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Lactic acid production parameter optimization was performed using cane molasses by design of experiment (DOE) with the help of Qualitek-4 software with bigger is better as quality characteristics with eight media components at three levels in submerged culture condition. Eight factors with three levels studied were yeast extract, CaCO3, MnSO4, pH, Temperature, molasses, urea, and Tween 80. These factors were optimized based on their S/N ratios obtained from Qualitek-4 software and their significant individual interactions, and interactions with each other have been studied. Effects of mixed N2 sources, Tween 80, and MnSO4 have been studied by their individual interactions and interactions among themselves. Lactic acid production was significantly affected by interactions of two factors such as temperature-urea, pH-CaCO3, temperature-Tween 80, but individually they have minimum impact on lactic acid production. Individually pH, yeast extract, molasses, and urea are the most significant factors in lactic ac...

Objective To record the costs of hospital care for HIV-positive and -negative patients in Nairobi, and identify costs paid by patients per admission. Design Cost data were collected on inpatients enrolled in a linked clinical study using standardized costing methods. Setting: Kenyatta National Hospital, Nairobi's main district hospital. Patients Consecutive adult medical admissions to one ward over 14 weeks who consented to enrolment; tertiary referrals were excluded. Main outcome measure Average length of stay and cost per patient admission. Results The hospital costs of 398 patients (163 HIV positive; 33 with clinical AIDS) were analysed. The mean length of stay was 9.3 days and the mean cost per patient admission was US$163. There was no significant difference in costs or mean lengths of stay between HIV-positive and -negative groups, nor were the costs and lengths of stay for clinical AIDS patients significantly different to those for HIV-positive patients without AIDS. The patient charges paid to the hospital per admission, recorded for 344 patients, were on average US$61; and did not differ by HIV status. Conclusion The similar cost patterns for inpatient care irrespective of HIV status or clinical AIDS probably reflects the limited provision of care beyond basic clinical services. Length of stay rather than differing treatment regimes thus appears to be the main cost driver. Private costs of medical care were high and were likely to pressurize households. When resources are limited, the introduction of new, more costly therapies needs careful planning. The study provides cost information for planning care services in resource-poor settings. (C) 2002 Lippincott Williams Wilkins.

Bloodstream infections are a frequent complication in human immunodeficiency virus (HIV)-infected adults in Africa and usually associated with a poor prognosis. We evaluated bloodstream infections across a decade in 3 prospective cross-sectional surveys of consecutive medical admissions to the Kenyatta National Hospital, Nairobi, Kenya. Participants received standard clinical care throughout. In 1988-1989, 29.5% (28 of 95) of HIV-positive patients had bloodstream infections, compared with 31.9% (46 of 144) in 1992 and 21.3% (43 of 197) in 1997. Bacteremia and mycobacteremia were significantly associated with HIV infection. Infections with Mycobacterium tuberculosis, non-typhi species of Salmonella (NTS), and Streptococcus pneumoniae predominated. Fungemia exclusively due to Cryptococcus neoformans was uncommon. Clinical features at presentation remained similar. Significant improvements in the survival rate were recorded among patients with NTS bacteremia (20%-83%; P

The yield of bacterial cultures from cerebrospinal fluid (CSF) at Kenyatta National Hospital (KNH) is very low. Bedside inoculation of culture media with CSF may improve yields.To compare the culture yield of CSF inoculated onto culture medium at the bedside to that of CSF inoculated onto culture medium in the microbiology laboratory.Cross-sectional comparative study.Accident and Emergency Department and medical wards at Kenyatta National Hospital.Cerebrospinal fluid from patients at KNH with a clinical diagnosis of acute meningitis.Two hundred and twenty CSF specimens were obtained during a four month period. S. pneumaniae was isolated from 24 CSF samples and H. influenzae from one. Bacterial cultures were positive in 25 (11.4%, 95% CI 7.0-15.6%) samples inoculated at the bedside and 23 (10.5%, 95% CI 6.5-14.5%) samples inoculated at the laboratory. Bacteria were isolated 5 hours earlier in samples inoculated at the bedside (95% CI 4.34-6.86 hrs, p0.05). Four per cent of S. pneumaniae isolates were resistant to crystalline penicillin.There was no significant difference in culture yield after bedside inoculation of culture media with CSF compared to traditional CSF culture method. Bedside inoculation of culture media with CSF resulted in faster time to positive culture.

