Rachs-1 system in risk stratification for congenital heart disease surgery outcome.

BACKGROUND: The Risk Adjustment in Congenital Heart Surgery (RACHS-1) system has been used as a benchmark to compare surgical results in developed countries. Its ability to stratify postoperative mortality risk has been validated in several developed countries, however, this has not been examined in a developing country. OBJECTIVES: To assess the ability of the RACHS-1 system to stratify postoperative mortality risk in a developing country. DESIGN: Retrospective study over a five year period between 1st January 2002 and 31st December 2006. SETTING: Kenyatta National Hospital, a teaching and referral hospital in Nairobi, Kenya. SUBJECTS: Three hundred and seventeen consecutive operations were performed on 313 patients aged between 0.25 and 204 months. RESULTS: Operations were performed in RACHS-1 categories 1, 2, 3 and 4 with hospital mortalities of 2.5%, 16.9%, 29.4% and 50% respectively. The difference in mortality between categories 1 and 2 was significant (p-value of 0.0003), however, the difference in mortality between categories 2 and 3 and categories 3 and 4 was not significant (p-values 0.193 and 0.67 respectively). CONCLUSIONS: The RACHS-1 system did not adequately stratify risk in a low case load setting. The use of the RACHS-1 method as a benchmark to compare surgical results of paediatric cardiac surgery services in developing countries may be limited.

Risk of conjunctival contamination from blood splashes during surgery at the Kenyatta National Hospital, Nairobi.

OBJECTIVES: To determine the utilisation rate of design specific eye protection by surgeons and to assess the risk of conjunctival contamination with blood splashes during surgery. DESIGN: Cross sectional, observational study. SETTING: The theatre suite of Kenyatta National Hospital, Nairobi SUBJECTS: Surgeons from all specialties operating in the theatre suite. RESULTS: The minority of surgeons, 5.2% utilised protective eye goggles compared to 3.5% of assistants. Prescription eye spectacles were the most common form of eye protection at 41.9 and 20.9% respectively for surgeons and their assistants. The contamination rate for provided protective eye wear was 53.1% with the average number of droplets being 2.48 per procedure for the principal surgeon. The duration of surgery and the use of power tools influenced the contamination rate. CONCLUSIONS: The utilisation rate of design specific protective eye wear is low and with a significant risk of conjunctival contamination, changes in attitudes and practices are needed to increase utilisation.

Management pathway for congenital heart disease at Kenyatta National Hospital, Nairobi.

BACKGROUND: Congenital heart disease (CHD) is a significant cause of death amongst infants. The timing of treatment in relation to the natural history of the disease correlates with the treatment outcome. OBJECTIVES: To determine the age at first suspicion of CHD, the age at confirmation of the diagnosis of CHD and the percentage follow-up at the first post diagnosis out patient clinic and to determine the influence of patient's sex, parental income and parental education have on the MP. DESIGN: A five year retrospective study. SETTING: Kenyatta National Hospital between January 1st 2000 and December 31st 2004. SUBJECTS: Two hundred and fourteen patients were studied. RESULTS: The overall mean age at referral to a paediatric cardiologist was 16.9 +/- 24.4 months [n = 102]. The mean age at which CHD was confirmed by echocardiography was 18.6 +/- 25.6 months [n = 202]. The mean age at which CHD was first suspected in patients from the province with the highest parental income was 9.5 +/- 5.1 months [n = 6]. The mean age at which CHD was first suspected in patients from a province with a significantly lower parent income was 19.1 +/- 23.2 months [n = 22], (p = 0. 046). The mean age at which CHD was confirmed in referred male patients was 16.0 +/- 17.6 months [n=48] and the mean age at which CHD was confirmed in referred female patients was 18.8 +/- 21.7 months [n = 52] (p = 0.25). CONCLUSION: The mean age at referral to a paediatric cardiologist was 16.9 months. This suggests that a significant number of patients may miss the opportunity to have optimal surgical intervention. Parental income appears to influence the MP, however, the level of parental education and patient sex did not.

