Cellular mechanism of action of 2-nitroimidazoles as hypoxia-selective therapeutic agents.

Solid tumours are often poorly oxygenated, which confers resistance to standard treatment modalities. Targeting hypoxic tumours requires compounds, such as nitroimidazoles (NIs), equipped with the ability to reach and become activated within diffusion limited tumour niches. NIs become selectively entrapped in hypoxic cells through bioreductive activation, and have shown promise as hypoxia directed therapeutics. However, little is known about their mechanism of action, hindering the broader clinical usage of NIs. Iodoazomycin arabinofuranoside (IAZA) and fluoroazomycin arabinofuranoside (FAZA) are clinically validated 2-NI hypoxic radiotracers with excellent tumour uptake properties. Hypoxic cancer cells have also shown preferential susceptibility to IAZA and FAZA treatment, making them ideal candidates for an in-depth study in a therapeutic setting. Using a head and neck cancer model, we show that hypoxic cells display higher sensitivity to IAZA and FAZA, where the drugs alter cell morphology, compromise DNA replication, slow down cell cycle progression and induce replication stress, ultimately leading to cytostasis. Effects of IAZA and FAZA on target cellular macromolecules (DNA, proteins and glutathione) were characterized to uncover potential mechanism(s) of action. Covalent binding of these NIs was only observed to cellular proteins, but not to DNA, under hypoxia. While protein levels remained unaffected, catalytic activities of NI target proteins, such as the glycolytic enzyme glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and the detoxification enzyme glutathione S-transferase (GST) were significantly curtailed in response to drug treatment under hypoxia. Intraperitoneal administration of IAZA was well-tolerated in mice and produced early (but transient) growth inhibition of subcutaneous mouse tumours.

Identification of proteins and cellular pathways targeted by 2-nitroimidazole hypoxic cytotoxins.

Tumour hypoxia negatively impacts therapy outcomes and continues to be a major unsolved clinical problem. Nitroimidazoles are hypoxia selective compounds that become entrapped in hypoxic cells by forming drug-protein adducts. They are widely used as hypoxia diagnostics and have also shown promise as hypoxia-directed therapeutics. However, little is known about the protein targets of nitroimidazoles and the resulting effects of their modification on cancer cells. Here, we report the synthesis and applications of azidoazomycin arabinofuranoside (N3-AZA), a novel click-chemistry compatible 2-nitroimidazole, designed to facilitate (a) the LC-MS/MS-based proteomic analysis of 2-nitroimidazole targeted proteins in FaDu head and neck cancer cells, and (b) rapid and efficient labelling of hypoxic cells and tissues. Bioinformatic analysis revealed that many of the 62 target proteins we identified participate in key canonical pathways including glycolysis and HIF1A signaling that play critical roles in the cellular response to hypoxia. Critical cellular proteins such as the glycolytic enzyme glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and the detoxification enzyme glutathione S-transferase P (GSTP1) appeared as top hits, and N3-AZA adduct formation significantly reduced their enzymatic activities only under hypoxia. Therefore, GAPDH, GSTP1 and other proteins reported here may represent candidate targets to further enhance the potential for nitroimidazole-based cancer therapeutics.

Relationship between executive functions and academic performance among Moroccan middle school students.

Executive functions (EF) play a central role in the development of social and cognitive skills and academic learning. OBJECTIVE: For this reason, this study aims to determine the relationship between executive functions and academic performance among middle school students in the Middle Atlas of Morocco. METHODS: This study focuses on 137 middle school students studying at four colleges located in the Middle Atlas of Morocco. The sample studied was divided into two groups: the first consisting of students with learning difficulties; and the second considered a control. To assess EF, three tests were administered to learners in both groups (Tracking Test, Stroop Test and Number Span Test). RESULTS: In the sample, average age of the learners was 14.5±1.3 years and sex ratio was balanced. The students with learning difficulties had lower performance on tests measuring cognitive flexibility, inhibitory processes and working memory compared to the control group. CONCLUSION: From these results, it can be concluded that students with learning disabilities performed poorly on the three basic components of executive functions. Therefore, thorough neuropsychological diagnosis would be desirable to identify learners who may have cognitive or behavioural disorders and allow adequate intervention to improve their executive functions and subsequently their academic success.

