Background: Fluid resuscitation is widely considered a life saving intervention in septic

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BackgroundFluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints.MethodsA prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6–60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer’s lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28.ResultsTwenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-5/m2 indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids.ConclusionBaseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-017-1679-0) contains supplementary material, which is available to authorized users.

BackgroundThe World Health Organization (WHO) recommended physician to population ratio is 23:10,000. Kenya has a physician to population ratio of 1.8:10,000 and is among 57 countries listed as having a serious shortage of health workers. Approximately 52 % of physicians work in urban areas, 6 % in rural and 42 % in peri-urban locations. This study explored factors influencing the choice of career specialization and location for practice among final year medical students by gender.MethodsA descriptive cross-sectional study was carried out on final year students in 2013 at the University of Nairobi’s, School of Medicine in Kenya. Sample size was calculated at 156 students for simple random sampling. Data collected using a pre-tested self-administered questionnaire included socio-demographic characteristics of the population, first and second choices for specialization. Outcome variables collected were factors affecting choice of specialty and location for practice. Bivariate analysis by gender was carried out between the listed factors and outcome variables with calculation of odds ratios and chi-square statistics at an alpha level of significance of 0.05. Factors included in a binomial logistic regression model were analysed to score the independent categorical variables affecting choice of specialty and location of practice.ResultsInternal medicine, Surgery, Obstetrics/Gynaecology and Paediatrics accounted for 58.7 % of all choices of specialization. Female students were less likely to select Obs/Gyn (OR 0.41, 95 % CI =0.17-0.99) and Surgery (OR 0.33, 95 % CI = 0.13-0.86) but eight times more likely to select Paediatrics (OR 8.67, 95 % CI = 1.91-39.30). Surgery was primarily selected because of the ‘perceived prestige of the specialty’ (OR 4.3 95 % CI = 1.35-14.1). Paediatrics was selected due to ‘Ease of raising a family’ (OR 4.08 95 % CI = 1.08-15.4). Rural origin increased the odds of practicing in a rural area (OR 2.5, 95 % CI = 1.04-6.04). Training abroad was more likely to result in preference for working abroad (OR 9.27 95 % CI = 2.1-41.9).ConclusionsThe 4 core specialties predominate as career preferences. Females are more likely to select career choices due to ‘ease of raising a family’. Rural origin of students was found to be the most important factor for retention of rural health workforce. This data can be used to design prospective cohort studies in an effort to understand the dynamic influence that governments, educational institutions, work environments, family and friends exert on medical students’ careers.Electronic supplementary materialThe online version of this article (doi:10.1186/s12909-016-0528-1) contains supplementary material, which is available to authorized users.

Background/Aims: Ventriculoperitoneal shunt complications have scarcely been reported in sub-Saharan Africa. This study aimed at determining the frequency of these complications and their associated risk factors in a Kenyan National Teaching and Referral Hospital. Methods: This cross-sectional study retrospectively covered 117 patients admitted to the Kenyatta National Hospital neurosurgical ward between January 2005 and December 2007 with ventriculoperitoneal shunt complications. The data obtained were analysed using the Statistical Package for the Social Sciences. Results: The most common complication was obstruction in 63 patients (53.8%), followed by migration in 25 (21.4%) and infection in 23 (19.7%) of the patients. Up to 49.6% of the complications occurred in patients younger than 6 months. Multiple complications were seen in 23.9% of the cases. The mean shunt duration was 18.05 months. Positive correlations existed between the presence of a shunt complication and patient age, shunt duration and the number of complications developed. These correlations were, however, neither strong nor statistically significant. Conclusion: This study reports the highest frequencies of shunt obstruction and migration ever recorded in the literature. The high rate of development of multiple shunt failures coupled with a short shunt duration calls for a closer monitoring of patients with ventriculoperitoneal shunts.

Key Points Question Do high-risk African children with severe malnutrition show abnormal myocardial function consistent with biventricular failure and/or life-threatening arrhythmias? Findings In a longitudinal case-control study of 88 children with severe, acute malnutrition, no evidence was found that malnourished children were at greater risk of cardiac dysfunction or clinically significant arrhythmias than nonmalnourished controls. Myocardial function was similar in the 2 marasmus and kwashiorkor clinical phenotypes, and myocardial indices following intravenous rehydration indicated fluid-responsive changes with no child developing fluid overload. Meaning Research is needed to address current guidelines restricting rehydration for severe gastroenteritis to oral therapy.

The acute respiratory distress syndrome (ARDS) describes a heterogenous population of patients with acute severe respiratory failure. However, contemporary advances have begun to identify distinct sub‐phenotypes that exist within its broader envelope. These sub‐phenotypes have varied outcomes and respond differently to several previously studied interventions. A more precise understanding of their pathobiology and an ability to prospectively identify them, may allow for the development of precision therapies in ARDS. Historically, animal models have played a key role in translational research, although few studies have so far assessed either the ability of animal models to replicate these sub‐phenotypes or investigated the presence of sub‐phenotypes within animal models. Here, in three ovine models of ARDS, using combinations of oleic acid and intravenous, or intratracheal lipopolysaccharide, we investigated the presence of sub‐phenotypes which qualitatively resemble those found in clinical cohorts. Principal Component Analysis and partitional clustering identified two clusters, differentiated by markers of shock, inflammation, and lung injury. This study provides a first exploration of ARDS phenotypes in preclinical models and suggests a methodology for investigating this phenomenon in future studies.

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