Weight change post oesophagectomy for carcinoma of oesophagus.

OBJECTIVE: To determine the pattern of weight changes observed in postoperative oesophagectomy patients at the Kenyatta National Hospital and evaluate weight change with selected preoperative variables. DESIGN: A prospective analysis of post-operative weight change of patients following oesophagectomy utilising body mass index (BMI). SETTING: The cardiothoracic unit, Kenyatta National Hospital, Nairobi. SUBJECTS: All patients with oesophageal cancer, with a confirmed histological diagnosis of squamous cell carcinoma and discharged post oesophagectomy. INTERVENTION: Oesophagectomy. MAIN OUTCOME MEASURE: Changes observed in the BMI during respective clinic visits. RESULTS: Fifty nine patients were enrolled into the study with a mean preoperative weight of 50.4 kilograms and mean BMI of 19.4 kg/m2 (+/- 4.3). Sixty seven point seven percent of patients preoperatively fell into the underweight category (less than 20kg/m2); normal were 16 patients (27.1%) and overweight included six patients (10.2%). Postoperatively the majority of patients continued to loose weight and the overall average BMI at the study endpoint was calculated as 18.0 kg/m2 (+/- 3.2). This value was significantly lower compared with the preoperative value (p = 0.004). None of the selected variables showed a significant relationship to the postoperative weight change pattern observed, though the patients gaining weight postoperatively had an apparently better survival pattern compared to the others. Analysis of the selected variables versus weight change pattern (gain, stable or weight loss) showed no significant relationships. CONCLUSION: This study population presented a lower initial preoperative weight compared to similar studies from the developed world, with the majority being underweight. The majority of patients exhibited a continued postoperative weight loss with only a small number showing any weight gain. The study unfortunately was not able to demonstrate association of weight change with any of the selected variables.

Post-infarction ventricular septal defect in Nairobi: case report.

Post infarction ventricular septal defect results from perforation of the ventricular septum secondary to ischaemic injury following myocardial infarction. Ischaemic heart disease till recently was thought to be an uncommon disease in this part of the world, but now more and more cases are being seen as a result of the changes in thelife styles of the population in this country and in the developing world in general. This is a case report of the first case of post infarction ventricular septal defect presenting to surgery for repair in this country.

Thirty day mortality and related variables in open heart patients at the Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the thirty-day mortality of open-heart patients at the Kenyatta National Hospital in Nairobi from June 1973 to October 2000 and; to look at likely variables related to mortality. DESIGN: A retrospective analysis of data from the unit database. Data on this database were collected prospectively from September 1997 to the time of study. Data in respect of the period prior to this were collected retrospectively from patient files, ward and theatre records. SETTING: Kenyatta National Hospital (KNH), Nairobi. PATIENTS: A total of 563 open-heart patients operated at the KNH were included in the study. RESULTS: The thirty-day mortality rate calculated at 17.4% for the study period compared to a hospital mortality rate of 16.9%. Surgical repair for complex congenital pathology, surgery on patients with a left atrial (LA) dimension or a left ventricular end systolic dimension (LVESD) greater than 5 cm or/and a cross clamp time greater than 60 minutes all had a significantly greater risk of mortality on bivariate analysis. This is compared to surgery for simple hole in the heart, LA and LVESD dimensions less than 5 cm and cross clamp times less than 60 minutes (p < 0.05). The increased risk of mortality with these variables was 3.33, 3.95, 3.18 and 1.8 times greater than their counterparts, respectively. For patients having surgery for an acquired pathology, only a cross clamp time greater than 60 minutes and a left atrial size greater than 5 cm were independent risk factors for thirty day mortality using logistic regression analysis. For patients having surgery for correction of a congenital defect, only a cross clamp time of more than 60 minutes was an independent predictor of mortality (p < 0.05). CONCLUSIONS: The higher mortality rate is amongst others, probably related to the late presentation of our patients for surgery when their myocardial function is below the optimum for surgery. There is a need to bring down the mortality through more stringent patient selection, preoperative preparation and reduction of surgical ischaemic times, however without depriving the patients in need of surgery.

