Objectives: Flexible bronchoscopy (FB) is an essential diagnostic and therapeutic tool for managing respiratory diseases, and an audit of its practice is important; it enhances standardization of practice and improves outcomes and patient safety. This study aimed to describe the FB practice at Kenyatta National Hospital (KNH) regarding indications, peri-procedure practice, gross and histologic findings, and safety. Materials and Methods: This study was a quantitative and retrospective chart review of files of 282 patients who underwent flexible bronchoscopies over 5 years in KNH. Results: We reviewed 282 flexible bronchoscopies done between January 2016 and December 2020. There was a significant documentation gap (22%); 54 out of the 282 cases audited had incomplete documentation. The male-to-female ratio was 1:1, with a median age of 51 years. Most (58.2%) of the patients were residents of counties outside Nairobi. Despite a lack of evidence for routine evaluation, we noted significant rates (75.9%) of routine laboratory evaluations (International normalized ratio (INR), platelet count). The most common indication of bronchoscopy was the evaluation of a lung mass (100) 35.7%, pulmonary infiltrate 53 (18.9%), and assessment for interstitial lung disease 39 (13.9%). The most common gross bronchoscopic findings were visible tumors at 38.5% (107) and normal endoscopic findings at 29.5% (82). The practice was safe, with a complication rate of 3.2%. The most common diagnostic outcome was lung cancer (40.1%), with adenocarcinoma being the most common (45.1%) histologic subtype. The diagnostic yield for malignancy where there was a visible tumor was 87.2%. Conclusion: Our study showed that FB practice at KNH is safe and provides a good diagnostic yield, but a significant documentation gap and record keeping exist. Adenocarcinoma was the most predominant lung cancer histologic subtype among the mostly non-smoker population.

Antimicrobial stewardship encourages appropriate antibiotic use, the specific activities of which will vary by institutional context. We investigated regional variation in antibiotic use by surveying three regional public hospitals in Kenya. Hospital-level data for antimicrobial stewardship activities, infection prevention and control, and laboratory diagnostic capacities were collected from hospital administrators, heads of infection prevention and control units, and laboratory directors, respectively. Patient-level antibiotic use data were abstracted from medical records using a modified World Health Organization point-prevalence survey form. Altogether, 1,071 consenting patients were surveyed at Kenyatta National Hospital (KNH, n = 579), Coast Provincial General Hospital (CPGH, n = 229) and Moi Teaching and Referral Hospital (MTRH, n = 263). The majority (67%, 722/1071) were ≥18 years and 53% (563/1071) were female. Forty-six percent (46%, 489/1071) were receiving at least one antibiotic. Antibiotic use was higher among children <5 years (70%, 150/224) than among other age groups (40%, 339/847; P < 0.001). Critical care (82%, 14/17 patients) and pediatric wards (59%, 155/265) had the highest proportion of antibiotic users. Amoxicillin/clavulanate was the most frequently used antibiotic at KNH (17%, 64/383 antibiotic doses), and ceftriaxone was most used at CPGH (29%, 55/189) and MTRH (31%, 57/184). Forty-three percent (326/756) of all antibiotic prescriptions had at least one missed dose recorded. Forty-six percent (204/489) of patients on antibiotics had a specific infectious disease diagnosis, of which 18% (37/204) had soft-tissue infections, 17% (35/204) had clinical sepsis, 15% (31/204) had pneumonia, 13% (27/204) had central nervous system infections and 10% (20/204) had obstetric or gynecological infections. Of these, 27% (56/204) had bacterial culture tests ordered, with culture results available for 68% (38/56) of tests. Missed antibiotic doses, low use of specimen cultures to guide therapy, high rates of antibiotic use, particularly in the pediatric and surgical population, and preference for broad-spectrum antibiotics suggest antibiotic use in these tertiary care hospitals is not optimal. Antimicrobial stewardship programs, policies, and guidelines should be tailored to address these areas.