Background : Although artesunate and mefloquine have been used as monotherapies in the treatment of malaria in Kenya for a long time, there is insufficient data on the clinical outcome when used as combination therapy in this population. Objective : To derive data on the efficacy and safety profile of artesunate - mefloquine combination in the treatment of uncomplicated Plasmodium falciparum malaria in Kenya. Design : An open label single arm clinical trial. Setting : Bungoma district Hospital. Study area was Bungoma District of Kenya, an endemic area of malaria. The study was conducted between January 2004 and April 2004. Subjects : A total of 200 males and females with uncomplicated plasmodium falciparum malaria weighing 35kg and above were recruited in the study. Results : In the evaluable patient population the day 28 cure rate was 98.4% while day 14 and 7 cure rates were 98.4% and 99.2% respectively. There was rapid relief of symptoms the median time of fever clearance was one day and the most common drug related adverse events were headache dizziness and asthenia. There was no significant derangement in the haematological, biochemical and ECG parameters in the patients on treatment. Conclusion : Artesunate-mefloquine combination given simultaneously was found to be highly effective and safe in the treatment of uncomplicated malaria. East African Medical Journal Vol. 83(5) 2006: 236-242

Although artesunate and mefloquine have been used as monotherapies in the treatment of malaria in Kenya for a long time, there is insufficient data on the clinical outcome when used as combination therapy in this population.To derive data on the efficacy and safety profile of artesunate-mefloquine combination in the treatment of uncomplicated Plasmodium falciparum malaria in Kenya.An open label single arm clinical trial.Bungoma district Hospital. Study area was Bungoma District of Kenya, an endemic area of malaria. The study was conducted between January 2004 and April 2004.A total of 200 males and females with uncomplicated plasmodium falciparum malaria weighing 35kg and above were recruited in the study.In the evaluable patient population the day 28 cure rate was 98.4% while day 14 and 7 cure rates were 98.4% and 99.2% respectively. There was rapid relief of symptoms the median time of fever clearance was one day and the most common drug related adverse events were headache dizziness and asthenia. There was no significant derangement in the haematological, biochemical and ECG parameters in the patients on treatment.Artesunate-mefloquine combination given simultaneously was found to be highly effective and safe in the treatment of uncomplicated malaria.

Nairobi City Council Chest Clinic, Nairobi, Kenya.To determine if under-reading of sputum smears is a contributing factor in the disproportionate increase in smear-negative tuberculosis in Nairobi, Kenya.Between October 1997 and November 1998, patients fulfilling the local programme definition of smear-negative presumed pulmonary tuberculosis were enrolled in the study. Two further sputum specimens were collected for examination in a research laboratory by fluorescence microscopy.Of 163 adult subjects enrolled, 55% were seropositive for the human immunodeficiency virus type 1 (HIV-1). One hundred subjects had had two pre-study sputum smears assessed before recruitment and produced two further sputum specimens for re-examination in the research laboratory; of these 19 (19%) were sputum smear-positive on re-examination and a further seven (7%) became smear-positive on second re-examination.Of those patients with smear-negative presumed pulmonary tuberculosis by the local programme definition, 26% were smear-positive when reexamined carefully with two repeat sputum smears. This suggests that the high rates of smear-negative tuberculosis being seen may in part be due to under-reading. This is probably as a result of the overwhelming burden of tuberculosis leading to over rapid and inaccurate sputum examination. Retraining of existing technicians and training of more technicians is likely to reduce underreading and increase the yield of smear-positive tuberculosis. This finding also stresses the need for regular quality assurance.

