PROF AGGREY WASUNNA

Both secretin, and the single substance which possesses both cholecystokinin and pancreozymin activity, have been shown to inhibit gastric acid secretory responses. Since potentiation may occur between pairs of stimulants of gastric secretion, the effects of combining secretin and cholecystokinin/pancreozymin have been studied in Heidenhain pouches stimulated by continuous intravenous pentagastrin. Evidence suggesting potentiation between these two inhibitor agents is presented

In dogs with either vagally innervated or denervated pouches, the acid responses to a standard meal, a meal which bypassed the greater part of the small bowel, and a meal introduced directly into the small intestine were measured before and after exclusion of 75% of the small bowel.After intestinal exclusion an increase in acid secretion was found in the latter part of the acid response to the standard meal and the intestinal meal. No increase in acid secretion resulted from the meals which bypassed the small bowel. These findings suggest that an increase in stimulation from the remaining small intestine is responsible for the elevation in acid secretion following small bowel exclusion.

{ BACKGROUND: Meningitis occurs in up to one third of neonates with septicaemia. Diagnosis is difficult due to its non-specificity of signs and symptoms. While neonatal septicaemia is a common problem at Kenyatta National Hospital (KNH), there are no recent data on the incidence and clinical characteristics of neonatal meningitis at the hospital. OBJECTIVE: To evaluate the prevalence and the bacterial aetiology of meningitis in neonates at the Newborn Unit (NBU) of KNH. DESIGN: Descriptive cross-sectional study. SETTING: Newborn Unit of Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS AND METHODS: Lumbar punctures were performed on eighty-four neonates with suspected sepsis based on specified clinical criteria. Cases were defined as meningitis if the cerebrospinal fluid (CSF) was positive for bacteria by Gram stain, aerobic bacterial culture or latex particle agglutination assay. RESULTS: The prevalence of meningitis amongst cases of suspected sepsis was 17.9%. The male:female ratio was 1.5:1 mean birth weight 2116.7 grams (1682.2-2551.2) mean gestational age 35.7 weeks (32.6-38.8) and the mean postnatal age was 4.1 days (2.7-5.4) with none of the parameters being significantly different from those without meningitis. Feed intolerance and lethargy were the most common clinical features, present in 73.3% and 60% of patients with meningitis respectively. Neonates with meningitis had a higher mean CSF protein value (2.67 g/L vs 1.97 g/L

School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. paul.mcneill@unsw.edu.au

{ Serum C-reactive protein (CRP) concentration was measured by a new solid phase ligand-binding radiometric monoclonal antibody immunoassay in a prospective study of 193 consecutively born preterm infants. In 104 with no clinical or laboratory evidence of infection the median CRP in cord serum was 0.125 mg/l (range 0.011-6.0 mg/l), at 24 h it was 1 mg/l (0.016-7.0) and at 48 h 2 mg/l (0.400-8.0). The present highly sensitive assay has enabled these normal ranges to be defined for the first time, at levels below the threshold of non-labelled immunoassays and of all commercially available CRP assays. The values in cord serum were significantly lower than in normal healthy adults (median 0.8 mg/l, range 0.07-29 mg/l

KEMRI Centre for Geographic Medicine Research-Coast, P,O, Box 43640, Nairobi, Kenya. sekela_mwakyusa@yahoo.com BACKGROUND: The structured admission form is an apparently simple measure to improve data quality. Poor motivation, lack of supervision, lack of resources and other factors are conceivably major barriers to their successful use in a Kenyan public hospital setting. Here we have examined the feasibility and acceptability of a structured paediatric admission record (PAR) for district hospitals as a means of improving documentation of illness. METHODS: The PAR was primarily based on symptoms and signs included in the Integrated Management of Childhood Illness (IMCI) diagnostic algorithms. It was introduced with a three-hour training session, repeated subsequently for those absent, aiming for complete coverage of admitting clinical staff. Data from consecutive records before (n = 163) and from a 60% random sample of dates after intervention (n = 705) were then collected to evaluate record quality. The post-intervention period was further divided into four 2-month blocks by open, feedback meetings for hospital staff on the uptake and completeness of the PAR. RESULTS: The frequency of use of the PAR increased from 50% in the first 2 months to 84% in the final 2 months, although there was significant variation in use among clinicians. The quality of documentation also improved considerably over time. For example documentation of skin turgor in cases of diarrhoea improved from 2% pre-intervention to 83% in the final 2 months of observation. Even in the area of preventive care documentation of immunization status improved from 1% of children before intervention to 21% in the final 2 months. CONCLUSION: The PAR was well accepted by most clinicians and greatly improved documentation of features recommended by IMCI for identifying and classifying severity of common diseases. The PAR could provide a useful platform for implementing standard referral care treatment guidelines. PMID: 16857044 [PubMed] PMCID: PMC1555611

No abstract available.

