QUALITY OF ANTENATAL CARE SERVICES AND PREGNANCY OUTCOMES AMONG PATIENTS WITH PRE-ECLAMPSIA WITH SEVERE FEATURES MANAGED AT KENYATTA NATIONAL HOSPITAL Introduction. Hypertensive disorders in pregnancy are the second most common cause of maternal mortality after obstetric hemorrhage and occur in 6-8% of all pregnancies Pre-eclampsia with severe features (PES) still remains a major medical and public health concern. High quality of antenatal care (ANC) is associated with improved maternal, fetal and neonatal outcomes. Globally although 86% of pregnant women access ANC with skilled health personnel at least once, only 3 in 5 (62%) receive ≥ 4 ANC visits (UNICEF, 2016). In Kenya, 60% of pregnant women had ≥ 4 ANC visits (KDHS 2014) Objective: The primary objectives were to determine the association between the quality of ANC services, pregnancy outcomes, the types of health facilities and the patients’ perception of ANC services among patients with PES managed at Kenyatta National Hospital. Methodology This was a descriptive cross-sectional study in which postpartum patients who were diagnosed with PES at a gestation period of 28 weeks or higher and who had delivered within the first 72 hrs were consecutively sampled. The study was conducted at the Post Natal Wards (GFA, GFB, 1A) of Kenyatta National Hospital. Quality of care was defined as presence of all parameters of the 2016 ANC World Health Organization (WHO) recommendations and Ministry of Health guidelines which were; appropriate ANC visits by gestation, prescription of prenatal vitamins, a complete antenatal profile (HIV/VDRL/HB/Urinalysis/Blood Group/Blood sugar/), discussion of a delivery plan, weight measurement, counseling on fetal movements, assessment of uterine fundal height and fetal heart rate, nutritional counseling and information on progress of antecedent pregnancy. Hypertension related parameters that were assessed during ANC included: blood pressure, administration of antihypertensive drugs, counseling on danger signs, and administration of MgSO4. These parameters were assessed using the patients file, ANC booklet, and interviewer questionnaires. Pregnancy outcomes were adverse or good maternal, fetal and neonatal outcomes. Data was entered into and analyzed using of SPSS® version 21. Categorical data was analyzed and presented as frequencies and proportions; continuous data was summarized and presented as means and standard deviations and compared using the chi-square test. Continuous variables were calculated using mean and SD or median and inter-quartile range and compared using Independent t- test. Chi square test was used to assess factors associated with adverse outcomes. Results: Between April and July 2019, 240 postpartum women with PES were screened and 161 (67%) who were eligible enrolled. About one third (n=56, 35%) of study participants received good quality of ANC. The most performed general ANC parameter was prescription of prenatal vitamins (70.2%) while the least performed was discussion of a delivery plan during ANC (55.3%). The most performed hypertension related ANC parameter was weight measurement during ANC (68.3%) while the least was administration of MgSO4(38.5%) There were more adverse maternal and neonatal xvi outcomes in women who had poor (61%) compared to those who had good (31%) quality of ANC, however this was not statistically significant (p=0.085). Majority (61%) of patients who had poor quality of care, received ANC from government health facilities. Patients who received poor quality of ANC ranked their care at 75% compared to those who received good quality ANC who ranked their care at 85% Conclusion: Overall poor quality of ANC services was offered to patients with PES. Poor quality of ANC services was associated with adverse outcomes (maternal/fetal/neonatal). Patients with PES were more likely to receive poor quality of ANC services in a government facility as compared to a non-government facility. There was no difference between perceived and received quality of care. Recommendation: Antenatal clinics especially those at government facilities should improve the quality of care overall and for patients with preeclampsia. Patients with PES who attend ANC should be given prenatal vitamins, have a complete antenatal profile, be counseled on fetal movements, undergo fetal surveillance (detection of fetal heart), be informed on the progress of their ongoing pregnancy, have nutritional counseling and have discussed and agreed on a delivery plan. Under hypertension related parameters all patients with PES should have their blood pressures monitored, be given the necessary antihypertensives, be counseled on danger signs in pregnancy and be given MgSO4. ANC clients should be educated and encouraged to demand better quality of ANC services offered to them by healthcare workers.

