EPidemiology, clinical characteristics and Outcomes of 4546 adult admissions to high-dependency and intensive care units in Kenya (EPOK): a multicentre registry-based observational study.

Objective: to describe clinical, management and outcome features of critically ill patients admitted to intensive care units (ICUs) and high dependency units (HDUs) in Kenya. Design: prospective registry-based observational study. Setting: three HDUs and eight ICUs in Kenya. Patients: consecutive adult patients admitted between January 2021 and June 2022. Interventions: none. Measurements and main results: data was entered in a cloud based platform using a common data model. Study endpoints included case mix variables, management features and patient centred outcomes. Patients with Coronavirus disease 2019 (COVID-19) were reported separately. Of the 3892/4546 patients without COVID-19, 2445 patients (62.8%) were from HDUs and 1447 (37.2%) from ICUs. Patients had a median age of 53 years (interquartile range [IQR] 38-68), with HDU patients being older but with a lower severity (APACHE II 6 [3-9] in HDUs vs 12 [7-17] in ICUs; p<0.001). One out of four patients were postoperative with 604 (63.4%) receiving emergency surgery. Readmission rate was 4.8%. Hypertension and diabetes were prevalent comorbidities, with a 4.0% HIV/AIDS rate. Invasive mechanical ventilation (IMV) was applied in 3.4% in HDUs vs. 47.6% in ICUs (P<0.001), with a duration of 7 days (IQR 3-21). There was a similar use of renal replacement therapy (4.0% vs. 4.7%; P<0.001). Vasopressor use was infrequent while half of patients received antibiotics. Average length of stay was 2 days (IQR 1-5). Crude HDU mortality rate was 6.5% in HDUs versus 30.5% in the ICUs (P<0.001). Of the 654 COVID-19 admissions, most were admitted in ICUs (72.3%) with a 33.2% mortality. Conclusions: We provide the first multicenter observational cohort study from an African ICU national registry. Distinct management features and outcomes characterise HDU from ICU patients. Study registration: Clinicaltrials.gov (reference number NCT05456217, date of registration 07 Nov 2022).

Oxygen saturation targets for adults with acute hypoxemia in low and lower-middle income countries: a scoping review with analysis of contextual factors.

Knowing the target oxygen saturation (SpO2) range that results in the best outcomes for acutely hypoxemic adults is important for clinical care, training, and research in low-income and lower-middle income countries (collectively LMICs). The evidence we have for SpO2 targets emanates from high-income countries (HICs), and therefore may miss important contextual factors for LMIC settings. Furthermore, the evidence from HICs is mixed, amplifying the importance of specific circumstances. For this literature review and analysis, we considered SpO2 targets used in previous trials, international and national society guidelines, and direct trial evidence comparing outcomes using different SpO2 ranges (all from HICs). We also considered contextual factors, including emerging data on pulse oximetry performance in different skin pigmentation ranges, the risk of depleting oxygen resources in LMIC settings, the lack of access to arterial blood gases that necessitates consideration of the subpopulation of hypoxemic patients who are also hypercapnic, and the impact of altitude on median SpO2 values. This process of integrating prior study protocols, society guidelines, available evidence, and contextual factors is potentially useful for the development of other clinical guidelines for LMIC settings. We suggest that a goal SpO2 range of 90-94% is reasonable, using high-performing pulse oximeters. Answering context-specific research questions, such as an optimal SpO2 target range in LMIC contexts, is critical for advancing equity in clinical outcomes globally.

The World Organization of Family Doctors Air Health Train the Trainer Program: lessons learned and implications for planetary health education.

The World Organization of Family Doctors (WONCA) Air Health Train the Trainer Program was a pilot educational programme that focused on a key aspect of planetary health: the intersection of air pollution, human health, and climate change. In this Viewpoint, we-the coordinators of the training programme and some of the most active trainers-briefly describe the programme and discuss implementation successes, challenges, and lessons learned, which relate to the creation and use of training materials appropriate for health professionals in low-income and middle-income countries, strategies to improve the retention of trainers to deliver activities in their communities, and the development of stronger networks and further tools to support trainers. These findings could be applied to future education and training programmes.

Ecology and age, but not genetic ancestry, predict fetal loss in a wild baboon hybrid zone.