Consequences of the growing HIV/AIDS epidemic for health services in sub-Saharan Africa remain poorly defined. Longitudinal data from the same center are scarce. The authors aimed to describe the impact of a rapidly rising HIV/AIDS disease burden on an urban hospital over the last decade. Cross-sectional observational study was conducted in 1997 compared to similar data from 1988/89 and 1992. The study was carried out in the Kenyatta National Hospital Nairobi Kenya. Consecutive adult medical patients were enrolled on admission and then followed up until death or discharge. The main outcome measures were clinical stage HIV status bacteremia length of stay bed occupancy final diagnosis and outcome of hospital admission. In 1997 518 patients 493 with HIV serology were enrolled: HIV prevalence was 40.0% bed occupancy 190% the mean length of stay 9.5 days (standard deviation 12) and overall mortality 18.5%. The mean number of HIV-positive admissions per day steadily rose from 4.3 [95% confidence interval (CI) 0.6] patients in 1988/89 through 9.6 (95% CI 1.4) in 1992 to 13.1 (95% CI 2.8) or 13.9 adjusted for those enrolled without HIV serology in 1997. In contrast the mean number admitted with clinical AIDS 1.7 in 1988/89 and 3.3 in 1992 fell to 2.6 cases per day in 1997. With HIV-negative admissions increasing by 37% and bed occupancy nearly doubling in 1997 HIV prevalence appeared to be stabilizing (19% then 39% and 40% respectively). Over time fewer HIV-infected patients were bacteremic (26% 24% and 14%; P < 0.01); had clinical AIDS (39% 34% and 24% respectively; P < 0.01); or died (36% 35% and 22.6%; P < 0.02). HIV-negative mortality 14% in 1988/89 rose to 23% in 1992 but fell to 15% in 1997. The mean length of hospital stay (9.5-10 days) did not differ according to HIV status nor did it change across the decade. The HIV/AIDS disease burden in Kenyatta National Hospital medical wards has risen inexorably over the last decade. Most recently the number of HIV-uninfected patients has also risen leading to bed occupancy figures of 190%. Despite overcrowding and irrespective of HIV status in-patient mortality has fallen. Time trends suggest fewer clinical AIDS patients are presenting for hospital care implying a rising community burden of chronic HIV/AIDS disease. Although widely predicted it is not inevitable that medical services in urban African hospitals dealing with large volumes of HIV/AIDS disease will collapse or become overwhelmed with chronic end-stage disease and death. (authors)

HIV infection has now been consistently identified as the major cause of death in young Africans in both urban and rural areas. In Africa, several studies have defined the clinical presentation of HIV disease but there have only been a limited number of autopsy studies. Because of the scarcity of autopsy data and the possibility of differing type and frequency of opportunistic infections between different geographic locations we set out to study consecutive new adult medical admissions to a tertiary referral hospital in Nairobi and perform autopsies on a sample of HIV-1-positive and HIV-1-negative patients who died in the hospital ward. Basic demographic data were collected on all patients admitted to two acute medical wards over an 11-month period. Final outcome and final clinical diagnoses were recorded at discharge or death. An autopsy examination was requested if the patient died in the ward. Autopsy examination was performed in 75 HIV-1-positive (40 men, 35 women) and 47 HIV-1-negative (28 men, 19 women) adults who died in the hospital. This represented 48.4% of all HIV-1-positive deaths and 33.3% of all HIV-1-negative deaths. Tuberculosis (TB) and bacterial and interstitial bronchopneumonia accounted for 96% of the major pathology in patients found to be HIV-1-positive at autopsy. TB was present in half the HIV-1-positive autopsy patients and was disseminated in over 80% of cases. Meningeal involvement was present in 26% of those with disseminated TB. By contrast, TB was much less common in the HIV-1-negative patients at autopsy in whom bacterial bronchopneumonia and malignancies were the most common pathologies. The type pathology found in the HIV-1-positive autopsy patients was not different than that found in other areas in Africa so far studied.

Between June and December 1992 forty AIDS patients as defined by the CDC criteria, admitted to the medical wards of the Kenyatta National Hospital, were studied to determine the prevalence and pattern of peripheral neuropathy. Their mean age was 33 +/- 3 years with a range of 16 to 55 years. Clinical and laboratory assessment were carried out both to confirm peripheral neuropathy and exclude other causes of peripheral neuropathy apart from AIDS. All the patients had nerve conduction and electromyographic studies done. Eighteen patients were asymptomatic while fourteen had both signs and symptoms. The commonest symptom was painful paresthesiae of the limbs (35%) while the commonest sign was loss of vibration sense (60%). When symptoms, signs, and electrophysiological studies were combined, all the patients fitted the definition of peripheral neuropathy. The commonest type of peripheral neuropathy was distal symmetrical peripheral neuropathy (DSPN) (37.5%).In Kenya, physicians evaluated 40 AIDS patients admitted to Kenyatta National Hospital during June-December 1992 to determine the prevalence and types of peripheral neuropathy in AIDS patients. 75% were 21-40 years old. 18 (45%) of the 40 AIDS patients had symptoms of peripheral neuropathy. Symptoms included increased sensitivity to stimulation (43%), hyperpathia (15%), and muscle or limb weakness (13%). 26 AIDS patients had signs of peripheral neuropathy, especially impaired sense of vibration (60%). 14 of these patients had both signs and symptoms. Electromyographic and nerve conduction velocity revealed peripheral neuropathy in 16 (40%) AIDS patients. The types of peripheral neuropathy included distal symmetrical peripheral neuropathy (37.5%), polyneuropathy, and mononeuritis multiplex. When the symptoms, signs, and electroneurophysiological test findings were considered, all 40 AIDS patients had evidence of peripheral neuropathy.