Background- Decompression Sickness is the greatest danger to the health and wellbeing of diving fishermen, potentially rendering them permanently disabled or dead. Published prevalence of decompression sickness in professional and military divers stand at 3.4% and 2.9% respectively. Artisanal diving fishermen suffer disproportionately more, with prevalence ranging from 20 to 94%. There is paucity of data on the prevalence of decompression sickness in Kenya, on knowledge, attitude, and practices of diving fishermen in Kenya. Study Design- A cross sectional study of a fishing community in Vanga, Kwale County was undertaken from June 2019. Data collection was conducted between July 7th and August 30th, 2020. Methods- Eligible study subjects were identified from the Beach Management Unit register and screened by administration of an adapted Kenya Navy survey tool. A total of 246 randomly sampled diving fishermen were included in the study. Anonymised sociodemographic data was collected, in addition to data on predictor variables of decompression sickness- knowledge, attitudes and practices of diving fishermen. Categorical data analysis was used. R statistical software was used for data analysis and visualisation. Results- All study participants (N=246) were male, the median chronological age being 36, range from 19 to 76 years. Nearly all the study participants (99.2%, n=244) had either no formal education or incomplete primary education. Apprenticeship was the main method knowledge was imparted to majority (66.3%, n=163) of diving fishermen. Significant associations between knowledge and decompression sickness, and attitude of diving fishermen and decompression sickness were found. The prevalence of decompression sickness in this community was 28%. Lack of a local health care worker and distance to Kenya Navy recompression chamber were found to be barriers to healthcare access. Conclusion- This study gives credence to the idea that diving accidents are preventable through training and establishing of standards of safe diving practices. Recommendation- Continuous skills upgrade with a recertification system developed by Kwale County with assistance from Kenya Navy to address dangerous diving practices.

Background: Road traffic crash injuries constitute a major public health burden and has led to an increase in morbidity, disability and mortality for the victims. Motorcycle crashes (MCC) contribute a large proportion of road traffic crashes (RTC) in Kenya. Use of motorcycles as a means of transport has increased explosively in the last decade due to their affordability and convenience. Road traffic crashes due to MCC have also concomitantly increased, with an increased burden in trauma management at hospitals and the health care system in Kenya as a whole. The injuries include musculoskeletal trauma which result in debilitating and life threating injuries to the victims. MCC-related musculoskeletal injury distribution, fracture patterns, severity as well as mechanisms of injury are not well described in Kenya and local studies describing the injuries are scarce. Study objective: To determine the distribution, patterns and severity of musculoskeletal injuries among motorcycle crash victims at Kenyatta National Hospital. Study design and setting: Descriptive prospective cross-sectional study at Kenyatta National Hospital. Study population: All motorcycle riders, pillion passengers and pedestrians involved in motorcycle crashes presenting at KNH A&E Department, admitted in Orthopaedic wards and ICU with musculoskeletal injuries between April and June 2021. Methods: One hundred and twenty six consecutive patients with motorcycle crash-related musculoskeletal injuries were prospectively studied. Data were obtained by interviews, physical and radiological examination and recorded in a pre-designed questionnaire. The data were stratified and analyzed on age, sex, anatomical fracture distribution, mechanism of injury, pattern and severity of fractures classified under AO/OTA classification and Gustilo-Anderson open fracture classification, associated injuries and type of protective gear used by the operators and the pillion passengers. Data analysis was done using Statistical Package for Social Sciences (SPSS®).