One-hundred-forty-one Blacks (135 unrelated) from Kenya and Tanzania have been tissue-typed (HLA-A, B and C loci) as part of a study of host factors involved in Burkitt's lymphoma and naso-pharyngeal carcinoma. Evidence is presented for the existence in this population of several B15-related antigens which together occur with a relatively high frequency of 30% in unrelated individuals. It is likely that these variants may include the antigens SV and perhaps Bu recently defined with population frequencies of under 1% in Caucasians. In the absence of monospecific typing sera, identification of these variants may be helped by their apparently strong association with C-locus antigens in Blacks. Recognition of these B15 variants has been largely responsible for reducing the proportion of unidentified or "blank" B-locus antigens in this population to only 6%. These findings substantiate and amplify previous reports suspecting the presence of such antigens in Blacks, and should facilitate studies of possible associations of disease with HLA in these populations.

{ BACKGROUND: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya. METHODS/PRINCIPAL FINDINGS: We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group

OBJECTIVE: To compare the morbidity and outcome of low birthweight babies (birthweight < 2000 gm) of adolescent (age < 20 years) and older mothers. DESIGN: Cross sectional descriptive study. SETTING: The newborn Unit of the Kenyatta National Hospital. MAIN OUTCOME MEASURES: All babies weighing less than 2000 gm at birth whose mothers consented to the study had their gestational age verified using the Dubowitz scoring system. They were then followed up by daily clinical assessment until discharge, death or up to one month in the ward. The babies were divided into two groups according to their mother's age and then compared with respect to episodes of illness, duration of hospital stay, and overall outcome. RESULTS: One hundred and forty two babies were studied. Of these, 64 were born to adolescent mothers. Babies of the adolescent mothers tended to be more premature (p = 0.0174), be lower in weight (p = 0.0078), had more occurrences of respiratory distress and anaemia (probably reflecting their increased prematurity) and had frequent multiple morbidity events They also had longer hospital stay and they were more likely to die (57.7% compared to 42.3% of babies of older mothers). CONCLUSION: Low birthweight babies of the adolescent mothers were found to be more likely to have increased morbidity and adverse outcome compared to similar babies of older mothers.

PIP: A study of 125 children aged 0-6 months who were seen at Kenyatta National Hospital for acute diarrhea was conducted between 1982-1983 to determine the benefits of oral rehydration therapy (ORT) in treatment of diarrheal illness. At admission, specimens of stool, blood and urine were collected and examine for bacterial, parasitic, and viral agents (including malaria), serum electrolytes, urea, white cell counts and hematocrit. Children were started on oral rehydration solution (ORS) unless severly dehydrated, in which case intravenous therapy was initiated. 84% of the children were successfully treated with ORS alone regardless of etiological agent found; 15% required IV therapy initially, then were placed on ORS. Average hospital stay was 56.2 hours. Cost of treatment by ORT is less than 20% the cost of IV therapy. When investigators surveyed other health institutions, they found that ORT was used alone in less than 10% of all children seen with diarrhea. A side benefit of ORT is the utilization of mothers in preparation and administration of solution, reducing the demand on hospital staff. Since 20% of all pediatric admissions at Kenyatta are due to acute diarrheal disease, use of ORT would reduce costs tremendously. Initiation of ORT at home may prevent development of dehydration altogether.