Blackwater fever was an important cause of morbidity and mortality in the beginning of this century particularly in West and Central Africa. There has been a marked reduction in the incidence of blackwater fever since 1950 and only sporadic cases occur nowadays. At the Kenyatta National Hospital, three cases of blackwater fever have been seen in the past four years whereas not a single case had been reported between 1975 and 1988. Two of the patients fit into the classical description of blackwater fever and one was possibly due to drug induced haemolysis in a G6PD deficiency patient.

A 33-year old female patient presented with recurrent polyneuropathy during two consecutive pregnancies and recovered completely after spontaneous abortion the first time and after a normal delivery the second time. The patient has had a tubal ligation since then and has remained well up to date.

Malaria is the most prevalent and devastating public health problem in Africa despite much research and control effort over the last two decades. In most parts of Africa, individuals should take 200 mg of Proguanil daily together with chloroquine 5 mg/kg per week as prophylaxis. Pregnant women and individuals with underlying disease such as sickle cell making them susceptible to severe or complicated malaria, however, should take just 200 mg Proguanil daily. In hard-core multi-drug resistance areas, mefloquine 250 mg once weekly together with chloroquine 300 mg weekly is recommended as prophylaxis. Since no anti-malarial drug confers absolute protection against infection, however, using mosquito nets impregnated with permethrin, insecticides, and mosquito repellents is also advocated for those at high risk of severe malaria. The need also exists to treat cases of malaria when prevention is unsuccessful. Chloroquine in total dose 25 mg/Kg over three days is the first choice treatment of uncomplicated malaria in 4-aminoquinoline sensitive areas. Amodiaquine 25 mg/Kg over three days is the second line treatment, while pyrimethamine/sulphonamide combinations are useful in areas where there is resistance to 4-aminoquinalines. Finally, quinine 10 mg/kg every eight hours for seven days is the treatment of choice for severe and complicated malaria.

In summary we found no significant difference between the radiographic appearances of pneumococcal pneumonia in HIV-1-infected and uninfected Kenyan adults. In clinical practice lobar and segmental consolidatory changes on chest X-ray with or without a pleural effusion can be used to support a diagnosis of pneumococcal pneumonia irrespective of HIV status. Variations from this pattern particularly the presence of mediastinal lymphadenopathy would suggest dual or alternative pulmonary pathology other than S. pneumoniae of which tuberculosis is the most important. (excerpt)

A case of an HIV positive man with multiple sexually acquired disease occurring concurrently is described. Risk behaviours that could have predisposed him to HIV infection are discussed. The factors which might have interacted to make the sexually acquired infections severe and difficult to treat are postulated.The case of an HIV-seropositive man with gonorrhea, syphilis, genital warts, and chancroid is described. Multiple sexual partners, genital ulcer diseases, and lack of circumcision may have predisposed him to HIV infection. As indicated by his CD4/CD8 ratio of 0.5, his immunological status was not very compromised. Other factors were therefore probably behind these multiple sexually transmitted diseases (STD). This 30-year old man was inadequately treated for a long time for urethral discharge and genital ulcer disease, and ultimately collapsed on the job with a comprised central nervous system. Bacterial infection related to the multiple STDs could certainly have caused this collapse. The time demands of this man's work, the lack of medical facilities to diagnose and treat such conditions, his unprotected sexual behavior with multiple partners, and broader socioeconomic conditions which separate wage- earning males from their families in Africa conspire to produce multiply-afflicted cases such as these.

The range of clinical presentations of HIV-related disease in Africa has not been adequately described, despite the fact that many hospitals have to rely heavily on clinical diagnosis. Six hundred adult medical patients seen in the Casualty Department of the main Government hospital in Nairobi were enrolled in a study of the presentation and outcome of HIV-related disease: 506 of these patients were admitted, of whom 19 per cent (95) were HIV seropositive. The remaining 94 were dealt with as outpatients: 11 percent (10) of these were seropositive. A history of prior treatment for sexually transmitted disease and, if male, being uncircumcised, were associated with being seropositive. Three presentations were strongly associated with HIV infection: acute fever with no focus except the gastrointestinal tract (enteric fever-like illness), acute cough with fever (community-acquired pneumonia) and chronic diarrhoea with wasting. The WHO clinical case definition (CCD) for AIDS missed a substantial amount of HIV-related morbidity (sensitivity 39 per cent) and misidentified many seronegative patients (positive predictive value 59 per cent). In comparison with the Centers for Disease Control surveillance definition for AIDS, the CCD was specific (91 per cent) and sensitive (79 per cent) but only had a positive predictive values of 30 per cent: the CCD may therefore be a poor surveillance tool for AIDS. Seropositive patients were much more likely to die than were seronegative patients (39 per cent vs. 15 per cent mortality). Enteric fever-like illness was the presentation which most commonly proved fatal. A wider spectrum of disease is associated with underlying HIV immunosuppression than has previously been described in Africa.