Follow up of oesophageal cancer therapy at the Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the pattern of follow-up for oesophageal cancer patients following hospital discharge and reviewing followup results of the different treatment modalities with emphasis on oesophagectomies. DESIGN: A retrospective hospital based study covering the period January 1987 to January 2001. SETTING: Surgical outpatient clinic, Kenyatta National Hospital, Nairobi. MAIN OUTCOME MEASURES: Determination and the comparison of the one, two and three-year followup rates for the different treatment modalities and their median follow-up period in addition to reviewing the common variables associated with follow-up. RESULTS: The median followup for patients managed by oesophagectomy was 9.5 months with a 43%, 22% and 10% one-, two- and three-year followup rates respectively. This compared to a median of two months and a 7% and 3% one-, and two- year followup rate for patients managed by intubation, and a 3-month median followup with a one- and two- year follow-up rate of 12% and 4% respectively for radiotherapy treated patients. Oesophagectomy patients had a better followup compared to intubations and radiotherapy (p<.00001). Oesophagectomy for stage T4 tumours had an apparently better follow-up compared to both stage T1-3 tumours and patients managed with intubations (p=.002 and .02 respectively).

Warfarin-related bleeding following open heart surgery in Nairobi.

OBJECTIVES: To review anticoagulant-related bleeding in heart valve patients on warfarin at the Kenyatta National Hospital and to determine the variables associated with anticoagulant-related bleeding. DESIGN: A combined retrospective and prospective review of patients operated at the Kenyatta National Hospital. Retrospective period from June 1973 to 31st July 1997, while prospective period from August 1st 1997 to June 1st 2000. SETTING: Surgical Outpatient Department, Kenyatta National Hospital, Nairobi. MAIN OUTCOME MEASURES: Linearised occurrence rate of anticoagulant-related bleeding and the one- five- and ten- year bleed free rates. Independent risk factors associated with anticoagulant-related bleeding determined using Cox's proportional hazards. RESULTS: Thirty one bleeding episodes were recorded in 150 patients followed up for a total of 745 patient-years. The risk of occurrence of the first bleed was 16.0%; while the risk of a subsequent bleed increased thereafter with a 16.7%, 50% and 50% risk after the first, second and third bleeds respectively. The linearised rate for minor anticoagulant-related bleed was 4.16% per patient per year however, half the bleeds occurred within the first year of valve implantation or previous bleeding episode. The one-, five- and ten-year bleed free rates for all valves combined were 93%, 85% and 78% respectively. There was no statistically signicant difference between the curves comparing the bleed free rates for the first and second bleeding episodes (p=0.098). The number of valves implanted, the site of implant and the time to the occurrence of bleeding were independent risk factors associated with the occurrence of bleeding (p<.05). CONCLUSION: The occurrence of anticoagulant-related bleeding is relatively common being slightly above the internationally reported range. Most episodes of bleeding will occur within one year of hospital discharge or the previous bleeding episode. The risk of another bleeding episode occurring increases with each episode with up to a 50% risk of re-bleed after the second bleeding episode. In this study, the number of valves implanted, their position and the time of occurrence of the bleed were risk factors to the occurrence of bleeding.

Long term valve-related morbidity following open-heart surgery at the Kenyatta National Hospital.

