Towards the quantification of perioperative cardiovascular risk in the African context: A sub-analysis of the South African Surgical Outcomes Study and the African Surgical Outcomes Study.

BACKGROUND: The burden of cardiovascular disease in patients requiring non-cardiac surgery in Africa is not known. These patients are at increased risk for postoperative cardiovascular complications. OBJECTIVES: In this sub-study, to use data on comorbidities and surgical outcomes from two large observational studies, the South African Surgical Outcomes Study (SASOS) and the African Surgical Outcomes Study (ASOS), to investigate the prevalence of cardiovascular disease in elective surgical patients and the risk of postoperative cardiovascular complications in this population. METHODS: SASOS and ASOS were both prospective, observational cohort studies that collected data over 1 week in each participating centre. The primary outcome was in-hospital postoperative complications, which included prespecified and defined cardiovascular complications. We defined the cardiovascular disease burden of patients aged ≥45 years presenting for surgery (main objective), determined the relative risk of developing postoperative cardiovascular complications (secondary objective) and assessed the utility of the Revised Cardiac Risk Index (RCRI) for preoperative cardiovascular risk stratification of elective, non-cardiac surgical patients in Africa (third objective). RESULTS: The primary outcome analysis of 3 045 patients showed that patients with major cardiac complications were significantly older, with a higher prevalence of hypertension, coronary artery disease or congestive cardiac failure, and had undergone major surgery. In-hospital mortality for the cohort was 1.2%. CONCLUSIONS: The substantial burden of cardiovascular disease in patients presenting for non-cardiac surgery in Africa is shown in the principal findings of this study. The RCRI has moderate discrimination for major cardiac complications and major adverse cardiac events in African patients undergoing non-cardiac surgery.

The African Surgical OutcomeS-2 (ASOS-2) Pilot Trial, a mixed-methods implementation study

Background: The African Surgical Outcomes Study (ASOS) showed that surgical patients in Africa have a mortality twice the global average. The working hypothesis is that patients die as a result of failure to rescue following complications in the postoperative period. The African Surgical OutcomeS-2 (ASOS-2) Trial plans to test the efficacy of increased postoperative surveillance in high risk patients for decreasing perioperative morbidity and mortality. This pilot trial aimed i) to evaluate the adequacy of data produced by the data collection strategies of the ASOS-2 Trial, ii) to evaluate the fidelity of implementation of the increased postoperative surveillance intervention, and iii) to understand the acceptability, appropriateness and feasibility of the intervention and the trial processes. Methods: The ASOS-2 Pilot Trial was a mixed-methods (quantitative-qualitative) implementation study focusing on the intervention arm of the proposed ASOS-2 Trial. The intervention is increased postoperative surveillance for high-risk surgical patients. The intervention protocol was implemented at all sites for a seven-day period. A post pilot trial survey was used to collect data on the implementation outcomes. Results: 803 patients were recruited from 16 hospitals in eight African countries. The sampling and data collection strategies provided 98% complete data collection. Seventy-three percent of respondents believed that they truly provided increased postoperative surveillance to high risk patients. In reality 83/125 (66%) of high-risk patients received some form of increased postoperative surveillance. However, the individual components of the increased postoperative surveillance intervention were implemented in less than 50% of high-risk patients (excepting increasing nursing observations). The components most frequently unavailable were the ability to provide care in a higher care ward (32.1%) and assigning the patient to a bed in view of the nurses' station (28.4%). Failure to comply with available components of the intervention ranged from 27.5% to 54.3%. The post pilot survey had a response rate of 30/40 (75%). In Likert scale questions about acceptability, appropriateness, and feasibility of the ASOS-2 intervention, 63% to 87% of respondents indicated agreement. Respondents reported barriers related to resources, trial processes, teamwork and communication as reasons for disagreement. Conclusions: The proposed ASOS-2 Trial appears to be appropriate, acceptable and feasible in Africa. This pilot trial provides support for the proposed ASOS-2 Trial. It emphasises the need for establishing trial site teams which address the needs of all stakeholders during the trial. A concerted effort must be made to help participating hospitals to increase compliance with all the components of the proposed intervention of 'increased postoperative surveillance' during the ASOS-2 Trial

Burns: the epidemiological pattern, risk and safety awareness at Kenyatta National Hospital, Nairobi.

