RP-Department of Surgery & Orthopaedics
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Item Protocol: Identifying Policy, System, and Environment Change Interventions to Enhance Availability of Blood for Transfusion in Kenya, a Mixed Methods Study(BMC Health Services Research, 2023) Valencia, Alejandro Munoz; Aridi, Jackline O.; Barnes, Linda S.; Rudd, Kristina E.; Bidanda, Bopaya; Epuu, Tonny; Kamu, Robert; Kivuli, Tecla; Macleod, Jana; Makanga, Cindy M.; Makin, Jennifer; Mate, Muthoni; Muiru, Carolyne Njoki; Murithi, Gatwiri; Musa, Abdirahaman; Nyagol, Hellen; Ochieng, Kevin; Rajgopal, Jayant; Raykar, Nakul P.; Tian, Yiqi; Yazer, Mark H.; Zeng, Bo; Olayo, Bernard; Kumar, Pratap; Puyana, Juan CarlosBackground Safe blood is essential for the care of patients with life-threatening anemia and hemorrhage. Low blood donation rates, inefcient testing procedures, and other supply chain disruptions in blood administration afect patients in low-resource settings across Sub-Saharan countries, including Kenya. Most eforts to improve access to transfusion have been unidimensional, usually focusing on only point along the blood system continuum, and have excluded community stakeholders from early stages of intervention development. Context-appropriate interventions to improve the availability of safe blood at the point of use in low-resource settings are of paramount importance. Thus, this protocol proposes a multifaceted approach to characterize the Kenyan blood supply chain through quantitative and qualitative analyses as well as an industrial engineering approach. Methods This study will use a mixed-methods approach in addition to engineering process mapping, modeling and simulation of blood availability in Kenya. It will be guided by a multidimensional three-by-three-by-three matrix: three socioeconomic settings, three components of the blood system continuum, and three levels of urgency of blood transfusion. Qualitative data collection includes one-on-one interviews and focus group discussions with stakeholders across the continuum to characterize ground-level defcits and potential policy, systems, and envi‑ ronment (PSE) interventions. Prospectively-collected quantitative data will be used to estimate blood collection and transfusion of blood. We will create a process map of the blood system continuum to model the response to PSE changes proposed by stakeholders. Lastly, we will identify those PSE changes that may have the greatest impact on blood transfusion availability, accounting for diferences across socioeconomic settings and levels of urgency. Discussion Identifying and prioritizing community-driven interventions to improve blood supply in low-resource settings are of utmost importance. Varied constraints in blood collection, processing, delivery, and use make each socioeconomic setting unique. Using a multifaceted approach to understand the Kenyan blood supply and model the response to stakeholder-proposed PSE changes may lead to identifcation of contextually appropriate interven‑ tion targets to meet the transfusion needs of the population.Item Case Report: Chiari Zero Malformation(2023) Njau, Mwangi Ken; Nyangau, Nyaoncha Andrew; Arnold, Adili WobenjoIntroduction: Chiari zero, initially dubbed syringohydromyelia without hindbrain herniation, is a rare subset of Chiari malformations. The clinical presentation is usually due to syringohydromyelia. The mode of management is foramen magnum decompression. We report a case of Chiari 0 with multiseptated/multiloculated syringohydromyelia and review the literature. Case report: We presented a 41-year-old man with an 8-year history of progressive numbness. A neurological exam revealed left-sided upper-limb hypopselaphesia, diminished algesthesia, and temperature sensation in the left upper limb and trunk. MRI noted cervicothoracic syringohydromyelia with tonsillar herniation. We performed foramen magnum decompression with duraplasty. His syringomyelia reduced significantly, and his neurological status improved during the three-month follow-up. Conclusion: Chiari 0 is a rare entity thought to occur due to altered dynamics in CSF flow at the craniovertebral junction with resultant syringohydromyelia without tonsillar herniation. Foramen magnum decompression with duraplasty remains the most widely accepted surgical interventionItem Epidemiology of Acute Intestinal Obstruction in Uasin Gishu County, Kenya(Kenyatta University, 2017) Jumbi, G.; Tenge, R. K.; Khwa-Otsyula, B. O.; Menya, D.; Bwombengi, S. O.; Ombito, B. R.Background: Acute Intestinal Obstruction (AIO) is a common life threatening emergency in all general hospitals all over the world. This study