As funções executivas (FEs) desempenham um papel central no desenvolvimento de habilidades sociais e cognitivas e no aprendizado acadêmico. OBJETIVO: Por esse motivo, nosso estudo teve como objetivo determinar a relação entre FEs e desempenho acadêmico entre estudantes do ensino médio no Atlas Médio de Marrocos. MÉTODOS: Nosso estudo se concentrou em 137 alunos do ensino médio que estudavam em quatro colégios localizados no Atlas Médio de Marrocos. A amostra estudada foi dividida em dois grupos, o primeiro composto por alunos com dificuldades de aprendizagem e o segundo considerado como controle. Para avaliar os FEs, três testes foram administrados aos alunos de ambos os grupos (Testes de Trilhas, Teste de Stroop e Teste de Extensão de Dígitos). RESULTADOS: A idade média dos alunos em nossa amostra foi de 14,5±1,3 anos, com uma relação entre gêneros equilibrada. Em nosso estudo, os alunos com dificuldades de aprendizagem apresentaram desempenho inferior nos testes que mediram flexibilidade cognitiva, processo inibitório e memória de trabalho em comparação ao grupo controle. CONCLUSÃO: Do ​​nosso resultado, podemos concluir que alunos com dificuldades de aprendizagem apresentam um desempenho fraco nos três componentes básicos das FEs. Por esse motivo, seria desejável um diagnóstico neuropsicológico completo, para identificar alunos que possam ter distúrbios cognitivos ou comportamentais para uma correção adequada para melhorar seus FEs e, posteriormente, seu sucesso acadêmico.

Relationship between executive functions and academic performance among Moroccan middle school students / Relação entre funções executivas e desempenho acadêmico em estudantes marroquinos do ensino médio

ABSTRACT. Executive functions (EF) play a central role in the development of social and cognitive skills and academic learning. Objective: For this reason, this study aims to determine the relationship between executive functions and academic performance among middle school students in the Middle Atlas of Morocco. Methods: This study focuses on 137 middle school students studying at four colleges located in the Middle Atlas of Morocco. The sample studied was divided into two groups: the first consisting of students with learning difficulties; and the second considered a control. To assess EF, three tests were administered to learners in both groups (Tracking Test, Stroop Test and Number Span Test). Results: In the sample, average age of the learners was 14.5±1.3 years and sex ratio was balanced. The students with learning difficulties had lower performance on tests measuring cognitive flexibility, inhibitory processes and working memory compared to the control group. Conclusion: From these results, it can be concluded that students with learning disabilities performed poorly on the three basic components of executive functions. Therefore, thorough neuropsychological diagnosis would be desirable to identify learners who may have cognitive or behavioural disorders and allow adequate intervention to improve their executive functions and subsequently their academic success.

RESUMO. As funções executivas (FEs) desempenham um papel central no desenvolvimento de habilidades sociais e cognitivas e no aprendizado acadêmico. Objetivo: Por esse motivo, nosso estudo teve como objetivo determinar a relação entre FEs e desempenho acadêmico entre estudantes do ensino médio no Atlas Médio de Marrocos. Métodos: Nosso estudo se concentrou em 137 alunos do ensino médio que estudavam em quatro colégios localizados no Atlas Médio de Marrocos. A amostra estudada foi dividida em dois grupos, o primeiro composto por alunos com dificuldades de aprendizagem e o segundo considerado como controle. Para avaliar os FEs, três testes foram administrados aos alunos de ambos os grupos (Testes de Trilhas, Teste de Stroop e Teste de Extensão de Dígitos). Resultados: A idade média dos alunos em nossa amostra foi de 14,5±1,3 anos, com uma relação entre gêneros equilibrada. Em nosso estudo, os alunos com dificuldades de aprendizagem apresentaram desempenho inferior nos testes que mediram flexibilidade cognitiva, processo inibitório e memória de trabalho em comparação ao grupo controle. Conclusão: Do ​​nosso resultado, podemos concluir que alunos com dificuldades de aprendizagem apresentam um desempenho fraco nos três componentes básicos das FEs. Por esse motivo, seria desejável um diagnóstico neuropsicológico completo, para identificar alunos que possam ter distúrbios cognitivos ou comportamentais para uma correção adequada para melhorar seus FEs e, posteriormente, seu sucesso acadêmico.