BACKGROUND: Many burns are preventable but there is no published local prospective data on the epidemiological pattern of burns that would form the basis of care and formulation of burn prevention strategies. OBJECTIVES: To determine the epidemiological pattern of burns and assess the awareness of burn risk and preventive measures among patients admitted at Kenyatta National Hospital (KNH) with burns. DESIGN: Cross-sectional study. SETTING: Kenyatta National Hospital. PATIENTS: One hundred and nine consecutive burn patients admitted at Kenyatta National Hospital. RESULTS: The mean age was 14.4 years (median 7.0, range 0.2-66 years). Mean total body surface area burned (TBSA) was 22.3% (median 13.0, range 1-95%). Children under five years were 48.6% with more scalds compared to adults. Open flames burns, involvement of accelerants and assault were prominent among adults. Education level above primary school was associated with higher risk awareness compared with primary level education or below. CONCLUSION: The pattern of burns noted resembles other reported series but the role of accelerants and assault appears enhanced in this study. Public education campaigns aimed at burns reduction could be tailored to the educational level of target population.

Nosocomial infections at Kenyatta National Hospital Intensive-Care Unit in Nairobi, Kenya.

The objective of this study was to identify the common bacteria isolated from patients, antibiotics used, sensitivity patterns, therapeutic procedures and cleaning protocols practised in Kenyatta National Hospital Intensive-Care Unit (ICU). Kenyatta National Hospital is a 1,800-bed referral and tertiary-care hospital which is also the Teaching University Hospital. The ICU has 20 beds. Two members of staff, a consultant and a senior nurse, did the study. Out of 195 patients admitted to the unit during the study period, 137 (70.3%) received antibiotics. The most frequently prescribed antibiotics included meropenem, ceftazidime, cefuroxime, piperacillin tazobactam, vancomycin, Augmentin and Flagyl. The most common bacteria isolated were Pseudomonas aeruginosa,Klebsiella, Citrobacter, Staphylococcus aureus, Staphylococcus pneumoniae, Acinetobactor and Escherichia coli isolated from tracheal aspirate, urine, blood and pus swabs.

Ethnic differences in propofol and fentanyl response: a comparison among Caucasians, Kenyan Africans and Brazilians.

BACKGROUND AND OBJECTIVE: Differences in sensitivity to anaesthetic drugs may exist among human races. Allelic variants for drug metabolizing isoenzymes and other pharmacokinetic/pharmacodynamic differences may account for a variable response to anaesthetic drugs. This study was designed to investigate comparatively the anaesthetic requirements and the recovery trends of three different ethnic groups: Caucasians, African blacks and Brazilians. METHODS: The anaesthetic depth and recovery of groups of 45 patients undergoing total intravenous anaesthesia with propofol and fentanyl were compared. The bispectral index and clinical parameters were used to assess the depth of anaesthesia. The bispectral index, the response to verbal stimuli and the eye opening time were used to assess recovery. RESULTS: After stopping propofol, the bispectral index values of Caucasians returned to the baseline in about 10.8 +/- 4 min, that of Kenyan African blacks in 18 +/- 7 min and that of Brazilians in a highly variable time ranging from 5 to 25 min, (14.9 +/- 9.9). The time from discontinuation of propofol and fentanyl infusion to eye opening was 18.8 +/- 7.1 min in African blacks (P < 0.01) and 13.5 +/- 8.8 min in Brazilians (P > 0.05) vs. 11.6 +/- 4.5 min in Caucasians. Time to respond to verbal commands was 16.8 +/- 8 min in African blacks (P < 0.01) and 12.8 +/- 8.1 min in Brazilians (P > 0.05) vs. 9.9 +/- 4.5 min in Caucasians. CONCLUSIONS: The recovery of Kenyan African blacks from anaesthesia with propofol and fentanyl is much slower, in comparison with Caucasians. The recovery time of Brazilians is much more variable, in comparison with Caucasians.

Renal transplantation during the twentieth century: a review.

OBJECTIVES: To provide an overview of the various advancements and problems associated with both live and cadaver donor renal allograft transplantation during the twentieth century. DATA SOURCE: Major published reviews on renal transplantation during the the last five decades of the twentieth century were reviewed using Medline internet search and the Index Medicus. The developments in immunosuppressive therapy associated with renal transplantation, the problem of the shortage of both live and cadaveric organ donors and post-transplant complications were examined. The future of renal transplantation including cross species transplantation (xenotransplantation) is discussed. CONCLUSION: Renal transplantation has evolved over the years to become a very successful and routine procedure. However, the transplant waiting lists have remained long due to a continuously shrinking kidney donor pool which is due to improved results of neurosurgical procedures, better emergency and intensive care services and the failure to adequately prevent and treat post transplant chronic renal failure.

Cancer of the penis at Kenyatta National Hospital.

