Lowering levels of bed occupancy is associated with decreased inhospital mortality and improved performance on the 4-hour target in a UK District General Hospital.

OBJECTIVE: To evaluate whether there is an association between an intervention to reduce medical bed occupancy and performance on the 4-hour target and hospital mortality. METHODS: This before-and-after study was undertaken in a large UK District General Hospital over a 32 month period. A range of interventions were undertaken to reduce medical bed occupancy within the Trust. Performance on the 4-hour target and hospital mortality (hospital standardised mortality ratio (HSMR), summary hospital-level mortality indicator (SHMI) and crude mortality) were compared before, and after, intervention. Daily data on medical bed occupancy and percentage of patients meeting the 4-hour target was collected from hospital records. Segmented regression analysis of interrupted time-series method was used to estimate the changes in levels and trends in average medical bed occupancy, monthly performance on the target and monthly mortality measures (HSMR, SHMI and crude mortality) that followed the intervention. RESULTS: Mean medical bed occupancy decreased significantly from 93.7% to 90.2% (p=0.02). The trend change in target performance, when comparing preintervention and postintervention, revealed a significant improvement (p=0.019). The intervention was associated with a mean reduction in all markers of mortality (range 4.5-4.8%). SHMI (p=0.02) and crude mortality (p=0.018) showed significant trend changes after intervention. CONCLUSIONS: Lowering medical bed occupancy is associated with reduced patient mortality and improved ability of the acute Trust to achieve the 95% 4-hour target. Whole system transformation is required to create lower average medical bed occupancy.

Bone marrow examination findings at Aga Khan University Hospital, Nairobi.

OBJECTIVE: To establish the bone marrow examination findings and determine the indication for bone marrow examination. DESIGN: A retrospective audit. SETTING: Aga Khan University Hospital, Nairobi. SUBJECTS: All bone marrow aspirates done at Aga Khan University for the period comprising February 2003 to February 2006 were retrieved and analysed. RESULTS: A total of 356 patient's case histories including bone marrow examination results were analysed. Ages of the patients ranged from 18 months to 91 years. Males were 180 (50.6%) and females were 176 (49.4%). Nutritional anaemia as a group was the most common haematological disorder found on bone marrow examination in our patients with megaloblastic anaemia predominating. Acute myeloid leukaemia was the most common malignant haematological disorder. The most common indication for bone marrow examination was anaemia followed by diagnostic work up of fever of unknown origin. CONCLUSION: Nutritional anaemia predominated as the commonest benign haematological finding on bone marrow examination while acute myeloid leukaemia was the most frequent haematological malignancy. Most bone marrow examinations were performed on patients with anaemia.

The GLIVEC international patient assistance programme: the Nairobi experience.

Glivec is a drug used in the treatment of chronic myeloid leukaemia (CML) and gastrointestinal stromal tumours (GISI). It is an expensive drug which would be out of reach for most patients in Kenya. Norvatis Pharmaceutical together with Axios International a healthcare management company and Max Foundation have made it possible for patients in developing countries to get access to the drug at no cost. Patients meet the cost of the confirmatory test and are recruited into the programme to receive the drug at no cost. A total of 201 patients are in the programme in Nairobi, mainly drawn from Kenyatta National Hospital the major referral hospital in Kenya. The age range is nine years to 75 years with a mean age of 39.5 years. Males make up 56.5% while females are 43.5%. CML are 173 (86%) while GIST patients are 28 (13.9%). Most of the CML cases are referred in the chronic stable phase (87.8%) and 85.7% have been on hydroxyurea as the initial treatment. Compliance rates are approximately 80%.

Multiple myeloma presenting as a painful mandibular swelling: a case report.

Multiple myeloma is a disease characterized by monoclonal proliferation of plasma cells, the most differentiated stage of B-cells. Primary manifestation of multiple myeloma in the jawbones is rare. In the case reported here, a 29-year-old woman who presented with a right mandibular swelling after extraction of a mobile painful tooth turned out to have multiple myeloma. Current diagnostic criteria and management strategies of the disease are discussed.