{ BACKGROUND: Meningitis occurs in up to one third of neonates with septicaemia. Diagnosis is difficult due to its non-specificity of signs and symptoms. While neonatal septicaemia is a common problem at Kenyatta National Hospital (KNH), there are no recent data on the incidence and clinical characteristics of neonatal meningitis at the hospital. OBJECTIVE: To evaluate the prevalence and the bacterial aetiology of meningitis in neonates at the Newborn Unit (NBU) of KNH. DESIGN: Descriptive cross-sectional study. SETTING: Newborn Unit of Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS AND METHODS: Lumbar punctures were performed on eighty-four neonates with suspected sepsis based on specified clinical criteria. Cases were defined as meningitis if the cerebrospinal fluid (CSF) was positive for bacteria by Gram stain, aerobic bacterial culture or latex particle agglutination assay. RESULTS: The prevalence of meningitis amongst cases of suspected sepsis was 17.9%. The male:female ratio was 1.5:1 mean birth weight 2116.7 grams (1682.2-2551.2) mean gestational age 35.7 weeks (32.6-38.8) and the mean postnatal age was 4.1 days (2.7-5.4) with none of the parameters being significantly different from those without meningitis. Feed intolerance and lethargy were the most common clinical features, present in 73.3% and 60% of patients with meningitis respectively. Neonates with meningitis had a higher mean CSF protein value (2.67 g/L vs 1.97 g/L

Two major etiological agents, hepatitis B virus and aflatoxin B1, are considered to be involved in the induction of liver cancer in Africa. In order to elucidate any synergistic effect of these two agents we conducted a study in various parts of Kenya with different liver cancer incidence in order to establish the rate of exposure to aflatoxin and the prevalence of hepatitis infections. Of all tested individuals 12.6% were positive for aflatoxin exposure as indicated by the urinary excretion of aflatoxin B1-guanine. Assuming no annual and seasonal variation, a regional variation in the exposure was observed. The highest rate of aflatoxin exposure was found in the Western Highlands and Central Province. The incidence of hepatitis infection nationwide as measured by the presence of the surface antigens was 10.6%, but a wide regional variation was observed. A multiplicative and additive regression analysis to investigate if hepatitis and aflatoxin exposure had a synergetic effect in the induction of liver cancer was negative. However, a moderate degree of correlation between the exposure to aflatoxin and liver cancer was observed when the study was limited to certain ethnic groups. The study gives additional support to the hypothesis that aflatoxin is a human liver carcinogen.

n/a

One hundred and twenty five measurements of arterial oxygen saturation (Stcao2) obtained with a transcutaneous pulse oximeter were compared with direct arterial oxygen tension (Pao2) in 13 preterm infants with predominantly fetal haemoglobin. Stcao2 of 86-92% corresponded to Pao2 of 5-13 kPa. Stcao2 above 92%, however, was sometimes associated with Pao2 above 13 kPa.

KEMRI Centre for Geographic Medicine Research-Coast, P,O, Box 43640, Nairobi, Kenya. sekela_mwakyusa@yahoo.com BACKGROUND: The structured admission form is an apparently simple measure to improve data quality. Poor motivation, lack of supervision, lack of resources and other factors are conceivably major barriers to their successful use in a Kenyan public hospital setting. Here we have examined the feasibility and acceptability of a structured paediatric admission record (PAR) for district hospitals as a means of improving documentation of illness. METHODS: The PAR was primarily based on symptoms and signs included in the Integrated Management of Childhood Illness (IMCI) diagnostic algorithms. It was introduced with a three-hour training session, repeated subsequently for those absent, aiming for complete coverage of admitting clinical staff. Data from consecutive records before (n = 163) and from a 60% random sample of dates after intervention (n = 705) were then collected to evaluate record quality. The post-intervention period was further divided into four 2-month blocks by open, feedback meetings for hospital staff on the uptake and completeness of the PAR. RESULTS: The frequency of use of the PAR increased from 50% in the first 2 months to 84% in the final 2 months, although there was significant variation in use among clinicians. The quality of documentation also improved considerably over time. For example documentation of skin turgor in cases of diarrhoea improved from 2% pre-intervention to 83% in the final 2 months of observation. Even in the area of preventive care documentation of immunization status improved from 1% of children before intervention to 21% in the final 2 months. CONCLUSION: The PAR was well accepted by most clinicians and greatly improved documentation of features recommended by IMCI for identifying and classifying severity of common diseases. The PAR could provide a useful platform for implementing standard referral care treatment guidelines. PMID: 16857044 [PubMed] PMCID: PMC1555611