OBJECTIVES: To determine how common cancer of penis is in this locality compared to all other malignant tumours and urological malignancies, and to determine and comment on the various methods of treatment available at KNH. DESIGN: A retrospective case study. SETTING: Kenyatta National Referral Hospital, Nairobi. SUBJECTS: All patients with histologically confirmed cancer of penis at the Kenyatta National hospital between January 1970 and December 1999. RESULTS: There were 55 patients with penile cancer representing 0.1% of all malignancies during the study period. The mean age was 47.9 years with a peak incidence between 40-61 year age groups. Penile cancer was the most rare urological tumour representing 5.1%. The most common was prostate cancer (56.0%), followed by bladder cancer (25.0%), kidney cancer (7.9%), and testicular cancer (6.1%). Thirty eight patients (69.1%) presented with advanced disease, Jacksons stages III and IV. The majority (96.4%) of the patients had glandular and preputial involvement. Histologically, 56.4% had well differentiated squamous cell carcinoma, (23.6%) had moderately differentiated and (20.0%) had undifferentiated carcinoma. Forty patients (72.7%) were circumcised, nine patients (16.4%) were circumcised as adolescents and three patients (5.5%) circumcised as adults. Twenty five patients had partial penectomy with radiotherapy and or chemotherapy. Eight patients had total penectomy and radiotherapy while four patients had local excision and radiotherapy. Eleven other patients had radiotherapy either alone or combined with chemotherapy. Two patients had circumcision only and inguinal lymphadenectomy was effected on five patients after penectomy and radiotherapy. CONCLUSION: Penile cancer is rare and the least common urological malignancy in this locality. It occurs in younger men with a mean age of 47.9 years, and presents as advanced Jackson's stages III and IV disease. The majority of patients had penectomy and local excision followed by radiotherapy.

Training of surgeons in Kenya at the University of Nairobi teaching hospital.

OBJECTIVE: To determine the number of surgeons trained by the Department of Surgery, Faculty of Medicine, College of Health Sciences, University of Nairobi, since its inception in 1967. DESIGN: This was a retrospective (1975-1987) and prospective study (1988-1999). SETTING: Kenyatta National Hospital, a National Referral Hospital and University of Nairobi Teaching Hospital. SUBJECTS: All surgeons trained by the Department of Surgery of the University of Nairobi for postgraduate MMed in general surgery, anaesthesia, ENT surgery and ophthalmology from 1975 to March 1999. RESULTS: Two hundred and eighty-five surgeons with Master of Medicine degree were trained by the Department of Surgery of the University of Nairobi between 1975 and March 1999. They included 181 (63.51%) general surgeons; 46 (16.14%) anaesthetists; 35 (12.28%) ophthalmologists and 23 (8.07% ear, nose and throat (ENT) surgeons. One hundred and seventy-six, (61.75%) were from retrospective studies; 94 (32.98%) were from prospective studies while 15 (5.26%) were from both retrospective and prospective studies. Two hundred and thirty-two (81.40%) surgeons were Kenyans while 53 (18.60%) were foreigners. The majority, 42 (79.24%) of the foreigners were from other African countries. Thirty one (58.50%) were from neighbouring Uganda, Sudan, Tanzania, Ethiopia and Zambia. There was also one PhD in anaesthesia and one MD in urology during the same period. CONCLUSION: The University of Nairobi, Department of Surgery based at Kenyatta National Hospital has played a very significant and leading role in the training of surgeons for Kenya and even other African and foreign countries since its inception. Of the forty surgeons who constitute the academic staff in the Departments of General Surgery, Orthopaedic Surgery and Ophthalmology of the University of Nairobi, thirty-five surgeons (87.50%) have been trained by the Faculty of Medicine at KNH.

PIP: This study was carried out as a retrospective (1975-87) and prospective study (1988-99) to determine the number of surgeons trained by the Department of Surgery, Faculty of Medicine, College of Health Sciences, University of Nairobi, Kenya, since its inception in 1967. Over the 25-year period (1975-99), the Department of Surgery of the University of Nairobi trained a total of 285 surgeons with a Master of Medicine degree. These included 181 (63.51%) general surgeons, 46 (16.14%) anesthetists, 35 (12.28%) ophthalmologists, and 23 (8.07%) ear, nose, and throat surgeons. 176 of the dissertations (61.75%) were from retrospective studies, 94 (32.98%) were from prospective studies, and 15 (5.26%) were from combined prospective and retrospective studies. 53 (18.60%) of these surgeons were foreigners, with the majority (79.24%) coming from other African countries. The neighboring countries of Uganda, Sudan, Tanzania, Ethiopia, and Zambia accounted for 31 (58.50%) of the foreign surgeons. There was also one Doctor of Philosophy in anesthesia and one Master's Degree in urology during the same period.

Anaesthetic management of carotid artery rupture: case report.

The anaesthetic management of a case of carotic artery rupture is reported. The need for quick action in patient handling in all hospital departments and adequate monitoring during surgery are emphasized.