OBJECTIVES: Pregnancy failure represents a major fitness cost for any mammal, particularly those with slow life histories such as primates. Here, we quantified the risk of fetal loss in wild hybrid baboons, including genetic, ecological, and demographic sources of variance. We were particularly interested in testing the hypothesis that hybridization increases fetal loss rates. Such an effect would help explain how baboons may maintain genetic and phenotypic integrity despite interspecific gene flow. MATERIALS AND METHODS: We analyzed outcomes for 1020 pregnancies observed over 46 years in a natural yellow baboon-anubis baboon hybrid zone. Fetal losses and live births were scored based on records of female reproductive state and the appearance of live neonates. We modeled the probability of fetal loss as a function of a female's genetic ancestry (the proportion of her genome estimated to be descended from anubis [vs. yellow] ancestors), age, number of previous fetal losses, dominance rank, group size, climate, and habitat quality using binomial mixed effects models. RESULTS: Female genetic ancestry did not predict fetal loss. Instead, the risk of fetal loss is elevated for very young and very old females. Fetal loss is most robustly predicted by ecological factors, including poor habitat quality prior to a home range shift and extreme heat during pregnancy. DISCUSSION: Our results suggest that gene flow between yellow and anubis baboons is not impeded by an increased risk of fetal loss for hybrid females. Instead, ecological conditions and female age are key determinants of this component of female reproductive success.

Hand injuries in Kenya: a chaff cutter menace.

Introduction Hand injuries are a recognized occupational hazard from the use of chaff cutters. With increasing mechanization of farming in our region, the burden of hand injuries is poised to increase. Methods We conducted a descriptive study of 47 patients presenting with chaff cutter hand injuries at our center in one year. Results They were predominantly male (98%) and the majority (70%) were aged between 21 and 40 years. The majority of patients who had not resumed work were those with severe injuries and those who had had an amputation. There was a positive correlation between age category and severity of injury. Discussion Chaff cutter injuries contribute considerably to hand amputations at our center. The majority of patients with severe injuries and those undergoing amputations do not return to gainful activities one year after sustaining the injury, suggesting increased dependency. Further research is paramount to identify safety features of chaff cutters in this region.

Implementing the Trauma Evaluation and Management (TEAM) Course in Kenya.

BACKGROUND: Trauma training provides crucial knowledge and skills for health-care providers in low- and middle-income countries (LMICs). Although such training has been adapted for physicians and emergency personnel in LMICs, few courses have been offered for medical students. The Trauma Evaluation and Management (TEAM) course, developed by the American College of Surgeons, provides a valuable framework for providing this content to medical students in an LMIC-context. MATERIALS AND METHODS: We implemented the TEAM course at a single medical school in rural Kenya, for final-year medical students, utilizing the multimodal instruction and reference materials provided by the American College of Surgeons. We administered precourse and postcourse assessments, adapted the content for particular low-resource considerations, expanded the course to 2 d, and utilized a multidisciplinary and multinational group of surgical expert instructors. RESULTS: The entire final-year medical school class participated, and all completed pretesting and posttesting (100%, n = 61). Posttesting revealed significant improvement (P < 0.001), demonstrating successful knowledge acquisition, with the greatest improvements among the poorest performing decile on the pretest (P < 0.05). On narrative course feedback (100% completion, n = 61), participants appreciated instructors' interactive teaching style and the course's practical demonstrations, while requesting more time allotment for trauma training. CONCLUSIONS: We describe the feasibility of implementing TEAM training for final-year medical students in Kenya and demonstrate the course's effectiveness in this context as shown by knowledge acquisition. We plan for additional study to assess interval knowledge and skill retention. With refinement based on these results, we plan to repeat and expand trauma-education initiatives for medical students in LMICs.

Sorption and degradation of 17ß-estradiol-17-sulfate in sterilized soil-water systems.

To identify abiotic processes that govern the fate of a sulfate conjugated estrogen, 17ß-estradiol-17-sulfate (E2-17S), soil batch experiments were conducted to investigate the dissipation, sorption, and degradation of radiolabeled E2-17S under sterilized conditions. The aqueous dissipation half-lives (DT50) for E2-17S ranged from 2.5 to 9.3h for the topsoil of high organic carbon (OC) content (1.29%), but E2-17S remained at ∼80% of applied dose in the low OC (0.26%) subsoil by 14 d. The non-linear sorption isotherms indicated limited sorption of E2-17S, and the concentration-dependent log KOC values were 2.20 and 2.45 for the topsoil and subsoil, respectively. Additionally, two types of hydroxyl E2-17S (OH-E2-17S and diOH-E2-17S) were found as major metabolites in the aqueous phase, which represented 9-25% and 6-7% of applied dose for the topsoil and subsoil at 14 d, respectively. Free estrogens, 17ß-estradiol (E2) and estrone (E1), were detected from the sorbed phase of the soil-water systems.