provides a population based incidence of acute intestinal obstruction derived from hospital data within a period of seven years preceding the year of the study (2008/9). Inpatient records can provide a fairly accurate data on the incidence of acute intestinal obstruction since almost all the cases are admitted in hospitals. Objectives: This study aims at determining the incidence and other epidemiological characteristics of AIO in Uasin Gishu County based on the hospital records and the national population census. Methods: The study was conducted in twelve hospitals (six within Uasin Gishu County) and six from the surrounding counties. Patient records for seven years preceding the period of study (2008) were retrieved and demographic information of the disease and treatment outcome (mortality) were analyzed against the projected population for the seven year period covered by the study (2001-2007). The population projections (the denominators) were based on Kenya population census and housing survey, 1999. Results: There were 444 cases of AIO from Uasin Gishu County during the seven year period of the study (2001- 2007). There were 319 males (71.8%) and 125 females (28.1%) (male/female ratio =2.6/1). The mean age was 31.4 years and the median age was 29 years. The population of Uasin Gishu County (1999 census) on which the population growth projections was based was 622,705. Mean annual incidence for the seven year period was 8.8 per 100,000 persons and this was significantly related to age and gender (p-values = 0.0001). Recovery (survival) rate was 93.5% and mortality (case fatality) rate was 6.5%. Mortality rate was not significantly related to age and gender (p-value>0.05). Conclusion: The observed annual incidence of acute intestinal obstruction in Uasin Gishu County was very low compared to available global data. Our findings could be a pointer to the general burden of AIO in Kenya (given the similarity of Uasin Gishu County and rest of the country in relation to demography, infrastructure and the state of health care services). The incidence increased exponentially with age. A prospective population based study on incidence could shed more light and confirm the low incidence found in this study.Item Barriers to Availability of Surgical Equipment in Kenya: A Surgical Equipment Journey Approach(Global Clinical Engineering, 2019) Oosting, Roos; Wauben, Linda; Mwaura, Salome; Madete, June; Groen, Reinou; Dankelman, JennyBackground & Objective: The need for surgery is currently not met in Sub-Saharan Africa, requiring both extra workforce and surgical equipment. Currently, there is a gap in the availability of surgical equipment which, among others, limits the provision of safe surgery. To design strategies to increase availability, the use of surgical equipment in this context needs to be understood. This study aims to: 1) identify the different phases surgical equipment goes through during its lifespan (i.e. the surgical equipment journey) in Kenya, and to 2) identify barriers that are perceived by biomedical equipment technicians (BMETs). Material & Methods: Seven semi-structured in-depth interview sessions were conducted with a total of 17 BMETs working in Kenya. Participants worked in six different hospitals (four public, one private and one mission). Interviews were conducted between December 2016 and December 2018. Participants were asked to describe or draw the surgical equipment journey and describe the perceived barriers during this journey. Results: The surgical equipment journey consists of three phases: procurement, usage, and disposal. Stakeholders involved in the surgical equipment journey are users, BMETs, procurement officers, local distributors and in case of donations, donation agencies. Bureaucracy during procurement, difficulties to obtain consumables and spare parts (especially for donated equipment), cleaning with heavy chemicals, and usage in challenging environments were identified as barriers during the surgical equipment journey. Conclusion: Sustainable interventions at multiple organisational levels are required to optimize the surgical equipment journey in hospitals in Kenya. Different strategies that can be applied in parallel to increase availability of surgical equipment in Kenya were identified by the participants in this study: policies on donations, procurement of durable equipment, more well-trained BMETs and university-trained biomedical engineers, and designs and business models that fit the local use in Kenya and presumably other countries in Sub-Saharan Africa.Item Proximal Femur Geometry in the Adult Kenyan Femur and Its Implications in Orthopaedic Surgery(African Journals