Tap water as a wound cleansing agent in accident and emergency.

OBJECTIVE: To investigate the bacterial cleanliness of tap water in a large accident and emergency (A&E) department for its possible use in the cleansing and irrigation of open traumatic wounds. METHODS: Tap water samples were collected from different areas within the department and analysed on two separate occasions for coliforms, S aureus, clostridia, pseudomonas, and beta haemolytic streptococci. RESULTS: Pathogenic bacteria were not isolated from the tap water samples within the A&E department. CONCLUSIONS: Tap water of drinking quality can be used to irrigate open traumatic wounds.

Specificity of a novel red blood cell agglutination assay ('SimpliRED') for HIV-1/HIV-2 infection.

The specificity and ease of use of a novel red blood cell assay for detection of HIV-1/HIV-2 antibodies was evaluated on 125 blood donor samples in Nairobi. The specificity was estimated as > 99%. The assay correctly identified five positive samples in the population, and was easy and rapid to perform. The data confirm results obtained for the assay from other regions and suggest that the assay is suitable for detection of HIV-infected individuals by minimally equipped laboratories.

The changing profile of poisoning and its management.

To identify changes in treatment methods and types of drugs taken in overdoses over a 10-year period we conducted a retrospective study in the accident and emergency department of a large teaching hospital. The influence of a protocol to direct medical management was also studied. Results were compared with those of a 1984 survey at the same institution. 409 cases of accidental and deliberate poisoning were reviewed. In deliberate poisoning 52% of drugs taken were prescription drugs, 41.6% over-the-counter medications and the remaining 6.4% illicit drugs. Only 13% of patients had a stomach emptying procedure compared with 75.2% of patients in the previous survey. Charcoal was administered or offered in over 95% of cases. Medical management of overdoses in this centre changed drastically over 10 years. A department protocol had been adhered to in the great majority of cases, and we recommend that all accident and emergency departments as well as medical and paediatric teams establish similar protocols. Over-the-counter drugs are increasingly troublesome, especially paracetamol, which accounts for 28.8% of drugs taken in deliberate overdose.

The consistent association between Epstein-Barr virus and Hodgkin's disease in children in Kenya.

Recent studies have suggested that Epstein-Barr virus (EBV) may play a role in the etiology of Hodgkin's disease (HD). In a previous study, we used a latent membrane protein 1 (LMP1)-specific antibodies to examine archival material from 74 British children with HD and found 50% of cases to be positive. It is known that there are geographic and ethnic variations in the incidence of HD. We have investigated LMP1 status in formalin-fixed, paraffin wax-embedded lymph nodes with HD involvement from 53 children and 48 adults from Kenya using immunohistochemical staining. We also developed sensitive and specific in vitro gene amplification protocols for examining the EBV strain type in such material using several combinations of primers derived from the EBNA 2 and EBNA 3 coding regions. LMP1 positivity was present in 100% of the pediatric cases (two lymphocyte-predominant, 25 nodular sclerosis, 16 mixed cellularity, 5 lymphocyte depletion, and 5 unclassified) and in 66% of the adult cases (two of three lymphocyte-predominant, 26 of 39 nodular, sclerosis, two of two mixed cellularity, and two of four lymphocyte depletion). Tests to type the EBV strain were undertaken in 25 EBV-positive pediatric cases. A combination of type-specific polymerase chain reactions for EBNA 2 and EBNA 3C genes indicated that seven patients had type 1, eight had type 2, and 10 had dual infections with both types. Five cases with dual infections were further investigated using a sensitive in situ hybridization for the EBV-encoded, small nuclear nonpolyadenylated RNAs (EBERs). EBER transcripts were detected in Reed-Sternberg and Hodgkin cells and in occasional infiltrating lymphocytes. These observations indicate that in Kenya EBV is consistently associated with pediatric cases of HD, and that biopsies from a number of such cases appear to carry both type 1 and type 2 viral sequences.