Objective: To determine disease activity in Systemic Lupus Erythematosus (SLE) patients and correlate it with quality of life.Design: Cross-sectional descriptive study.Methods: SLE patients fulfilling SLICC 2012 criteria for SLE were included in this cross-sectional study. Disease activity was measured using the clinical Systematic Lupus Erythematosus Disease Activity Index (SLEDAI-2K). Quality of life was assessed using the self-administered LupusQoL.Results: The study group had 62 patients (60 females and 2 males) with a mean age of 34±11.8 years, and the mean duration of follow up was 36 months. The mean cSLEDAI-2K score was 7±5.2, and the median disease activity score was 7. All the domains of LupusQoL were impaired. Higher disease activity scores were associated with lower QoL scores in the domains of physical health, pain, burden to others, body image and general health. Patients with renal disease had significantly lower QoL compared to other patients, and the pain, intimate relationships and body image were most affected. Age and disease duration had a positive correlation with QoL. Disease duration (p=0.01), was associated with a better QoL in the pain, emotional health and body image domains.Conclusion: This study is showing a low HRQoL in those with active disease mainly in the young age group. A recent diagnosis of lupus and the presence of renal disease was associated with a more reduced quality of life. Key words: SLE, Disease activity, Health-Related Quality of Life, cSLEDAI-2K, LUPUSQoL

Systemic lupus erythematosus is a chronic, auto-immune inflammatory syndrome with a diverse clinical phenotype. Lupus nephritis (LN) affects 40-60% of patients. There is significant racial disparity in lupus nephritis with Blacks and Hispanics having more aggressive disease and worse outcomes. Moreover, lupus predominantly affects young females and is associated with significant morbidity and mortality. Notably, the number of lupus patients in Kenya has been on the rise over successive years. There is a paucity of data regarding diagnosis, management and outcome of LN in Africa.

Background Systemic lupus erythematosus (SLE) is an autoimmune disorder characterised by inflammation in different organ systems. Disease activity varies from remissions to exacerbations and progression. Health-related quality of life (HRQoL) represents the patients subjective perception of living with the disease and how it affects their physical, emotional and social functions. The aim of this study was to assess the impact of disease activity on HRQoL. Methods This was a cross-sectional descriptive study conducted at Kenyatta National Hospital rheumatology and renal outpatient clinics. 62 patients fulfilling ≥4 Systemic Lupus International Collaborating Clinics Criteria (SLICC) 2012 for classification of SLE were consecutively recruited. 27 patients with overlap syndromes were excluded. Disease activity was assessed by the modified Systemic Lupus Erythematosus Disease Activity Index 2000 (cSLEDAI-2K). HRQoL was evaluated using self-administered LupusQoL with scores ranging from 0 (worst) to 100 (best). HRQoL was correlated with age, disease duration and disease activity. Data analysis was performed on SPSS version 23. Results The study comprised 60 female patients with mean age 34.7±11.8 years. The median disease duration was 36 months and ranged from 1–324 months. Mean cSLEDAI score was 7±5.2 and median disease activity score was 7. Renal involvement occurred in 53.2%. All domains of LupusQoL were impaired. The mean LupusQoL score was 56%±24.4 (figure 1). SLEDAI scores inversely correlated with scores of physical health, pain, burden to others, body image and general health. The patients with renal disease had significantly lower QoL compared to other patients. Age and disease duration were positively correlated with QoL. Disease duration was associated with a better QoL in the pain, emotional health and body image domains. Conclusions Our study showed a low HRQoL in those with active disease. Young age, a recent diagnosis of lupus and presence of renal disease was associated with a poorer QoL.

Staphylococcus aureus (S. aureus) is a leading cause of hospital and community acquired infections globally. Methicillin-resistant Staphylococcus aureus (MRSA) prevalence has been reported to be high in various settings and is associated with increased morbidity, mortality and risk of nosocomial outbreaks. Surveillance of prevalence and antibiotic susceptibility patterns is important to ensure appropriate antibiotic prescription. The objective of our study was to establish the prevalence of S. aureus, to identify patterns of susceptibility to commonly used antibiotics and quantify contemporary penicillin resistance among S. aureus. A retrospective study was conducted at the Mater Misericordiae Hospital, Nairobi. The study involved a review of non-duplicate records of specimens analyzed between January 2014 and December 2018.A specimen was categorized as Penicillin susceptible (PSSA) if susceptible to Penicillin and Oxacillin, MSSA if resistant to Penicillin but susceptible to Oxacillin, and MRSA if resistant to Oxacillin. We present proportions of S. aureus that was PSSA, MSSA and MRSA. Multivariate logistic regression was used to determine the association between the presence of S. aureus isolates and the source of the clinical specimen (in vs. outpatient), age and gender. A total of 659 specimens of S. aureus were analyzed in the 5-year period. ​​PSSA was the most prevalent organism seen (60.85%) while MRSA was the least prevalent (0.61 %). Most S. aureus was isolated in pus from wound swabs-644 (73. 3%). A significant increase in susceptibility of S. aureus to Penicillin and Amoxicillin-clavulanic acid was observed during the study period however, sensitivity to Amoxicillin declined. This study demonstrated a high prevalence of Penicillin Sensitive S. aureus and a low prevalence of MRSA.