Online, 2017) Lakati, K. C.; Ndeleva, B. M.; Mouti, N.; Kibet, J.Background: Numerous orthopaedic procedures are carried out on the proximal femur. For optimal hip function, these procedures must restore the anatomy of the proximal femur to as near normal as possible. There are currently no local studies that have described in detail the normal anatomy of the proximal femur and its implications in operations on the proximal femur. Objective: The aim of this study was to determine the neck-shaft angle, femoral neck anteversion angle, femoral neck width and femoral head diameter in adult femora, compare the results with other studied populations and examine the implications of the same in operations on the proximal femur. Methods: Femoral neck anteversion angle and the neck-shaft angle were determined from digital photographs of 70 cadaveric femora using an open-source image analysis software, ImageJ®(National Institutes of Health, Bethesda, Maryland). Femoral neck width and femoral head diameter were determined by measurement using a digital vernier caliper. The dimensions of available implants were searched from local suppliers of the implants. Results: Mean femoral neck-shaft angle was found to be 129.21º, while the mean femoral neck anteversion angle was found to be 23.06º. Mean neck-shaft angle was found to be 128.67º on the left while on the right side, it was 129.03º. This difference was not statistically significant. Mean femoral neck anteversion angle was found to be 23.97º on the left side, and 23.03º on the right side, but this difference was not statistically significant. Mean femoral neck width was found to be 29.36mm, with mean width of the left side being 28.67mm and that of the right being 29.36mm. The difference was not statistically significant. Mean femoral head diameter was 42.6mm, with mean diameter of the left side being 41.2mm and that of the right side being 42.6mm. The difference was not statistically significant. Conclusion: The current study has shown that the femoral neck-shaft and anteversion angles in the Kenyan femora vary from those of other populations. The available implants have angles which may not be suitable for a significant proportion of the local population. It would be prudent to avail a range of implants with different angles to improve the choices available to the surgeon when faced with a patient who requires an operation on the proximal femur.Item Urolithiasis in Nairobi, Kenya.(Kenya Medical Association, 2010) Ngugi, P. M.; Magoha, G. A.; Kiptoon, D.Background: Urolithiasis is an emerging problem in Kenya previously thought to be very rare and in which the use of modern methods of treatment has not been widely practiced Objective: To review the presentation and management of patients presenting with urolithiasis in Nairobi, Kenya Design: A retrospective study Setting: The Nairobi hospital and Upper Hill Medical Centre a day care facility next to the Nairobi hospital Subjects: One hundred and twenty five males and fifty three females aged 9 to 75 years Results: One hundred and seventy eight patients were treated for urolithiasis over a five-and- half year period. Their mean age was 44.8 years, and the median was 45 years The 178 patients required 262 procedures to achieve stone clearance. One hundred and two patients had ESWL, with an overall stone clearance rate of 95%. Twentythree patients had PCNL; 18 as the first procedure and 5 after failed ESWL. Fifty-one patients had ureteroscopic Management: Fourty seven had laser or pneumatic lithotripsy while four had stone removal by Dormia basket. Seven patients had bladder calculi managed by either cystolitholapaxy or forceps retrieval. Conclusions: This study demonstrates a higher annual incidence of urolithiasis in Nairobi than earlier literature. Study demonstrates that ESWL and ureteroscopic methods are highly effective in the treatment of renal and ureteral calculi as day care procedures.Item OSCEs for Undergraduate Clinical Examination in Orthopaedics: Inter-Examiner Variability(AJOL, 2016) Ndeleva, B.M.Background: The traditional clinical examination has fallen into disfavour on account of considerable inter-examiner variability. The OSCE is gaining popularity as it is perceived to be less prone to this. Objective: To establish whether inter-examiner variability is still a significant factor for the undergraduate orthopaedic clinical examination in our institution. Method: Thirty three final year students were randomly divided into two groups of 17 and 16 students. Two standardized OSCE questions were administered to each student by four examiners with each group being examined by one lecturer for each of the