Department of Paediatrics, University of Nairobi. To determine whether the "Baby Cloche" heat shield improves temperature control in low birth-weight infants we compared serial temperatures in 11 preterm infants nursed with or without the Cloche. Mean birth weights were 1490 and 1510 gm, mean weights at time of study 1680 and 1710 gm and mean postnatal age 20 and 27 days for study and control infants respectively. Serial measurements of rectal, abdominal skin, dorsum of the foot, Cloche wall and room temperature were recorded once or twice daily for 2 to 5 days. Mean rectal temperatures increased with increasing age from 35.3 in the first week of life to 37.0 degrees C by the third week (P less than 0.001). In infants nursed under the Cloche who were over 2 weeks of age mean rectal, abdominal and foot temperatures were 0.5, 0.6 and 1.6 degrees C higher (P less than 0.001); in younger infants there was no significant difference in any of the temperatures. Our findings suggest that the "Baby Cloche" improves temperature control in preterm infants over 1600 gm who are more than 2 weeks of age. PMID: 1628548 [PubMed - indexed for MEDLINE]

A clinical, radiological, histological, and geographical study of carcinoma of the esophagus in Kenya is reported. It was found that this cancer is diagnosed more often in males than in females, with a ration of 8:1 (Kenya Cancer Registry). The most common age in males and females is 50 to 59 years. The regions of the esophagus most commonly involved are the middle and lower thirds, in almost equal proportions. An unexplained tendency for the tumor to be poorly differentiated towards the lower third is noted. In addition a review on the possible etiological factors is presented.

{ BACKGROUND: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya. METHODS/PRINCIPAL FINDINGS: We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group

OBJECTIVE: To determine the pattern of growth and development of institutionalised infants and to compare the outcome with that of infants living with their biological mothers. DESIGN: A cross-sectional survey. SETTING: Seven children's homes; Kenyatta National Hospital's New Born Unit and Well Baby Clinics in Nairobi, Kenya. PARTICIPANTS: Eighty-two abandoned babies who fulfilled the selection criteria were recruited and for each abandoned baby two mothered babies matched for age and sex were selected from the well baby clinics. MAIN OUTCOME MEASURES: Anthropometric measures of weight, length, head circumference and left mid arm circumference (LUMAC) were taken and the mean values and Z scores determined to demonstrate growth pattern and nutritional status of the babies. The Revised Denver Development Screening Test (RDDST) was used to assess the development pattern of infants. RESULTS: Seventy per cent of infants were below six months old and 73% were abandoned within the first week of life. Abandoned babies were significantly thinner with the mean LUMAC of 10.8 cm versus 12.3 cm (p = 0.02) Institutionalised babies were significantly wasted (p = 0.00001) and stunted (p = 0.00001). Abandoned babies were significantly delayed in development (p < 0.0001). In all the four sectors tested for, institutionalised babies showed significant delay, p < 0.0001 in each sector. CONCLUSION: This study demonstrates that infants under institutional care have poorer growth and development compared to mothered infants. PIP: This cross-sectional study examined the pattern of growth and development of infants in some of the baby institutions in Nairobi and compared the outcome with that of infants living with their biological mothers. The participating institutions included the Kenyatta National Hospital and 7 children's homes within the city. The study recruited 82 abandoned babies aged 1-18 months who had been abandoned for at least 2 weeks. Each abandoned baby was paired with 2 mothered babies matched for age and sex. Anthropometric measures of weight, length, head circumference, and left mid arm circumference (LUMAC) were taken. The mean values and Z scores were determined to assess growth pattern and nutritional status of the babies. The results showed that abandoned babies were significantly thinner, with a mean LUMAC of 10.8 cm vs. 12.3 cm. Moreover, abandoned babies were significantly wasted (p = 0.00001), stunted (p = 0.00001), and delayed in development (p 0.0001). These findings indicate that institutionalized infants have poorer growth and development compared to mothered infants.

Food samples collected in Murang'a district, Kenya are known to be contaminated with a mycotoxin, aflatoxin B1 (AFB), and a positive correlation exists between the dietary intake of AFB and the incidence of liver cancer. When urine samples collected in this district were analyzed for the presence of 2,3-dihydro-2-(7'-guanyl)-3-hydroxyaflatoxin B1 (AFB-GuaI) by h.p.l.c., 6 of 81 samples had a detectable level of a compound whose fluorescence spectrum was identical to chemically synthesized AFB-GuaI as confirmed by photoncounting fluorescence spectrophotometry. These results are an indication of interaction between the ultimate carcinogenic form of AFB and cellular nucleic acids in vivo and further support the hypothesis that AFB may play an important role in the etiology of human liver cancer.