Nine-point plan to improve care of the injured patient: A case study from Kenya.

BACKGROUND: Injury rates in low- and middle-income countries are among the greatest in the world, with >90% of unintentional injury occurring in low- or middle-income countries. The risk of death from injuries is 6 times more in low- and middle-income countries than in high-income countries. This increased rate of injury is partly due to the lack of availability and access to timely and appropriate medical care for injured individuals. Kenya, like most low- and middle-income countries, has seen a 5-fold increase in injury fatalities throughout the past 4 decades, in large part related to the absence of a coordinated, integrated system of trauma care. METHODS: We aimed to assess the trauma-care system in Kenya and to develop and implement a plan to improve it. A trauma system profile was performed to understand the landscape for the care of the injured patient in Kenya. This process helped identify key gaps in care ranging from prehospital to hospital-based care. RESULTS: In response to this observation, a 9-point plan to improve trauma care in Kenya was developed and implemented in close collaboration with local stakeholders. The 9-point plan was centered on engagement of the stakeholders, generation of key data to guide and improve services, capacity development for prehospital and hospital care, and strengthening policy and legislation. CONCLUSION: There is an urgent need for coordinated strategies to provide appropriate and timely medical care to injured individuals in low- or middle-income countries to decrease the burden of injuries and related fatalities. Our work in Kenya shows that such an integrated system of trauma care could be achieved through a step-by-step integrated and multifaceted approach that emphasizes engagement of local stakeholders and evidence-based approaches to ensure effectiveness, efficiency, and sustainability of system-wide improvements. This plan and lessons learned in its development and implementation could be adaptable to other similar settings to improve the care of the injured patient in low- or middle-income countries.

Exploring injury severity measures and in-hospital mortality: A multi-hospital study in Kenya.

INTRODUCTION: Low- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya. METHODS: This study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations. RESULTS: A total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866-0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852-0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736-0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures. CONCLUSIONS: This multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya.

Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital.

BACKGROUND: Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes. METHODS: An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes. RESULTS: A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity. CONCLUSION: The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.

Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study.

BACKGROUND: Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low- and middle-income countries where more than 90% of injury-related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low- and middle-income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital-based trauma registries. METHODS: From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes. RESULTS: A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries. CONCLUSION: Hospital-based trauma registries can be important sources of data to study the epidemiology of injuries in low- and middle-income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality-of-care improvement programs.

Variant Anatomy of the Nasal and Labial Branches of the Infraorbital Nerve.

Comprehensive understanding of the variations in the branches of the infraorbital nerve (ION) is vital to the prevention of iatrogenic nerve injury and successful ION blockade during orbitozygomatic facial procedures. Only a few studies exist on the variant anatomy of the branching patterns of this nerve. This article provides a detailed description of the variations of the nasal and superior labial branches of the ION. This study was performed on 84 IONs by dissecting 42 formalin-fixed cadavers from the Laboratory of Topographic Anatomy, Department of Human Anatomy, University of Nairobi. The branches were exposed at their origin and followed to their termination. The findings included variant emergence patterns, anomalous course, and absence as well as extra branches. It was noted that the external nasal nerve was absent in 34.53% cases. There were common trunks between the internal and external nasal nerves and cases of communication between branches of these nerves were also noted. Accessory superior labial nerves were present in 9.52% of the nerves. This detailed study reveals additional variations in the emergence and branching pattern of the ION. Caution is imperative during orbitozygomatic facial surgery to prevent injury to these branches. These variations also underlie the lack of response to surgical treatment for trigeminal neuralgia and also the need for a filtration to achieve full anesthesia after ION block. In addition, the extra branches identified raise the prospects of using these nerves for grafting purposes if their precise patterns are determined.

