondary data analysis.

PIP: This was part of a survey conducted between November 1989 and March 1990 to determine the knowledge, attitude, practice, and provision of family planning (FP) by a sample of Kenyan medical doctors. This part of the survey reports on the attitude as assessed through several attitudinal variables. Medical doctors had an average-to-high (60-98%) positive attitude about the relationship between population/economic growth and the need for FP, the effectiveness of the FP campaign in Kenya, and the ideal family size being 0-4 children. However, the proportion of doctors who considered the ideal family size to be 0-2 children dropped to a mere 23%. In light of the 1993 Kenyan total fertility rate of 5.4, an ideal family size of 0-4 children would be a worthwhile ambition for Kenyans, the majority of whom are of low socioeconomic status. Important covariates were future fertility intentions (desire for children), doctors' place of work, and religion. It is very important that the FP campaign continue to promote small families in Kenya.^ieng