OBJECTIVE: To compare some socio-demographic and obstetric factors between adolescent mothers (aged below 20 years) and older mothers of low birthweight (birthweight < 2000 gm) babies. DESIGN: Cross sectional descriptive study. SETTING: The Newborn Unit of the Kenyatta National Hospital. RESULTS: Sixty nine adolescent mothers and 73 older mothers were studied. Adolescent mothers were more likely to be unmarried (p = 0.0001) have less formal education (p < 0.0001) be unemployed and be primigravida (76.5% compared to 36% of older mothers). Although the obstetric factors of antenatal clinic attendance, premature rupture of the membranes, pre-eclamptic toxaemia, infections and interventronal delivery tended to be more frequent among the adolescent mothers, non of these differences were significant probably due to the small numbers of patients studied. CONCLUSION: This study does suggest mothers of very low birthweight babies tend to have unfavourable socio-demographic and obstetric factors like being single parents having less formal education, being unemployed and having obstetric risks for poor pregnancy outcome.

A possible role of aflatoxin B1 (AFB) in the etiology of human liver cancer has been suggested from several epidemiological studies. This has been based upon the association between consumption of AFB-contaminated food and the liver cancer incidence in different parts of the world. To further establish the role of AFB as a major factor, we initiated a pilot study in three different districts of Kenya to determine the number of individuals exposed to significant amounts of AFB as measured by the urinary excretion of 8,9-dihydro-8-(7-guanyl)-9-hydroxyaflatoxin B1 (AFB-Gua), an adduct formed between the ultimate carcinogenic form of AFB and nucleic acids. This product has previously been detected in urine from rats treated with AFB. Urine collected at the outpatient clinics at the district hospitals were concentrated on C18 Sep-Pak columns and analyzed by high-pressure liquid chromatography under two different chromatographic conditions. The chemical identity of the samples showing a positive response in both chromatographic systems was verified by synchronous scanning fluorescence spectrophotometry. The highest number of individuals with detectable urinary AFB-Gua lived in either Murang'a district or the neighboring Meru and Embu districts. In Murang'a district a rate of 12% was observed in the January-March period, while only 1 of 32 patients (3%) had a detectable exposure in July-August.(ABSTRACT TRUNCATED AT 250 WORDS)

{ BACKGROUND: Meningitis occurs in up to one third of neonates with septicaemia. Diagnosis is difficult due to its non-specificity of signs and symptoms. While neonatal septicaemia is a common problem at Kenyatta National Hospital (KNH), there are no recent data on the incidence and clinical characteristics of neonatal meningitis at the hospital. OBJECTIVE: To evaluate the prevalence and the bacterial aetiology of meningitis in neonates at the Newborn Unit (NBU) of KNH. DESIGN: Descriptive cross-sectional study. SETTING: Newborn Unit of Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS AND METHODS: Lumbar punctures were performed on eighty-four neonates with suspected sepsis based on specified clinical criteria. Cases were defined as meningitis if the cerebrospinal fluid (CSF) was positive for bacteria by Gram stain, aerobic bacterial culture or latex particle agglutination assay. RESULTS: The prevalence of meningitis amongst cases of suspected sepsis was 17.9%. The male:female ratio was 1.5:1 mean birth weight 2116.7 grams (1682.2-2551.2) mean gestational age 35.7 weeks (32.6-38.8) and the mean postnatal age was 4.1 days (2.7-5.4) with none of the parameters being significantly different from those without meningitis. Feed intolerance and lethargy were the most common clinical features, present in 73.3% and 60% of patients with meningitis respectively. Neonates with meningitis had a higher mean CSF protein value (2.67 g/L vs 1.97 g/L

We aimed to investigate provision of paediatric care in government district hospitals in Kenya. We surveyed 14 first-referral level hospitals from seven of Kenya's eight provinces and obtained data for workload, outcome of admission, infrastructure, and resources and the views of hospital staff and caretakers of admitted children. Paediatric admission rates varied almost ten-fold. Basic anti-infective drugs, clinical supplies, and laboratory tests were available in at least 12 hospitals, although these might be charged for on discharge. In at least 11 hospitals, antistaphylococcal drugs, appropriate treatment for malnutrition, newborn feeds, and measurement of bilirubin were rarely or never available. Staff highlighted infrastructure and human and consumable resources as problems. However, a strong sense of commitment, support for the work of the hospital, and a desire for improvement were expressed. Caretakers' views were generally positive, although dissatisfaction with the physical environment in which care took place was common. The capacity of the district hospital in Kenya needs strengthening by comprehensive policies that address real needs if current or new interventions and services at this level of care are to enhance child survival.