Repeated Exposure to Dissection Does Not Influence Students' Attitudes towards Human Body Donation for Anatomy Teaching.

The use of unclaimed bodies for anatomical dissection has been the main method of instruction at our institution. There is however a shortage of cadavers for dissection given the increase in the number of medical schools as well as in the number of students enrolling in these schools. This shortage could be mitigated by having voluntary human body donation programs. This study aimed at assessing the attitudes of medical students and surgical residents towards body donation for anatomy learning. We conducted an online survey involving 72 first-year medical students and 41 surgical residents at University of Nairobi who had completed one year of anatomy dissection. For the medical students, this was their first dissection experience while it was the second exposure for the surgery trainees. Most of the surgical trainees (70.7%) and medical students (68.1%) were opposed to self-body donation. This was mainly due to cultural (37%) and religious (20%) barriers. Surprisingly, of those not willing to donate themselves, 67.9% (82.8% surgical trainees, 59.2% medical students) would recommend the practice to other people. Exposure to repeated dissection does not change the perceptions towards body donation. It is noteworthy that culture and religion rank high as clear barriers amongst this "highly informed" group of potential donors.

Effect of Monocular Deprivation on Rabbit Neural Retinal Cell Densities.

PURPOSE: To describe the effect of monocular deprivation on densities of neural retinal cells in rabbits. METHODS: Thirty rabbits, comprised of 18 subject and 12 control animals, were included and monocular deprivation was achieved through unilateral lid suturing in all subject animals. The rabbits were observed for three weeks. At the end of each week, 6 experimental and 3 control animals were euthanized, their retinas was harvested and processed for light microscopy. Photomicrographs of the retina were taken and imported into FIJI software for analysis. RESULTS: Neural retinal cell densities of deprived eyes were reduced along with increasing period of deprivation. The percentage of reductions were 60.9% (P < 0.001), 41.6% (P = 0.003), and 18.9% (P = 0.326) for ganglion, inner nuclear, and outer nuclear cells, respectively. In non-deprived eyes, cell densities in contrast were increased by 116% (P < 0.001), 52% (P < 0.001) and 59.6% (P < 0.001) in ganglion, inner nuclear, and outer nuclear cells, respectively. CONCLUSION: In this rabbit model, monocular deprivation resulted in activity-dependent changes in cell densities of the neural retina in favour of the non-deprived eye along with reduced cell densities in the deprived eye.

The effect of a knowledge-based ergonomic intervention amongst administrators at Aga Khan University Hospital, Nairobi.

BACKGROUND: Low back pain (LBP) and neck pain are part of the common work-related musculoskeletal disorders with a large impact on the affected person. Despite having a multifactorial aetiology, ergonomic factors play a major role thus necessitating workers' education. OBJECTIVE: To determine the prevalence of ergonomic-related LBP and neck pain, and describe the effect of a knowledge-based ergonomic intervention amongst administrators in Aga Khan University Hospital, Nairobi. METHODS: This study applied a mixed method design utilizing a survey and two focus group discussions (FGD). A self-administered questionnaire was distributed to 208 participants through systematic sampling. A one hour knowledge-based ergonomic session founded on the survey results was thereafter administered to interested participants, followed by two FGDs a month later with purposive selection of eight participants to explore their experience of the ergonomic intervention. Quantitative data was captured and analyzed using SPSS by means of descriptive and inferential statistics, whereas thematic content analysis was used for qualitative data. RESULTS: Most participants were knowledgeable about ergonomic-related LBP and neck pain with a twelve month prevalence of 75.5% and 67.8% respectively. CONCLUSION: Continual ergonomic education is necessary for adherence to health-related behaviours that will preventwork-related LBP and neck pain.