OBJECTIVE: To determine the incidence of valve morbidity associated with post-operative valve patients at the Kenyatta National Hospital, Nairobi. DESIGN: A combined retrospective and prospective study. Restrospective period from 1973 to 31st July 1977 and prospective period from there on to 31st July 1998. SETTING: Cardiothoracic outpatient clinic at Kenyatta National Hospital, Nairobi. PATIENTS: All valve replacement patients attending the cardiothoracic outpatient clinic on follow up following discharge from the ward. OUTCOME MEASURES: Morbidity was assessed by incidence of: stroke, thromboembolism, valve thrombosis, bleeding episodes, valve endocarditis and re-operation for valve failure. RESULTS: For all valve surgery combined the overall follow up rate equalled 476.3 patient years. The linearised occurrence rate for thromboembolism for all valves was 1.04% per patient year. For the mechanical valves this incidence was 1.32% per patient year. The stroke free rate at one year and five years was 97.7% and 95.9% respectively. The linearised incidence rate for stroke was 0.84% per patient year for all valves. The incidence of bleeding episodes, excluding menorrhagia, for mechanical valves was 0.79% per patient year. Three episodes of valve thrombosis were observed in this study group, all occurring with mechanical valves. For mechanical valves the incidence equalled 0.79% per patient year. The incidence of prosthetic valve endocarditis equalled 0.42% per patient year for all valves combined, or 0.53% per patient year for mechanical valves. Three patients in the series had redo surgery due to valve failure (0.63%). The commutative occurrence of valve related morbidity for the study population for all valves analysed was 2.73% per patient year. CONCLUSION: The incidence of the various valve morbidity at the Kenyatta National Hospital are below the internationally quoted figures in the literature for other centres. The high incidence of drop out to clinic follow up is likely to be the main reason for this with a lot of morbidity occurring outside the hospital environment and therefore not documented. The exact estimation of this incidence is difficult to assess. To help ascertain this occurrence an accurate patient database with accurate (real time) contacts needs to be put into place.

Pattern of anticoagulation control after heart valve surgery at the Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the pattern of anticoagulation control for post heart-valve surgery for patients on follow up at Kenyatta National Hospital (KNH). DESIGN: A combined prospective and restrospective hospital-based study. Retrospective period from January 1991 to 31st August 1997, while the prospective period was from 1st September 1997 to 31st November 1999. SETTING: Cardiothoracic surgery clinic, Kenyatta National Hospital, Nairobi. PATIENTS: Post heart valve surgery patients on warfarin and attending the cardiothoracic surgery clinic at Kenyatta National Hospital. MAIN OUTCOME MEASURES: Clinic attendance intervals, average warfarin dosages, interval of dosage change, INR values and variations from accepted normal. RESULTS: A total of 103 patients fulfilled the criteria for inclusion into the study consisting of 77 mitral valve replacements, 18 aortic valve replacements, seven double valve replacements and one mitral valve repair. The total follow up time for the study period is 316.9 patients years. On average, patients attended their anticoagulation clinic once every 59 days. The average dose of warfarin prescribed was 6.81 mg daily (+/-2.67 mg), with double valve replacement patients receiving a statistically significant lower dosage of 6.04 mg (+/-1.36 mg), (95% confidence limits). On average, a warfarin dose change was made 1.48 times a year per patient. For all the patients, the mean INR was 2.50 (+/-1.18). The respective values for mitral, aortic, double valve replacement and the mitral repairs were 2.53 (+/-1.21), 2.32 (+/-1.04), 2.5 (+/-1.05) and 2.02 (+/-0.53), respectively. Mitral valve repair patients maintained a significantly lower level of INR (95% confidence limits). Only during 18% of the follow up time was adequate anticoagulation maintained. During the study period only 6.9% of patients were able to maintain adequate anticoagulation for 50% or more of their follow up time. CONCLUSION: Anticoagulation control at the KNH still needs some improvements in clinic attendance and better dosage adjustments to achieve more appropriate INR values.

Pregnancy in open heart surgical patients at Kenyatta National Hospital.