Two major etiological agents, hepatitis B virus and aflatoxin B1, are considered to be involved in the induction of liver cancer in Africa. In order to elucidate any synergistic effect of these two agents we conducted a study in various parts of Kenya with different liver cancer incidence in order to establish the rate of exposure to aflatoxin and the prevalence of hepatitis infections. Of all tested individuals 12.6% were positive for aflatoxin exposure as indicated by the urinary excretion of aflatoxin B1-guanine. Assuming no annual and seasonal variation, a regional variation in the exposure was observed. The highest rate of aflatoxin exposure was found in the Western Highlands and Central Province. The incidence of hepatitis infection nationwide as measured by the presence of the surface antigens was 10.6%, but a wide regional variation was observed. A multiplicative and additive regression analysis to investigate if hepatitis and aflatoxin exposure had a synergetic effect in the induction of liver cancer was negative. However, a moderate degree of correlation between the exposure to aflatoxin and liver cancer was observed when the study was limited to certain ethnic groups. The study gives additional support to the hypothesis that aflatoxin is a human liver carcinogen.

School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. paul.mcneill@unsw.edu.au

Department of Paediatrics, University of Nairobi. To determine whether the "Baby Cloche" heat shield improves temperature control in low birth-weight infants we compared serial temperatures in 11 preterm infants nursed with or without the Cloche. Mean birth weights were 1490 and 1510 gm, mean weights at time of study 1680 and 1710 gm and mean postnatal age 20 and 27 days for study and control infants respectively. Serial measurements of rectal, abdominal skin, dorsum of the foot, Cloche wall and room temperature were recorded once or twice daily for 2 to 5 days. Mean rectal temperatures increased with increasing age from 35.3 in the first week of life to 37.0 degrees C by the third week (P less than 0.001). In infants nursed under the Cloche who were over 2 weeks of age mean rectal, abdominal and foot temperatures were 0.5, 0.6 and 1.6 degrees C higher (P less than 0.001); in younger infants there was no significant difference in any of the temperatures. Our findings suggest that the "Baby Cloche" improves temperature control in preterm infants over 1600 gm who are more than 2 weeks of age. PMID: 1628548 [PubMed - indexed for MEDLINE]

Fresh blood lymphocytes from nine health donors have been compared with samples from the same donors, recovered after period of 2 to 21 months storage in liquid nitrogen, for the capacity to respond to a range of mitogens in vitro. A microculture assay was used, requireing aliquots of only 25,000 cells. The mean levels of 14C-thymidine uptake for fresh and frozen samples were closely comparable when the cells had been stimulated by PHA, Pokeweed or mitomycin-C-treated allogeneic lymphoblastoid cells. Lymphocytes from six East African donors, frozen by a very simple technique, were recovered after 3 or more years storage in liquid nitrogen. Five of the samples were in good condition as judged by cell viability and the capacity to form spontaneous 'E' rosettes with sheep erythrocytes. These five samples also responded extremely well to PHA, PWM and mitomycin-C-treated allogeneic lymphoblastoid cells using the microculture assay. This study extends the range of applications of cell banks in which small aliquots of blood lymphocytes are stored in liquid nitrogen for periods of several years.

Small hospitals sit at the apex of the pyramid of primary care in the health systems of many low-income countries. If the Millennium Development Goal for child survival is to be achieved, hospital care for referred severely ill children will need to be improved considerably in parallel with primary care in many countries. Yet little is known about how to achieve this. This article describes the evolution and final design of an intervention study that is attempting to improve hospital care for children in Kenyan district hospitals. It illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system, rather than an individual, level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question: does it work? Although there are increasing calls for more health systems research in low-income countries, the importance of strong, broadly based local partnerships and long-term commitment even to initiate projects is not always appreciated.

Microanalysis of subcellular organelle marker enzymes was applied to cryopreserved lymphocytes (obtained and processed in the field) from East African blacks with moderate to severe malnutrition and subject to locally endemic parasitic and infectious diseases. An initial study demonstrated that activities of these enzymes, with the partial exception of catalase, were stable to cryopreservation. Cryopreserved and thawed lymphocyte specimens (1 to 3 X 10(6) viable cells) from 26 Africans and 20 Caucasian controls were studied. There was a highly significant decrease in 5'nucleotidase activity in these African subjects. Activity of another plasma membrane enzyme, gamma-glutamyl transferase, and of marker enzymes for other intracellular organelles, was not significantly different between the two groups, indicating that the nucleotidase alteration is highly specific. 5'Nucleotidase activity in a group of 17 East African blacks of high socio-economic status lay between the values obtained in the other two groups and was not significantly different from either. Further studies on 5'nucleotidase showed no evidence that the enzyme is functionally different in Africans. The differences in activity of this enzyme in Africans may reflect the known immuno-suppressive effects of infectious disease and malnutrition or may have a genetic basis which may in turn be associated with the pathogenesis of secondary immunodeficiency.