questions. For the first question, students in Group 1 were examined by Examiner A while those in Group 2 were examined by Examiner B. For the second question, students in Group 1 were examined by Examiner C while those in Group 2 were examined by Examiner D. The scores for each student were tabulated and the range, mean, and pass rate determined for each of the examiners. The Student’s t-test was calculated to determine if there was statistically significant interexaminer variability. Results: For Question 1, the mean score for students examined by Examiner A (Group 1) was 7.47 marks while that for Examiner B (Group 2) was 5.59 marks. The p-value was 0.01367 (95% confidence interval). For Question 2, the mean score for students examined by Examiner C (Group 1) was 7.32 marks while that for Examiner D (Group 2) was 8.625. The p-value was 0.001148 (95% confidence interval). Conclusion: There was statistically significant inter-examiner variability. We recommend that for all OSCE exams, examiners be paired with a deliberate attempt to pair a “Hawk” with a “Dove”. Statistical correction of biases is also recommendedItem The Anterior Curve of the Adult Femur in a Kenyan Population and its Mismatch with Available Intramedullary Nails(AJOL, 2016) Lakati, K.C.; Ndeleva, B.M.Background: There are currently no studies which have documented the anterior femoral curvature in Kenya or elsewhere in Africa, and compared it to the curvature of the available intramedullary nails. Objective: To determine the anterior femoral curvature in cadaveric femora and to compare this with the curvatures of locally available femoral intramedullary nails. Methods: We determined the radii of 66 cadaveric femora by the method described by Karakas and Harma. The radii of locally available femoral intramedullary nails were also obtained from the respective product monographs. Results: We found that the radius of the curvature ranged from 52.02cm to 165.82cm with a mean of 96.4cm and standard deviation of 25.61cm. The radii of locally available intra-medullary nails ranged from 127cm to 200cm. Conclusion: The radius of curvature of the adult femora in Kenyans is less than that of other populations. There was a large mismatch between the available intramedullary nails and the femoral curvature. Further study of the complications resulting from this mismatch and a review of the design of the nails for local use is recommended.Item Operative Exposure of a Surgical Trainee at a Tertiary Hospital in Kenya(Hindawi Publishing Corporation, 2015) Ojuka, Daniel Kinyuru; Macleod, Jana; Nyabuto, Catherine KwambokaBackground. Psychomotor domain training requires repetitive exposure in order to develop proficiency in skills. This depends on many training factors in any training institution. Objective.This study sought to look at the operative exposure of surgical trainees in a tertiary hospital in a developing country. Design and Setting.This was a six-month retrospective study performed in one surgical firm at Kenyatta National Hospital. Patients and Methods.The files of all patients admitted to the unit at that time were retrieved. Thedemographics, diagnosis at admission, need for surgery, and cadre of operating surgeon among others were recorded. Scientific Package for Social Sciences (SPSS) version 17.0 was used for data entry and analysis. Results.The study cohort was 402 patients of the 757 patients admitted in the study period.The average age was 36.7 years, a female tomale ratio of 1 : 2.5.Themajority (69.7%) of patients required surgery. Trauma was the most common reason for admission (44.5%). Year 2 residents received the most clinical exposure. Consultant was available in only 34.5% of the cases. Conclusion. The junior residents performed the vast majority of procedures with an unsatisfactory amount of supervision from the senior residents and facultyItem Hearing Disorders in HIV Positive Adult Patients(East and Central African Journal of Surgery, 2010) Ongulo, B. A.; Oburra, H. O.Background: This study was aimed at determining the prevalence and type of hearing disorders in HIV positive patients and any correlationship with the CD4 counts/stage of HIV/AIDS in patients attending the comprehensive care clinic (CCC). Methods: Case control study of 194 HIV positive patients attending CCC recruited into the study after informed consent. A thorough clinical examination and otoscopy done followed by tuning fork tests, Pure Tone Audiometry and tympanometric tests. This was compared with 124HIV negative subjects matched for age and sex who were recruited from the voluntary counseling and testing centre. The world health organization staging of the