Ten Kenyan patients with visceral leishmaniasis, unresponsive to sodium stibogluconate at a dose of 16 to 20 mg Sb/kg/day given for 30 to 98 days, have been studied clinically and immunologically and compared with 57 antimony-responsive patients. Pulmonary tuberculosis and previous treatment with antimonial drugs were the only factors which were more common in unresponsive patients. The degree of immunosuppression and rate of recovery of immunoreactivity did not differ between antimony-responsive and -unresponsive patients. Only one patient had never been treated before (primary unresponsiveness). In the other nine patients secondary unresponsiveness occurred after one or more treatment courses, suggesting that the parasite developed resistance to antimony. Antimony-unresponsiveness in visceral leishmaniasis is a serious problem numerically, clinically and economically. A plea is made that the initial treatment of visceral leishmaniasis should be adequate in dose and duration.

Ten Kenyan patients with visceral leishmaniasis unresponsive to sodium stibogluconate, at a dose of 16 to 20 mg Sb/kg body-weight/day given for 30 to 98 days, were treated with 20 mg Sb/kg bw given every eight hours. This regimen was modified or abandoned in six patients because of suspected toxicity, although toxicity was difficult to assess because of intercurrent illness. Toxic effects included lethargy, anorexia, vomiting, electrocardiographic changes, fall in haemoglobin and rise in liver enzymes. One patient died, probably from a cardiac arrhythmia. Two patients were cured, four responded partially and four showed no response. Pentamidine, at a dose of 4 mg/kg body-weight given one to 3 times per week for 5 to 39 weeks, was given as initial treatment in one patient and after failure of sodium stibogluconate in seven. Toxic effects included nephritis, hepatitis, transient diabetes and subcutaneous abscesses. Two patients were cured, two responded partially, three showed no response and one, after apparent cure, relapsed and was unresponsive to additional pentamidine treatment. Low-frequency, long-duration pentamidine was often useful in maintaining any improvement made during treatment with the less well tolerated high-dose, high frequency sodium stibogluconate. We observed the step-wise development of resistance to both sodium stibogluconate and pentamidine. The problems of managing patients with visceral leishmaniasis which is unresponsive to conventional doses of pentavalant antimonials are discussed and some tentative suggestions put forward.

A prospective randomized trial of three dosage regimens of sodium stibogluconate (PentostamR; Wellcome Foundation, London) to treat visceral leishmaniasis was conducted. Previously untreated patients were randomized to receive 31 doses of sodium stibogluconate (10 mg Sb/kg of body weight per dose) administered once daily for 31 days (group A), every 12 hr for 15 days (group B), or every 8 hr for 10 days (group C). Of the 29 patients who completed treatment, seven of 10 in group B and all of the patients in groups A and C responded to treatment and remained well for one year. One patient in group B failed to respond to treatment, and two others in group B initially responded to treatment but relapsed six weeks after discharge. None of the treatment regimens was toxic. Parasites disappeared from splenic aspirates most quickly and hemoglobin levels rose most rapidly in patients receiving sodium stibogluconate every 8 hr. Treatment of visceral leishmaniasis in Kenya with sodium stibogluconate at a dose of 10 mg Sb/kg every 8 hr for 10 days appears to be a safe alternative to conventional treatment. Its efficacy should be confirmed in a larger number of patients. Visceral leishmaniasis is a chronic infectious disease caused by the protozoan parasite Leishmania donovani, is transmitted by phlebotomine sandflies, and is characterized by splenomegaly, anemia, fever, weight loss, malnutrition, immune

A patient with a primary splenic pregnancy is described.

We describe the technique of splenic aspiration in 113 patients presenting with splenomegaly. It was used initially to establish a diagnosis, and in those patients with kala azar, to follow the response of the parasites to therapy until 'parasitological cure'. In all 671 aspirations were performed. No complications occurred in the 69 patients with active kala azar, who collectively had more than 600 aspirations. One patient in a moribund condition had a fatal haemorrhage. The aspirate suggested a lymphoma, confirmed at autopsy. In 68 of the 69 patients with active kala azar, the diagnosis was established at the first aspiration. The essentials of the technique are the use of a small calibre needle (21 G), and speed, the needle being in the spleen for less than a second, with the consequent procurement of a few drops of material only.