Introduction: Major cause of cause of death globally in children below the age of 5 years is attributed to prematurity. Intrauterine infection during pregnancy contributes significantly to preterm labor, PPROM and finally preterm birth. Approximately 40% cases of spontaneous preterm labor and birth are attributed to infections. The bacteria infecting the placental bed thus have the potential of causing adverse pregnancy outcomes like preterm premature rupture of membranes, chorioamnionitis, preterm labor and birth with resultant neonatal morbidity and mortality. Study Objective: To determine the prevalence of bacterial infections at the placental bed in patients with preterm births at KNH through placental bed bacterial culture and histopathology. Methodology: It was a descriptive cross-sectional study, that involved 116 pregnant women who presented for delivery between 28 and 37weeks‟ gestation at KNH obstetric unit. Informed consent was obtained. Pretested questionnaire was used to collect demographic and obstetric data. Immediately upon delivery, the placenta was placed in a sterilized container and refrigerated at a temperature of 2-8 0C at KNH Morgue. Using CHAMPS protocol for minimally invasive tissue sampling (MITS) Standard Operating Procedure (SOP) protocol v1.1 November 2017, placental cuts were made within 24 hours of specimen collection and submitted to microbiology laboratory for culture and sensitivity analysis. The rest of the placenta was fixed in 10% formalin, standard cuts made into cassettes and submitted to histology laboratory where they were processed into slides. Histological diagnosis was then made using Amsterdam Criteria. Results: From a sample of 116 placentas, the prevalence of placental bed bacterial infection was found to be 47.4%. The most commonly isolated microbes include E.coli(27.3%), Staphylococcus haemolyticus(7.3%),Klebsiella pneumonia(10.9%), Enterococcus faecalis(9.1%) and Acinetobacter baumanni(7.3%). Nitrofurantoin and ciprofloxacin were the most sensitive antibiotics. Histological chorioamnionitis was present in 40.5% of placentas. However, it was found in 40% of placentas that also had positive bacteria culture compared to 41% of placentas that had negative bacteria culture and was negative in 60% of placentas that had positive bacteria culture. There was absent bacterial culture growth and histological chorioamnionitis in 59% of the placentas. Other histological profiles identified include maternal vascular malperfusion, funisitis, fetal vascular malperfusion, Chorangiosis, fetal thrombotic vasculopathy and delayed villous maturation. Conclusion and Recommendations: There is need to update our guidelines to culture sensitive antimicrobials for treatment of patients presenting with preterm labor and PPROM. Molecular techniques of microbe isolation are recommended to supplement culture.

Rastrineobola argentea (Omena) is the second important fish catches after Nile Perch in Lake Victoria. Although rich in nutrients, huge postharvest losses are mainly reported during rainy seasons when large catches are made. This could be due to poor handling, processing and packaging practices causing infestation by fungi and subsequent production of aflatoxin under favourable conditions. Despite the economic importance, there are no studies in Kenya to quantify the aflatoxin associated with Rastrineobola argentea and its effects on micronutrient content. This study was therefore undertaken to determine public knowledge, diversity and content of aflatoxins in sun dried Rastrineobola argentea and assess its relationship with the moisture, calcium and iron content. To assess the public knowledge, a survey was carried out around Lake Victoria landing beaches in Kisumu, Migori and Siaya counties and fish markets in Nairobi. A total of 252 samples were collected in dry and wet seasons. The samples were blended and sub-sampled for proximate calcium and iron analysis as well as aflatoxin and moisture content determination. Iron and calcium levels were determined using Atomic Absorption Spectrometry. Total aflatoxin quantification was determined using fluorescence detector in High Performance Liquid Chromatography in reverse phase. Moisture content was quantified using an oven at 130 °C. There was female dominance in fish processing in the study sites. Illiteracy levels was high with majority of the respondents having attained only primary education. Sun drying was the most widely practiced method of fish preservation. There was a wide knowledge gap with 65.59 % unaware of aflatoxins contamination and its health implications. Proximate calcium levels ranged from 1,872.21 to 2,940.90 mg/kg compared to the recommended adult’s daily intake of 1,000 – 1,300 mg. Proximate iron content ranged from 5.62 to 15.64 mg/kg. The total aflatoxin detected in singular samples ranged from 0.44 μg/kg – 4.42 μg/kg signifying Omena aflatoxin contamination. Moisture content was from 10.13 to 14.40 %. Although, total aflatoxin levels were within the accepted limits in Kenya, continued consumption can lead to chronic aflatoxicosis making one vulnerable to liver cancer, neurological area impairment, immunosuppression, and micronutrients deficiencies, stunted growth, child mortality and spontaneous abortion. Hazard analysis of critical control point and good hygiene ought to be operationalized from harvesting through processing and distribution channels of sun dried Rastrineobola argentea to reduce the moisture content as well as the levels of aflatoxin contamination. The national and county Governments of Kenya should educate the general public on health hazards associated with consumption of contaminated Omena. The findings have contributed to science of analytical chemistry in mitigation of aflatoxin challenges while high calcium and iron content in omena helps in improved diet. The negative correlation of aflatoxin and moisture in Omena merits a further research study.