OBJECTIVE: To compare the morbidity and outcome of low birthweight babies (birthweight < 2000 gm) of adolescent (age < 20 years) and older mothers. DESIGN: Cross sectional descriptive study. SETTING: The newborn Unit of the Kenyatta National Hospital. MAIN OUTCOME MEASURES: All babies weighing less than 2000 gm at birth whose mothers consented to the study had their gestational age verified using the Dubowitz scoring system. They were then followed up by daily clinical assessment until discharge, death or up to one month in the ward. The babies were divided into two groups according to their mother's age and then compared with respect to episodes of illness, duration of hospital stay, and overall outcome. RESULTS: One hundred and forty two babies were studied. Of these, 64 were born to adolescent mothers. Babies of the adolescent mothers tended to be more premature (p = 0.0174), be lower in weight (p = 0.0078), had more occurrences of respiratory distress and anaemia (probably reflecting their increased prematurity) and had frequent multiple morbidity events They also had longer hospital stay and they were more likely to die (57.7% compared to 42.3% of babies of older mothers). CONCLUSION: Low birthweight babies of the adolescent mothers were found to be more likely to have increased morbidity and adverse outcome compared to similar babies of older mothers.

PIP: A study of 125 children aged 0-6 months who were seen at Kenyatta National Hospital for acute diarrhea was conducted between 1982-1983 to determine the benefits of oral rehydration therapy (ORT) in treatment of diarrheal illness. At admission, specimens of stool, blood and urine were collected and examine for bacterial, parasitic, and viral agents (including malaria), serum electrolytes, urea, white cell counts and hematocrit. Children were started on oral rehydration solution (ORS) unless severly dehydrated, in which case intravenous therapy was initiated. 84% of the children were successfully treated with ORS alone regardless of etiological agent found; 15% required IV therapy initially, then were placed on ORS. Average hospital stay was 56.2 hours. Cost of treatment by ORT is less than 20% the cost of IV therapy. When investigators surveyed other health institutions, they found that ORT was used alone in less than 10% of all children seen with diarrhea. A side benefit of ORT is the utilization of mothers in preparation and administration of solution, reducing the demand on hospital staff. Since 20% of all pediatric admissions at Kenyatta are due to acute diarrheal disease, use of ORT would reduce costs tremendously. Initiation of ORT at home may prevent development of dehydration altogether.

{ BACKGROUND: Meningitis occurs in up to one third of neonates with septicaemia. Diagnosis is difficult due to its non-specificity of signs and symptoms. While neonatal septicaemia is a common problem at Kenyatta National Hospital (KNH), there are no recent data on the incidence and clinical characteristics of neonatal meningitis at the hospital. OBJECTIVE: To evaluate the prevalence and the bacterial aetiology of meningitis in neonates at the Newborn Unit (NBU) of KNH. DESIGN: Descriptive cross-sectional study. SETTING: Newborn Unit of Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS AND METHODS: Lumbar punctures were performed on eighty-four neonates with suspected sepsis based on specified clinical criteria. Cases were defined as meningitis if the cerebrospinal fluid (CSF) was positive for bacteria by Gram stain, aerobic bacterial culture or latex particle agglutination assay. RESULTS: The prevalence of meningitis amongst cases of suspected sepsis was 17.9%. The male:female ratio was 1.5:1 mean birth weight 2116.7 grams (1682.2-2551.2) mean gestational age 35.7 weeks (32.6-38.8) and the mean postnatal age was 4.1 days (2.7-5.4) with none of the parameters being significantly different from those without meningitis. Feed intolerance and lethargy were the most common clinical features, present in 73.3% and 60% of patients with meningitis respectively. Neonates with meningitis had a higher mean CSF protein value (2.67 g/L vs 1.97 g/L

KEMRI Centre for Geographic Medicine Research, PO Box 230, Kilifi, Kenya. menglish@wtnairobi.mimcom.net