The role of Epstein-Barr virus in Hodgkin's disease from different geographical areas.

Recent studies have suggested that Epstein-Barr virus (EBV) may play a role in the aetiology of Hodgkin's disease. To determine the role of EBV in childhood Hodgkin's disease in different geographical areas, immunohistochemical staining and in situ hybridisation were used to analyse latent membrane protein 1 (LMP 1) and small nuclear non-transcribed RNAs (EBER-1) respectively. Testing for EBV within the Reed-Sternberg and Hodgkin's cells was carried out in childhood Hodgkin's disease from 10 different countries. The proportion of LMP 1 positive cases varied significantly, being 50% of cases from the United Kingdom (38/75), South Africa (9/18), Egypt (7/14), and Jordan (8/16), 60% from the United Arab Emirates (6/10), 70% from Australia (11/16), 81% from Costa Rica (34/42), 88% from Iran (7/8), 90% from Greece (20/22), and 100% of the 56 cases from Kenya. A sensitive polymerase chain reaction based EBV strain typing technique was established using archival tissues. EBV strain type 1 was shown to be predominant in childhood Hodgkin's disease from the United Kingdom, South Africa, Australia, and Greece. Type 2 was predominant in Egypt. EBV strain types 1 and 2 were both detected in some cases of childhood Hodgkin's disease in the United Kingdom, Costa Rica, and Kenya. The high incidence of EBV and the presence especially in developing countries of dual infection with both strain types 1 and 2 may reflect socioeconomic conditions leading to malnutrition induced immunological impairment. The possibility of HIV infection also needs to be explored.

The prevalence of hepatitis C virus antibodies in renal patients, blood donors and patients with chronic liver disease in Kenya.

We tested serum samples from four categories of patients with nephrological problems (nephrotic syndrome, stable chronic renal failure, haemodialysis patients and renal transplant recipients), patients with chronic liver disease and volunteer blood donors for the presence of antibody to hepatitis C virus (HCV). Screening was done by second-generation enzyme linked immunosorbent assay (ELISA) and confirmation with second-generation recombinant immunoblot assay (RIBA). Of all the renal patients, only 6.3% of the transplant patients tested positive for anti-HCV, while in patients with chronic liver disease anti-HCV was detected in 2.6% of the patients with chronic hepatitis and in none with liver cirrhosis or hepatocellular carcinoma. This finding of low prevalence in these patient groups was not in keeping with findings in studies done elsewhere. Our anti-HCV prevalence of 0.9% in blood donors was comparable to that found in Europe, USA and Taiwan. We recommend that the low prevalence of anti-HCV in some of our high risk groups should not lead to complacence and hence further studies are necessary to evaluate the infectivity of anti-HCV positive patients and the potential for cross infection.

Mucocutaneous manifestations of lymphomas and leukemias in black Kenyan children.

BACKGROUND: Childhood leukemia and lymphoma are common problems in Tropical Africa, including Kenya. Studies done in Western populations indicate that 25-50% of patients with leukemia and lymphoma have specific or nonspecific cutaneous signs. In dark-skinned patients, reports of such mucocutaneous manifestations are scarce. The lesions in these patients may easily be missed, if not specifically looked for. METHOD: Eighty-six indigenous Kenyan children with a confirmed diagnosis of leukemia or lymphoma were specifically examined for any mucocutaneous manifestations at presentation, during their treatment, and during subsequent follow-up. Whenever possible, an attempt was made to determine the causes of these lesions. All patients were given standard therapy for the primary hematologic disorder. RESULTS: Two-thirds of the patients had mucocutaneous symptomatology at presentation: 17.4% had skin infiltration by the malignant cells. During therapy an even larger number developed nonspecific skin manifestations. Most of these were the result of myelosuppression, immunosuppression, or direct cytotoxic effects on tissues. CONCLUSIONS: Mucocutaneous manifestations in black children with leukemia and lymphoma are very common.