Introduction Poor aqueous solubility presents a major formulation challenge for many active pharmaceutical ingredients. The use of surface-active agents is a common strategy to address poor drug solubility. Griseofulvin has previously been studied as a model of poorly soluble drugs, shown to posses improved solubility in the presence of surfactants. This study seeks to evaluate the effect of selected surface-active agents on the dissolution of griseofulvin granules prepared by melt granulation. Methodology Griseofulvin granules were prepared by melt granulation technology. The molten binder mimicked the granulating liquid and no additional liquid added. Polyethylene glycol 4000 was incorporated as the melt binder. The surfactants studied were Gelatin, Tween 80 and Sodium lauryl sulphate (SLS), at concentrations of 0.5%, 1% and 2% w/w. Dissolution was performed and sampling done at 5, 10, 20, 30 and 45 min. The griseofulvin released was quantified using Ultraviolet spectrophotometry and its assay in all formulations performed in accordance to the British Pharmacopoeia (2019) specifications. Griseofulvin tablets from Universal Corporation Ltd in the market were subjected to dissolution; sampling was done at 45 minutes. Results and Discussion Formulations containing SLS recorded the highest drug release of 96.7% at a concentration of 2% w/w whereas Tween 80 recorded its highest release of 79.9% at a concentration of 2% w/w. Gelatin formulations recorded the lowest release at all time points. The control formulation that did not have any surfactant had insignificant release at all time points confirming that the surfactants played a critical role in enhancing the dissolution. In all the formulations containing

Most large mammalian carnivores are in global decline, partly due to their involvement in livestock predation. Research that advances our understanding of predator livestock interaction is crucial to conflict mitigation and carnivore conservation and management. The study investigated the influence of environmental and socio-ecological factors on livestock predation by large carnivores in pastoral villages adjacent to the Amboseli National Park in Kenya during a 13-month period (July 2012 - July 2013). A number of factors were identified related to temporal and spatial variation that influences livestock predation rates. Aassessment on how environmental changes affected the distribution and dynamics of vegetation and animal populations. The overall purpose of this study was to determine the intensity of livestock predation by large carnivores in space and time around Amboseli National Park. In the study we investigated livestock predation by large carnivores and factors predisposing in Olgulului and Kimana community group ranches in the southern Kenya during the period between July 2012 and July 2013. In addition if livestock predation rate and intensity varied with season, boma (livestock shed) density and the carnivore species as well. Large camivore - livestock predation incidences were mapped and a total of 26 herbivore transect counts were conducted in and outside the park during both dry and wet season. The result revealed that there were more prey (herbivores) density inside the park during the dry season as compared with wet season. There was negative correlation between vegetation density, boma density and livestock predation incidences. A total of 1409 predation incidences recorded during the 13 months periods which were attributed to specific predators. Hyenas killed more livestock followed by Jackals, Cheetah and lions respectively. There were a positive correlation (r = 0.766, P = 0.131, n=5) indicating that some carnivores especially hyenas preferred to keep a certain distance from human settlements. More animals were killed while on the grazing fields and lions killed more livestock inside Borna. Conflict was most frequent during evening, late night and mid-morning. The predations by carnivore species were spatially clustered. This conforms to the assumption of non-homogenous distribution of natural resources needed by tbe animals. Some environmental variables such as human settlement and density of wild prey greatly influenced the observed pattern of carnivore attack distribution.

Background: Despite blood being lifesaving, it is not always available when needed. Prolonged turnaround time (TAT) and unavailability of blood and its components impact negatively on patient care. At the Kenyatta National Hospital (KNH) medical wards, the current practices of blood and blood components transfusion and the existing gaps and challenges had not been studied. Objective: The main objective of this study was to determine the practices and document challenges associated with blood and blood components use in the medical wards at KNH. Significance of the study: Results from the study have documented the current blood transfusion practices, existing gaps and challenges in the provision of blood transfusion services, and will inform blood transfusion policy formulation at KNH. Methodology: This was a cross-sectional descriptive study carried out at the KNH medical wards and the blood transfusion unit (BTU) in KNH. Blood request forms of patients admitted in the medical wards and healthcare workers working in the medical wards and the BTU were enrolled in the study. A data collection sheet was used to obtain demographic, clinical and laboratory data from in-patient files. The units of blood components transfused and TAT were obtained from the in-patient file 7 days from the date of the request. An open-ended questionnaire was used to document the challenges experienced by healthcare workers. Results: One hundred and thirty-eight blood request forms and 203 healthcare workers were enrolled in the study. Packed red cells were the most frequently requested blood component (29.0%). The transfusion rate was 8.7%. The top five clinical indications for blood and blood components were neoplasms, disorders of blood and blood forming organs, upper gastrointestinal bleeding, infections and chronic kidney disease, in that order. The mean TAT was 2.2 days (SD1.9). The unmet blood demand was 78.9%. Notably, 59.4% of the requests weren’t issued with a single unit of blood. Unavailability and delays in getting blood for transfusion were the most frequently reported challenges by all healthcare workers. Conclusion: The blood transfusion practices in the medical wards were comparable to standard practices in the world. However, the unmet blood demand in the medical wards was very high, with unavailability of blood being the most frequently cited challenge by all healthcare workers.