Introduction: There are positive aspects regarding the prescribing of fixed dose combinations (FDCs) versus prescribing the medicines separately. However, these have to be balanced against concerns including increased costs and their irrationality in some cases. Consequently, there is a need to review their value among lower- and middle-income countries (LMICs) which have the greatest prevalence of both infectious and noninfectious diseases and issues of affordability. Areas covered: Review of potential advantages, disadvantages, cost-effectiveness, and availability of FDCs in high priority disease areas in LMICs and possible initiatives to enhance the prescribing of valued FDCs and limit their use where there are concerns with their value. Expert commentary: FDCs are valued across LMICs. Advantages include potentially improved response rates, reduced adverse reactions, increased adherence rates, and reduced costs. Concerns include increased chances of drug:drug interactions, reduced effectiveness, potential for imprecise diagnoses and higher unjustified prices. Overall certain FDCs including those for malaria, tuberculosis, and hypertension are valued and listed in the country's essential medicine lists, with initiatives needed to enhance their prescribing where currently low prescribing rates. Proposed initiatives include robust clinical and economic data to address the current paucity of pharmacoeconomic data. Irrational FDCs persists in some countries which are being addressed.

OBJECTIVES:To evaluate the practice of aminoglycoside use/monitoring in Kenya and explore healthcare worker (HCW) perceptions of aminoglycoside monitoring to identify gaps and opportunities for future improvements, given the low therapeutic index of aminoglycosides.METHODS:This was a two-phase study whereby we reviewed patients' medical records at Kenyatta National Hospital (October-December 2016) in Phase 1 and interviewed HCWs face to face in Phase 2. Outcome measures included describing and evaluating the practice of aminoglycoside use and monitoring and compliance to guidelines. Data were analysed using descriptive and inferential analysis.RESULTS:Overall, out of the 2318 patients admitted, 192 patients (8.3%) were prescribed an aminoglycoside, of which 102 (53.1%) had aminoglycoside doses that did not conform to national guidelines. Aminoglycoside-related adverse effects were suspected in 65 (33.9%) patients. Monitoring of aminoglycoside therapy was performed in only 17 (8.9%) patients, with no therapeutic drug monitoring (TDM), attributed mainly to knowledge and skill gaps and lack of resources. Out of the 28 recruited HCWs, 18 (64.3%) needed training in how to perform and interpret TDM results.CONCLUSIONS:The practice of using and monitoring aminoglycosides was suboptimal, raising concerns around potential avoidable harm to patients. The identified gaps could form the basis for developing strategies to improve the future use of aminoglycosides, not only in Kenya but also in other countries with similar settings and resources.

Background: Hypertension is a major cause of global morbidity and mortality, with high prevalence rates in Africa including Kenya. Consequently, it is imperative to understand current treatment approaches and their effectiveness in practice. Currently, there is paucity of such data in Kenya, which is a concern. The aim is to describe prescribing patterns and adequacy of blood pressure (BP) control in adult hypertensive patients to guide future practice. Method: Retrospective study of patients attending a sub-county outpatient clinic combined with qualitative interviews. Results: 247 hypertensive patients, predominantly female, mean age 55.8 years on antihypertensive therapy for 1-5 years, were analyzed. ACEIs and thiazide diuretics were the most commonly prescribed drugs, mainly as combination therapy. Treatment typically complied with guidelines, mainly for stage 2 hypertension (75%). BP control was observed in 46% of patients, with a significant reduction in mean systolic (155 to 144 mmHg) and diastolic (91 to 83 mmHg) BP (P < 0.001). Patients on 2 antihypertensive drugs were more likely to have uncontrolled BP (OR:1.9, p = 0.021). Conclusion: Encouragingly good adherence to guidelines was helped by training. Poor blood pressure control in the majority needs to be addressed. Additional training of prescribers and follow-up of measures to improve BP control will be introduced and followed up.

Namibia has the highest burden and incidence of hypertension in sub-Sahara Africa. Though non-adherence to antihypertensive therapy is an important cardiovascular risk factor, little is known about potential ways to improve adherence in Namibia following universal access. The objective of this study is to validate the Hill-Bone compliance scale and determine the level and predictors of adherence to antihypertensive treatment in primary health care settings in sub-urban townships of Windhoek, Namibia.