Disseminated histoplasmosis in a patient with acquired immunodeficiency syndrome (AIDS): a case report.

A 27 year old female with AIDS and disseminated histoplasmosis is presented. The clinical features include fever, weight loss, productive cough, splenomegaly and moderate pallor. The initial working diagnosis was pulmonary tuberculosis. The diagnosis of disseminated histoplasmosis was made terminally from bone marrow aspirate examination. Disseminated histoplasmosis with its varied clinical picture is likely to be missed in a patient with AIDS, and therefore a high index of suspicion is necessary for diagnosis.

PIP: A 27-year old female from Nairobi was admitted to the medical wards of the Kenyatta National Hospital in May 1991. She presented with a 4-week history of productive cough, fever, weight loss, and night sweats. She acknowledged a history of contact with a patient known to have pulmonary tuberculosis. She has never received a blood transfusion. She was single and para 3 + 0. Examination revealed a sick patient, with moderate pallor, fever of 38 degrees Celsius, and who was wasted with moderate dehydration and oral thrush. There was no finger clubbing, lymphadenopathy, or pedal edema. Chest examination revealed bilateral basal pneumonia. The spleen was palpable 4 cm below the costal margin; the liver was not enlarged. The rest of the examination was normal. On admission, complete blood count showed a haemoglobin of 5.4 g/dl, total white cells were 12.5 x 10-9/L, with 82% polymorphonuclear cells and 18% lymphocytes, erythrocyte sedimentation rate (ESR) was 85 mm/hour, and platelet count was normal. The anemia was normocytic, normochromic, and no malaria parasites were seen. Urea and electrolytes and liver function tests were normal. Sputum showed no acid fast bacilli on Ziel-Neelson Stain. HIV-1 antibodies were positive by enzyme-linked immunosorbent assay (ELISA) and Western blot. Bone marrow aspirate revealed a hypercellular marrow with reversed M:E ration, dyserythropoesis, reticulum cell hyperplasia, plentiful golden yellow pigment, and clumps of Histoplasma capsulatum. Chest X-ray showed bilateral basal pneumonia. She was treated with antibiotics and intravenous fluids, but she remained febrile, her general condition progressively deteriorated, and she died a week after admission. Treatment for histoplasmosis had not been commenced, and no postmortem examination was carried out.

Hodgkin's disease in Kenya.

A total of 136 patients with Hodgkin's disease (HD) seen at a national referral hospital in Kenya over a 15-year period were studied. The overall male-to-female ratio was 2.6:1, with 65% of patients younger than 20 years of age. The bimodal incidence of HD frequently seen in the developed nations was absent, and the histologic pattern of the disease was similar to that seen in other African countries. Fifty percent of patients had advanced-stage disease when first seen. Over two thirds of patients treated had a clinical remission, and the relapse rate in all stages was approximately 30%. Therapy-related complications were common, with frequent myelosuppression and younger patients more susceptible.

Childhood aplastic anaemia in Kenya.

Forty two children with aplastic anaemia were seen at Kenyatta National Hospital, Nairobi, over a period of 8 years (1980-1988). These have been analysed with respect to sex, age and area of geographical origin. The overall male:female ratio is 1:1 with a preponderance of Kikuyu patients. Repeated transfusions was the commonest presenting feature and rapid onset was associated with poor prognosis. Exposure to herbicides/pesticides and other agrochemicals is implicated in the aetiopathogenesis of childhood aplastic anaemia in Kenya.

Acute Lymphoblastic Leukaemia Presenting as Bone Marrow Necrosis.

A young boy presented with recurrent anaemia which was initially attributed to malaria. On physical examination he was found to have generalized lymphadenopathy and hepatospleno-megaly. Peripheral blood showed neutropenia and bone marrow aspirate revealed bone marrow necrosis. Typical lymphoblasts were not seen in the peripheral blood until after intitiation of cytotoxic therapy. Needle aspirate of an enlarged lymph node and trephine biopsy established the diagnosis of acute lymphoblastic leukaemia.