I. Introduction Metabolic syndrome (MS) is a combination of interrelated risk factors of metabolic origin; the components include increased insulin resistance, obesity, dyslipidemia and hypertension. WHO defines HAART (highly active antiretroviral therapy) as a form of antiretroviral therapy for the treatment of persons infected with HIV. The use of HAART has decreased morbidity and mortality. The use of protease inhibitors (PIs) and nucleoside reverse transcriptase inhibitors (NTRIs) have been associated to development of lipodystrophy and metabolic abnormalities. In spite of the success of HAART, the prevalence of dyslipidemia, insulin resistance and fat redistribution have increased after its global step up. The prevalence of MS among HIV –infected patients globally ranges from 17.0% to 45.4%, with most reports produced in developed nations. The diagnosis of MS using the International Diabetes Federation is a rise in triglycerides greater than 1.7mMol/l, elevated fasting blood sugar greater than 5.6mMol/l and reduced HDL cholesterol less than 1.03mMol/l. There exists no data on the prevalence of MS among the prison population in Kenya. II. Study objectives The broad objective is to determine the prevalence of metabolic syndrome in inmates on HAART at Embu GK prison dispensary, comprehensive care clinic (CCC). The specific objectives were: i. To determine the serum concentration of fasting blood sugar, TC, LDL-C, HDL-C and triglyceride, ii. To determine the BMI and blood pressure among patients on HAART iii. To compare the different types of regimens to metabolic syndrome iv. To determine the prevalence of MS in prisoners on HAART

Background: Evaluation of the larynx and pharynx areas is not always performed during oesophagogastroduodenoscopy(OGD) despite the oropharynx and laryngopharynx being bypassed to get to the oesophagus. Laryngopharyngeal abnormalities have been picked in up to 5.4% OGDs. Main objective: To determine the diagnostic yield of laryngeal and pharyngeal pathology during OGD at Kenyatta national hospital (KNH) Study design and setting: This was a prospective cross sectional study on patients undergoing OGD from February to July 2020 at KNH endoscopy unit. Methodology: One hundred and twenty-one patients aged 18 years and above were recruited into the study. History and physical examination including video laryngoscopy were done followed by endoscopic evaluation of the pharynx and larynx during OGD. Data management and analysis: Data was expressed as means and standard deviations. Comparison between subsites and between both endoscopic groups was done using chi-squared. Sensitivity and specificity was calculated using indirect video laryngoscopy as the gold standard. Diagnostic accuracy was obtained using receiver operating characteristics curve. A P-value of <0.05 for a 95% confidence interval was considered significant. Results Among 121 patient recruited into the study, 17.35 % had laryngeal and pharyngeal abnormalities on OGD whereas 25.61% had abnormalities on video laryngoscopy(VL).The common pathologies on video laryngoscopy were LPR (10.79%), vocal cord paralysis (8.33%) then laryngeal leukoplakia (2.49%) while vocal cord paralysis (5.69%), LPR (4.96%) ,laryngeal and oropharyngeal leukoplakia (2.49%) were common on OGD. VL had higher odds of diagnosing pathologies of the oropharynx, larynx and hypopharynx compared to OGD. The mean time taken to evaluate the larynx and pharynx was 43±20.9 seconds while OGD procedure took 237.3±106.4 seconds. OGD was 63.4% sensitive and 91.3% specific in diagnosing pathologies of the various subsites, with positive and negative predictive values of 78.9% and 83.0% respectively. Conclusion The diagnostic yield of laryngeal and pharyngeal pathologies during OGD is significant and it only requires 43 seconds to do examination. Examination of the larynx and pharynx should be made part of OGD examination and reporting.