BACKGROUND: The district hospital is considered essential for delivering basic, cost-effective health care to children in resource poor countries. We aimed to investigate the performance of these facilities in Kenya. METHODS: Government hospitals providing first referral level care were prospectively sampled from 13 Kenyan districts. Workload statistics and data documenting the management and care of admitted children were obtained by specially trained health workers. FINDINGS: Data from 14 hospitals were surveyed with routine statistics showing considerable variation in inpatient paediatric mortality (range 4-15%) and specific case fatality rates (eg, anaemia 3-46%). The value of these routine data is seriously undermined by missing data, apparent avoidance of a diagnosis of HIV/AIDS, and absence of standard definitions. Case management practices are often not in line with national or international guidelines. For malaria, signs defining severity such as the level of consciousness and degree of respiratory distress are often not documented (range per hospital 0-100% and 9-77%, respectively), loading doses of quinine are rarely given (3% of cases) and dose errors are not uncommon. Resource constraints such as a lack of nutritional supplements for malnourished children also restrict the provision of basic, effective care. INTERPRETATION: Even crude performance measures suggest there is a great need to improve care and data quality, and to identify and tackle key health system constraints at the first referral level in Kenya. Appropriate intervention might lead to more effective use of health workers' efforts in such hospitals.

PMID: 15194254 [PubMed - indexed for MEDLINE]

Two major etiological agents, hepatitis B virus and aflatoxin B1, are considered to be involved in the induction of liver cancer in Africa. In order to elucidate any synergistic effect of these two agents we conducted a study in various parts of Kenya with different liver cancer incidence in order to establish the rate of exposure to aflatoxin and the prevalence of hepatitis infections. Of all tested individuals 12.6% were positive for aflatoxin exposure as indicated by the urinary excretion of aflatoxin B1-guanine. Assuming no annual and seasonal variation, a regional variation in the exposure was observed. The highest rate of aflatoxin exposure was found in the Western Highlands and Central Province. The incidence of hepatitis infection nationwide as measured by the presence of the surface antigens was 10.6%, but a wide regional variation was observed. A multiplicative and additive regression analysis to investigate if hepatitis and aflatoxin exposure had a synergetic effect in the induction of liver cancer was negative. However, a moderate degree of correlation between the exposure to aflatoxin and liver cancer was observed when the study was limited to certain ethnic groups. The study gives additional support to the hypothesis that aflatoxin is a human liver carcinogen.

BACKGROUND: Reports of osteopaenia/rickets of prematurity are on the increase due to improved survival rates of low birthweight infants. OBJECTIVE: To establish the incidence of rickets of prematurity by the age of six months in premature infants born at Kenyatta National Hospital, Nairobi. DESIGN: Prospective cohort study. SETTING: Newborn unit and paediatric outpatient follow up clinic of Kenyatta National Hospital. SUBJECTS: Successive surviving infants of birthweight less than 2000 g residents in Nairobi. RESULTS: Incidence of rickets of prematurity by six months of age was 58.8%. Rickets appeared more commonly in male infants compared to female infants. CONCLUSION: Rickets of prematurity is a common problem in the premature infants seen at Kenyatta National Hospital. Routine vitamin D supplements to premature infants in adequate doses of at least 400iu per day should be adopted in our centre.

There is a marked shortage of surgical manpower all over Africa. General surgeons undertake a very wide range of surgical work because of the lack of specialists. Orthopaedic and general surgeons both care for accident injuries. Current training and recruitment programs are inadequate in correcting existing gross manpower deficiencies. The situation is further aggravated by a gross maldistribution of available manpower in favor of large urban centers. In many parts of rural Africa, minor surgical procedures are carried out by suitably trained, non-physician health workers, but facilities and resources for surgery outside urban centers are generally inadequate. The World Health Organization program on essential surgical and anesthetic procedures, which is currently under way in collaboration with the International Federation of Surgical Colleges, the World Federation of Societies of Anesthesiologists, and other professional bodies, should have a significant impact on these urgent needs for basic surgery in rural district hospitals

Developments in biogenetics, medical devices, information and communication technologies, and in environmental technologies will have a profound impact on health in the coming decades. However, there are major barriers to the appropriate and effective utilization of current and future technologies, particularly for developing countries. This paper intends to strike a balance between the exciting potential of technologies and the conditions that need to be fulfilled to ensure that technologies are utilized appropriately and effectively. It will emphasize the significance of knowledge associated with technologies, the importance of technology assessment and the need for a broad and comprehensive technology management policy.