DR. AWORI MARK NELSON

Since cardiac structuring dimensions inform surgical decisions making, Z-score systematic error impairs surgical decision making and confounds outcome measurement, hence a similar error may affect the Nakata index. In this study, PubMed was searched using the terms: “pulmonary,” “artery,” “size,” “Nakata,” “Fontan,” and “outcome”. Studies that did not describe the outcome of the Fontan procedure and the size of the branch pulmonary arteries were excluded. Outcome measures of interest, in relation to BPA size, included: Operative mortality, Fontan “take-down”, length of ICU stay, pleural effusions and functional capacity. The results revealed that of 116 papers retrieved, 9 were included representing 1,042 patients who underwent the Fontan procedure. Six out of 9 papers representing 645 (61.9%) patients reported that BPA size had no relationship with the outcome of the Fontan procedure; while 2 out of 9 papers representing 366 (35.1%) patients found that BPA size did affect the outcome. One paper representing 31 (3%) patients was unable to find any relationship. All the papers that concluded that there was no relationship labelled normal sized BPAs as small because of a systematic error introduced by the Nakata index. Papers that found a relationship did not use the Nakata index. Thus, Nakata index systematic error may impair surgical decision making and confound outcome measurement in Fontan surgery. In addition, continued use of the Fontan index may have similar implications for other congenital heart lesions.

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

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.

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.

OBJECTIVE: To determine the local aetiological spectrum of surgically relevant causes of abdominal pain. DESIGN: A prospective descriptive study was carried out. SETTING: Kenyatta National Hospital, Nairobi, Kenya during the month of October 2002. SUBJECTS: Patients aged 13 years and older presenting to the casualty department with abdominal pain were followed through the hospital system to determine whether they would undergo laparotomy and, in those cases who underwent laparotomy, to determine the nature of the pathology found at laparatomy. RESULTS: Abdominal pain was a presenting complaint in 1557 (16.7%) of patients presenting to the casualty department during the study period. Abdominal pain accounted for 17.9% (398 out of 2225 patients) of all admissions via the casualty department. Laparotomy was performed on 68 (4.4%) of patients who presented with abdominal pain to the casualty department. In female patients presenting with abdominal pain, the incidence of ectopic pregnancy and acute appendicitis was 65.3% and 16.3% respectively. The incidence of neoplasia found at laparatomy, for abdominal pain, on patients admitted to the general surgical ward was 3.0%. The incidence of neoplasia, as a cause of abdominal pain resulting in laparatomy was 3.3%. CONCLUSION: The results highlight the fact, with respects to abdominal pain, that there are significant differences between the disease patterns in different geographical locations. Assuming the converse could adversely affect the management of patients with abdominal pain locally.