The Pan African Thoracic Society exists to promote respiratory health in Africa. It is supported by the Nuffield Foundation (UK) and the American Thoracic Society. www.africanthoracic.org FSG AFRICA LTD Correspondence to: African Journal of Respiratory Medicine FSG Africa Ltd, Vine House Fair Green, Reach, Cambridge CB25 0JD, UK www.fsg.co.uk Tel: +44 (0)1638 743633 Fax: +44 (0)1638 743998 E-mail: editor@fsg.co.uk

BACKGROUND:Isolated tuberculosis of the spleen has been described occasionally in literature, mostly in immunosuppressed individuals with various risk factors. Sequestration in the spleen makes such Mycobacterium tuberculosis infection difficult to diagnose. This report describes an extremely rare case of isolated splenic tuberculosis in an immunocompetent individual.CASE PRESENTATION:A 26 year old Kenyan male presented with pyrexia of unknown origin, with negative screening tests for bacterial, fungal and parasitic infections. Ziehl-Neelsen staining and GeneXpert tests were negative for M. tuberculosis. Diagnosis of isolated splenic tuberculosis was made on core biopsy of the spleen. The patient initially worsened upon treatment with antituberculous medication attributable to the 'Paradoxical Reaction' phenomenon, before making full recovery.CONCLUSIONS:This case highlights the need to continuously be on the lookout for tuberculosis especially in unusual presentations, including subsequent paradoxical reaction which may be encountered.

Welcome to Annals of Global Health,Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 3.64.Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. Authors of articles accepted for publication in Annals of Global Health will be asked to pay an Article Publication Charge (APC) to cover publication costs. This charge can normally be sourced from your funder or institution. We are committed to supporting authors from all countries to publish their work in Annals of Global Health regardless of national income level, and to achieve this goal, we waive the Article Publication Charge for manuscripts where all authors are from low-income or lower-middle-income countries (as defined by the World Bank). From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included “Strengthening Women’s Leadership in Global Health”, “Decolonizing Global Health Education”, and “Capacity Building for Global Health Leadership Training”. Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

Background : The cardiovascular system is frequently affected in patients with Systemic Lupus Erythematosus (SLE). Involvement of the pericardium, endocardium, myocardium, coronary and pulmonary vessels has been found in several clinical and autopsy studies in patients with SLE; most of which can be detected by noninvasive two dimensional and Doppler echocardiography. More than half of SLE patients experience clinical cardiovascular manifestation during the course of the disease and cardiovascular complications are among the leading causes of morbidity and mortality in patients with SLE. Objective : To determine the prevalence and spectrum of cardiac abnormalities; determined by echocardiography in SLE patients at Kenyatta National Hospital (KNH). Methods : This was a cross-sectional descriptive study of SLE patients attending clinic at KNH. A targeted history and physical examination and a detailed trans-thoracic echocardiography were performed for all patients. The independent variables included; age, sex, duration of disease and medications. The echocardiogram outcome variables included; pericardial effusion, thickening and calcification, systolic and diastolic dysfunction, mitral valve thickening, stenosis and regurgitation, aortic valve thickening, stenosis and regurgitation, and pulmonary hypertension. Results : Sixty three SLE patients participated in the study, the mean age was 36.7 years, with a female to male ration of 20:1 and a meadian duration of disease of 36 months. Over 70% of participants were on at least 2 disease modifying medication. The overall prevalence of echocardiographic abnormalities was 88.9%, the major drivers of this high prevalence being pericardial and valvular thickening. The single moast common cardiac lesion was pericardial thickening at 77.8%. The mitral valve was the most commonly affected valve with 69.8% and 30.2% having mitral thickening and regurgitation respectively. Aortic valve thickening and regurgitation was found in 25.4% and 6.3% of participants respectively. Diastolic dysfunction was found in 50.8% of participants and was found to be associated with older age at diagnosis. Pulmonary hypertension was found in 22.2% of participants. Conclusion : The study demonstrates a high prevalence of cardiac abnormalities among SLE patients despite being on disease modifying medications. Even though the majority of these abnormalities comprised of clinically insignificant pericardial and valvular thickening, the prevalence of valvular insufficiency and pulmonary hypertension are substantially high and relatively higher than the prevalence seen in other studies in the case of pulmonary hypertension.