BACKGROUND: In the past, the Kenyatta National Hospital heart unit policy has been to discourage pregnancy among patients following open heart surgery for valve replacement, in view of the adverse effects of warfarin. OBJECTIVE: To review the occurrence of pregnancy in open heart patients following discharge from hospital, and to compare the incidence with national figures. DESIGN: Retrospective and prospective. SETTING: Kenyatta National Hospital, Nairobi. PATIENTS: Of the 239 female patients operated upon at the cardiothoracic unit of the KNH during the period June 1973 and September 1998, 108 met the inclusion criteria; 56 of them had valve replacement surgery. RESULTS: At the time of surgery, 31% of all the female patients were in the reproductive age group of 14 to 45 years. Only two per cent were older than 45 years. Follow up was 490 patient years for the entire group, and 318 patient years for all with valvulopathy. For the whole group, irrespective of age, pregnancy rate was 6% and 15% at five and ten years of follow up respectively. There was no statistically significant difference between pregnancies occurring in patients who had valve surgery and those who had surgery for congenital heart disease, p = 0.35. CONCLUSION: Despite our previous policy of discouraging pregnancy among patients with mechanical valves, a significant number of them still became pregnant. The pregnancy rate in these patients was approximately one quarter of that in the general Kenyan population. An increasing number of centres now favour continuation of warfarin during pregnancy, the risks of maternal and foetal complications with heparin seem to be greater than the likely drawbacks associated with warfarin use in these patients.

Follow up of patients after open heart surgery.

OBJECTIVE: To determine the patient drop out to postoperative follow up for heart patients at the Kenyatta National Hospital. DESIGN SETTING AND PARTICIPANTS: The study analysed the postoperative attendance of heart patients to the surgical outpatient clinic at the KNH. Data on clinic attendance was collected over a one-year period from patient files and from clinic attendance. RESULTS: A total of four hundred and seventy-five open heart operations have been performed at the Kenyatta National Hospital over the last twenty-five years. The patients' mean age is 18.0 years. Clinic follow up rate over this period is 85% at one-year, 62% at five-years, 32% at ten-years and 13% at fifteen-years. A number of patients who had since fallen out to clinic follow up were traced during the study period, when included into the analysis the revised figures are 85%, 70%, 40% and 24% respectively. The difference is statistically significant (p = 0.019). There was no significant statistical difference in the follow up between males and females (p = 0.278), however between patients operated for congenital heart diseases compared to valve patients, the difference was significant (p = 0.007), valve patients having a better follow up. The five-year follow up for isolated mitral, aortic and double valve replacements were 94%, 74% and 78% respectively. CONCLUSION: Despite deceptively good follow up figures, our figures are in fact poor when age is considered. Financial combined with logistical problems are the most likely causes of poor follow up.

Fibrosarcoma of the lung with extrapulmonary manifestations: case report.

A 50-year-old female presented with a five months history of recurrent attacks of dizziness, sweatiness, tremors and fainting with loss of consciousness. These were found to be due to hypoglycaemic episodes with blood sugars less than 1 mmol/l and were treated as such. A diagnosis of insulinoma was initially considered, but the patient turned out to have fibrosarcoma of the lung, a rare lung tumour. She also had finger and toe clubbing and features of hypertrophic pulmonary osteoarthropathy.

Surgery of the oesophagus: a Nairobi experience.

On average, for every 100 patients with malignant dysphagia admitted into the Kenyatta National Hospital (KNH) in Nairobi, 28 will have their tumour resected. Seven in the tumour resected group will die during the postoperative period while there will be 12 deaths occurring in patients before surgery.

A study of haemorrhoids as seen at the Kenyatta National Hospital with special reference to asymptomatic haemorrhoids.

Eighty random patients were examined over a 9-month-period to determine the incidence of asymptomatic haemorrhoids at the Kenyatta National Hospital (KNH). The incidence of asymptomatic was found to be 21% all being first degree haemorrhoids, while in the age group 50 years and over, 29% had asymptomatic haemorrhoids. The mean age calculated as 44.3 years (+/- 18.3), with no statistical difference between the ages of the two sexes. Males however had a significant greater incidence of asymptomatic haemorrhoids than females.