HIV/AIDS disease and the CD4 positive lymphocyte cell count were carried out and correlated with any hearing disorder. Results were analyzed using statistical package for social sciences version 10.0. Results: Hearing loss (HL) was present in 33.5% of HIV positive compared to 8.1% in negative subjects. No gender bias in HL but HL worsened with advancement of age. SNHL was the most common and the higher frequencies were the most affected. Low CD4 cell count and advanced HIV disease were associated with increased chance of having a hearing loss. Conclusion: Hearing loss is more prevalent in HIV positive individuals than negative normal subjects and tends to worsen with the advancement of the HIV disease. This may negatively impact on the overall care and standard of living of HIV positive patients, hence otological care should be part of the comprehensive care.Item Hearing disorders in HIV positive adult patients not on anti-retroviral drugs at Kenyatta National Hospital(East African Medical Journal, 2010-09) Ongulo, B. A.; Oburra, H. O.Objectives: To determine the prevalence and type of hearing disorders in HIV positive patients not on anti - retroviral drugs (ARVs) and correlate this with the world health Organization (WHO) stage of HIV disease and CD4 positive cell counts. Design: Case control study. Setting: comprehensive care clinic (CCC) and voluntary counseling and testing centre at Kenyatta National Hospital. Subjects: One hundread and ninety four HIV positive patients attending CCC and 124 HIV negative subjects recruited from voluntary counseling and testing (VCT) centre. Results: Hearing loss (HL) was present in 33.5% of HIV positive compared to 8.1% in negative subjects. No gender bias in HL Sensorineural hearing loss (SNHL) was the most common and the frequencies most ‘affected were four and eight kHz Conclusion: Hearing loss is more prevalent in HIV positive individuals not on anti - retroviral drugs than negative normal subjects. Low CD4 cell count and advanced HIV diseases were associated with increased chance of having a hearing loss. Otological care should be part of the comprehensive care of HIV positive patients.Item The pattern of hearing disorders in HIV positive patients on antiretroviral drugs at Kenyatta national hospital(East African Medical Journal, 2010-10) Makau, S. M.; Ongulo, B. A; Mugwe, P.Objectives: To determine if patients on Anti - retroviral drugs (ARVs) develop hearing impairment. Design: The comprehensive care clinic (CCC), Kenyatta National Hospital (KNH), Nairobi. Setting : Case controlled study. Subjects: Two hundred and seventy one human immunodeficiency virus (HIV) positive patients on ARVs were matched for age and sex with 273 HIV positive patients who were not on ARVs. Results: Thirty four percent of HIV positive patients not on ARVs had a hearing loss compared to only 28% in patients who were on ARVs. sensorineural hearing loss was the most frequent hearing disorder in both groups. Majority of the patients had mild hearing loss and the higher frequencies were the most affected. There was a notable worsening of hearing loss with increase in age, but this was not statistically significant. It was noted that HIV positive patients hearing level worsened on starting ARVs but this improved after six months of ARV treatment. Conclusion: Prolonged usage of ARVs is not associated with decreased hearing function. The most common hearing loss found in patients on ARVs is sensorineural hearing loss (SNHL).Item Injury Pattern among Non-fatal Road Traffic Crash Victims(East African Orthopaedic Journal, 2007) Kinuthia, GichuhiObjective: To study and analyse the pattern of injuries among non-fatal road traffic crash victims. Design: Retrospective analytical study. Setting: Kenyatta National Hospital, Nairobi over a six-month period from February to July 2004. Subjects: Road traffic crashes victims treated at Kenyatta National Hospital, Nairobi during the period under study. Results: One thousand four hundred and twenty four victims of road traffic crashes were treated over a sixmonth period. The male: female ratio was 3:1 and the pedestrians were the majority (69.7%). The commonest injuries were fractures (69.0%) and the tibia/fibula being the most fractured bones (30.3%). Age group 15-44 years was the most affected (81.9%). There was one incidence of a ruptured eye in a passenger. Conclusion: Road traffic injuries are a major cause of death and disability globally with disproportionate number occurring in the developing countries. The most affected age group 15-44 years lead to double tragedy to these countries with loss of productive man-hours and expenditure incurred to treat them.