Effects of monocular deprivation on the dendritic features of retinal ganglion cells / Efectos de la privación monocular sobre las características dendríticas de las células ganglionares de la retina

Monocular deprivation results in anatomical changes in the visual cortex in favor of the non-deprived eye. Although the retina forms part of the visual pathway, there is scarcity of data on the effect of monocular deprivation on its structure. The objective of this study was to describe the effects of monocular deprivation on the retinal ganglion cell dendritic features. The study design was quasi-experimental. 30 rabbits (18 experimental, 12 controls) were examined. Monocular deprivation was achieved through unilateral lid suture in the experimental animals. The rabbits were observed for three weeks. Each week, 6 experimental and 3 control animals were euthanized, their retina harvested and processed for light microscopy. Photomicrographs of the retina were taken using a digital camera then entered into FIJI software for analysis. The number of primary branches, terminal branches and dendritic field area among the non-deprived eyes increased by 66.7%(p=0.385), 400%(p=0.002), and 88.4%(p=0.523) respectively. Non-deprived eyes had 114.3% more terminal dendrites (p=0.002) compared to controls. Among deprived eyes, all variables measured had a gradual rise in the first two weeks followed by decline with further deprivation. There were no statistically significant differences noted between the deprived and control eyes. Monocular deprivation results in increase in synaptic contacts in the non-deprived eye, with reciprocal changes occurring in the deprived eye.

La privación monocular de la visión resulta en cambios anatómicos en la corteza visual en favor del ojo no privado. Aunque la retina forma parte de la vía visual, hay escasez de datos sobre el efecto de la privación monocular en su estructura. El objetivo de esta investigación fue describir los efectos de la privación monocular en las características de las dendritas de las células ganglionares de la retina. Se diseñó un estudio cuasi-experimental. Se examinaron 30 conejos (18 experimentales, 12 controles). La privación monocular se logró a través de la sutura unilateral del párpado en los animales de experimentación. Los conejos fueron observados durante tres semanas. Cada semana, 6 animales experimentales y 3 control fueron eutanasiados, donde se obtuvo la retina y fue procesada para realizar microscopía óptica. Las microfotografías de la retina fueron tomadas con una cámara digital y luego se utilizó el software FIJI para su análisis. El número de dendritas primarias, terminales y el área del campo de dendritas en los ojos no privados aumentó un 66,7% (p=0,385), 400% (p=0,002), y 88,4% (p=0,523), respectivamente. Los ojos no privados, tenían 114,3% más dendritas terminales (p=0,002) en comparación con los controles. Entre los ojos privados, todas las variables medidas tuvieron un aumento gradual en las dos primeras semanas, seguido de descenso con mayor privación. No se observaron diferencias estadísticamente significativas entre los ojos privados y el grupo control. En conclusion, la privación monocular produce un aumento de los contactos sinápticos en los ojos no privados, con cambios recíprocos que se manifiestan en los ojos privados de la visión.

Variations in emergence and course of the inferior palpebral nerve.

Comprehensive understanding of the anatomy of the inferior palpebral (IP) nerve is crucial to preservation of sensation in the inferior eyelid and conjunctiva. Iatrogenic injuries may occur during blepharoplasty, repair of orbitozygomatic fracture and other maxillofacial surgeries involving this region. Although several studies depict the anatomical variations of the main infraorbital nerve (ION), little information exclusive to the IP nerve exists. This study provides information on the additional variations of the ION with reference to the IP nerve. The study was performed on 84 IP nerves by dissection of 42 formalin-fixed cadavers from the laboratory of topographic anatomy, Department of Human Anatomy, University of Nairobi, Kenya. Each of the nerves were exposed at the emergence and followed to their termination. Variations encountered involved emergence, course, and even absence. Variant emergence was through an accessory infraorbital foramen, an infraorbital notch, and as a common trunk with the external nasal nerve. This nerve shows high anatomical variability that may account for the difficulties and complications encountered in clinical interventions. It is believed that this information will improve clinical management of conditions affecting the region of distribution of the IP nerve.