Dissipation and transformation of 17ß-estradiol-17-sulfate in soil-water systems.

In the environment, estrogen conjugates can be precursors to the endocrine-disrupting free estrogens, 17ß-estradiol (E2) and estrone (E1). Compared to other estrogen conjugates, 17ß-estradiol-17-sulfate (E2-17S) is detected at relatively high concentrations and frequencies in animal manure and surface runoff from fields receiving manure. To elucidate the lifecycle of manure-borne estrogens and their conjugates in the environment, the fate of radiolabelled E2-17S in agricultural soils was investigated using laboratory batch studies with soils of different organic carbon (OC) content (1.29% for topsoil versus 0.26% for subsoil). E2-17S was found relatively persistent in the aqueous phase throughout the duration of the 14 d experiment. The aqueous E2-17S persisted longer in the subsoil (half-lives (DT50)=64-173 h) than the topsoil (DT50=4.9-26 h), and the aqueous persistence of E2-17S depended on its initial concentration. The major transformation pathway was hydroxylation, yielding mono- and di-hydroxy-E2-17S (OH-E2-17S and diOH-E2-17S). Free estrogens, E2 and E1, were only observed in the sorbed phase of the soil at low concentrations (∼1% of applied dose), which demonstrated that deconjugation and subsequent oxidation had occurred. Although deconjugation was not a major pathway, E2-17S could be a precursor of free estrogens in the environment.

Effects of field-manure applications on stratified 17ß-estradiol concentrations.

The occurrence of the manure-borne estrogen, 17ß-estradiol (E2), was investigated in laboratory and field soils. In the laboratory, E2 was applied to soil to simulate concentrations found in swine (Sus scrofa domestica) manure (5000ngL(-1)). The aqueous-extracted E2 dissipated in the soil by 98% within 1h and was not significantly different from background concentrations (18ng L(-1)) for the duration of the experiment (64h). In the field study, soil cores were taken before and several dates after swine manure application. Equivalent porewater concentrations of water-extractable E2 were determined in 0.15-m increments down to the water table (0.70-2.00m deep). The average frequency of detection for 168 samples was 38% (average=40ng L(-1) porewater equivalents). Eleven days after manure application there was no significant effect on E2 detection frequency or concentration. However, E2 concentrations significantly increased by 6 months after manure application, and appeared to be related to precipitation. Concentrations then returned to original levels by 17 months after manure application. Manure did not have an immediate effect on E2 occurrence due to the capacity of the soil to rapidly sorb E2. However, it appears that soil may act as a long-term reservoir for E2 in the environment, which may be periodically released through desorption.

An on-farm survey of spatial and temporal stratifications of 17ß-estradiol concentrations.

17ß-estradiol (E2) is a natural estrogenic hormone found in animal manure and urine, which may cause endocrine disruption in sensitive organisms. 17ß-Estradiol has been widely detected in the environment, and animal agriculture may be an important source. The objectives of this study were to investigate the potential sources and/or spatial and temporal characteristics contributing to detections of E2 at the farm-scale. Soil cores, segmented into 0.15m increments, were taken down to the water table from four locations (three potential E2 sources and one control) at or around a swine (Sus scrofa domesticus) farm on five different dates between 2006 and 2007. Estradiol was quantified in the soil-water extracts using liquid chromatography-with tandem mass spectrometry (LC/MS/MS) analysis. Estradiol detections were widespread and found in 128 out of 345 extractions (37%). Concentrations ranged from 0 to 1910 ng L⁻¹ (porewater equivalents). A location that received field application of manure had significantly lower E2 concentrations compared to other locations. Also, the spring 2007 E2 concentrations were significantly higher than all other sample dates, perhaps related to climatic and hydrological events. Results suggested E2 was not directly related to manure sources, but was widespread in this environment. Where E2 was detected, highest concentrations favored the upper profile, while the greatest frequency of detections was in the lower profile and near the water table. Detections of E2 were associated with high organic mater contents in the upper profile and high sand contents in the lower profile. The study suggests that E2 is widespread in some soil environments, raising questions as to the source and mechanisms that facilitate its transport and mobility.