Mortality after road traffic crashes in a system with limited trauma data capability.

BACKGROUND: Africa has 4% of the global vehicles but accounts for about one tenth of global vehicular deaths. Major trauma in Kenya is associated with excess mortality in comparison with series from trauma centers. The determinants of this mortality have not been completely explored. OBJECTIVES: To determine the factors affecting mortality among road users in Nairobi, Kenya. METHODS: Cross-sectional study of prospectively collected data of trauma admissions at the Kenyatta National Hospital over a calendar year (2009-2010). Information collected included age, gender, road user type, principal anatomical region of injury, admission status, admission blood pressure and GCS, disposition destination, Injury Severity Score (ISS), injuries sustained, treatment and mortality at two weeks. Major or severe injury was defined as injuries of ISS > 15. Groups based on in-hospital survival were compared using determinants of mortality using X2 or students t-test as appropriate. Logistic regression was used to assess the independence of predictive variables. RESULTS: One thousand six hundred forty seven (1647) patients were admitted for trauma during the study period. Traffic admissions were 1013 (61.7%) and males predominated (79.8%). The average age of patients admitted was 31.7 years. Pedestrians, vehicle occupants and motorcyclists represented 43.3%, 27.2% and 15.2% of the road users injured. The proportion of patients with ISS > 15 was 10.9%.The overall mortality was 7.7%. Mortality for ISS > 15 was 27.6%. The following factors significantly predicted mortality on univariate analysis: head injury, abdominal injury, transfer in status, blood transfusion, ICU admission, age > 60 years, Glasgow coma scale (GCS) and injury severity. GCS (p = 0.001) and ISS > 15 (p < 0.05) remained significant predictors on regression analysis. CONCLUSION: Trauma mortality rates in this study exceed those from mature trauma systems. Head injury and injury severity based on the ISS are independent predictors of mortality after traffic trauma. Improvements in neurosurgical and critical care services ingrained within wider primary and secondary prevention initiatives are logical targets.

Trauma deaths outside the hospital: uncovering the typology in Kenyan capital.

BACKGROUND: Immediate trauma fatality is not amenable to trauma care and primary prevention is the key. The published profiles of deaths due to trauma differ in different regions. Injury mortality rates are higher in developing countries where injury data capture systems are unreliable for prevention purposes. OBJECTIVE: To describe the pattern of pre-hospital injury (immediate) deaths at the Nairobi city mortuary and compare these with hospital (late) trauma deaths. METHODS: Consecutive trauma autopsies performed over one year (November 2009 to December 2010) at the main mortuary of the Nairobi city council were analyzed for demographic (age, sex, occupation) characteristics, circumstances of the trauma and injury patterns. The patterns of injuries were compared to those of victims who survived and later died at the Kenyatta National Hospital over the same period. RESULTS: Two hundred and thirty seven trauma autopsies were analyzed. The average age of the victims was 29.8 years (range 1-67 years). Christians (93.7%) and males (89.5%) predominated. The place of injury was the road in 32.9% and home/neighborhood in 57.5% of cases. The main mechanisms of fatal injury were traffic (35.4%), gunshot wounds (25.7%) and assault (19.8%). Burns and suicides accounted for 5.9% and 6.3% of fatalities. Most fatalities were intentional (59.4%) Of vehicular injuries, pedestrians predominated (65.5%). For assault, blunt and penetrating injuries accounted for 68.7% and 31.11% of fatalities. Law enforcement officers were responsible for majority of gunshot deaths. Fatal injuries were sustained in single, two and multiple regions in 56.2%, 25.7% and 14.2% of cases. The body region most involved was the head/neck (40.5%). Twelve children under 15 years died. Compared to in-hospital deaths, pre-hospital deaths were associated with intentional injuries, night-time occurrence and preponderance of gun involvement. CONCLUSION: Injury was a significant cause of mortality among adults of working age in this urban African setting. Intentional injuries predominate in causation of immediate but not late deaths. Local prevention programs should incorporate mortuary data to unravel further aspects of trauma and address violence as a key determinant of prehospital mortality.

Branching pattern of inferior mesenteric artery in a black african population: a dissection study.

Background. Branching pattern of inferior mesenteric artery (IMA) and pattern of vascular supply to the left colon and rectosigmoid areas, though important during colorectal surgery, display interethnic variations. Further, these regions have notable vascular "weak points" reported to be highly susceptible to ischemic colitis. This study aimed at evaluating the branching pattern of IMA in a black African population. Materials and Methods. Fifty-seven formalin-embalmed cadavers (28 Male, 27 Female) were studied. The length, branching pattern, and diameter of IMA at its origin were recorded. Results. IMA mean length and diameter at origin were 30.57 ± 10.0 mm and 4.10 ± 0.9 mm, respectively. IMA most frequently branched into left colic artery and a common sigmoid trunk in 23 cases while the classical branching pattern was observed in only 7 cases. Colic marginal artery was absent at the splenic flexure and sigmoid colon in 7 and 5 cases, respectively. Arc of Riolan was observed in 9 cases. Conclusion. Branching pattern of IMA shows variations from the previously reported cases which might help account for some of the untoward outcomes observed following colon surgery. An angiographic study to further delineate functionality of the arterial anastomoses in this region is recommended.

Establishing hospital-based trauma registry systems: lessons from Kenya.

OBJECTIVE: In the developing world, data about the burden of injury, injury outcomes, and complications of care are limited. Hospital-based trauma registries are a data source that can help define this burden. Under the trauma care component of the Bloomberg Global Road Safety Partnership, trauma registries have been implemented at three sites in Kenya. We describe the challenges and lessons learned from this effort. METHODS: A paper-based trauma surveillance form was developed, in collaboration with local hospital partners, to collect data on all trauma patients presenting for care. The form includes demographic information, pre-hospital care given, and patient care and clinical information necessary to calculate estimated injury surveillance. The type of data collected was standardized across all three sites. Frequent reviews of the data collection process, quality, and completeness, in addition to regular meetings and conference calls, have allowed us to optimize the process to improve efficiency and make corrective actions where required. RESULTS: Trauma registries have been implemented in three hospitals in Kenya, with potential for expansion to other hospitals and facilities caring for injured patients. The process of establishing registries was associated with both general and site-specific challenges. Problems were identified in planning, data collection, entry processes, and analysis. Problems were addressed when identified, resulting in improved data quality. CONCLUSIONS: Trauma registries are a key data source for defining the burden of injury and developing quality improvement processes. Trauma registries were implemented at three sites in Kenya. Problems and challenges in data collection were identified and corrected. Through the registry data, gaps in care were identified and systemic changes made to improve the care of the injured.

Unusual formation of the median nerve associated with the third head of biceps brachii.

Unilateral variations in the formation of the median nerve, with the presence of the third head of the biceps brachii entrapping the nerve are very rare. These variations were observed on the right side, of a 30-year-old male cadaver during routine dissection at the Department of Human Anatomy, University of Nairobi. The median nerve was formed by the union of three contributions; two from the lateral cord and one from the medial cord. An additional head of the biceps brachii looped over the formed median nerve. On the left side, the median nerve was formed classically by single contributions from the medial and the lateral cords. These variations are clinically important because symptoms of high median nerve compression arising from similar formations are often confused with more common causes such as radiculopathy and carpal tunnel syndrome.