Conceptualizing Community Engagement for Mental and Brain Health Research in Low- and Middle-Income Countries: A Case of Kilifi County, Kenya.

Community engagement (CE) has increasingly been recognized as a critical element for successful health promotion and intervention programs. However, the term CE has been used to mean different things in different settings. In this article, we explore how CE has been conceptualized in the field of mental and brain health in Kilifi County, Kenya. We used ethnographic methods encompassing focused group discussions, key informant interviews, and observations with 65 participants, purposively recruited from Kilifi County. Data were transcribed verbatim and thematically analyzed. Our findings show that community members and stakeholders had diverse perceptions of and experiences with CE. Factors such as trust between researchers and community members, sensitization, and awareness creation were key for acceptance of research projects. Partial involvement in research, lack of access to information, poverty and socio-economic challenges, and financial expectations from researchers hindered CE and led to resistance to participation in research projects. For effective CE, there is a need to work closely with community gatekeepers, create awareness of the research projects, use local languages, and ensure continuous engagement that promotes equitable research participation. Our findings suggest that tacit knowledge, context, and mechanisms for research are all critical features of CE and should be considered to enhance acceptance and sustainability of mental and brain health interventions in Kenya.

Outcomes of different steroid dosing regimens in critical Covid-19 pneumonia at a Kenyan hospital: A retrospective cohort study.

BACKGROUND: Among therapeutic options for severe and critical COVID- 19 infection, dexamethasone six milligrams once daily for ten days has demonstrated mortality benefit and is guideline recommended at this dose. In practice, variable doses of steroids have been used, especially in critical care settings. Our study aimed to determine the pattern of steroid dosing and outcomes in terms of critical care mortality, occurrence of dysglycaemias, and occurrence of superadded infections in patients with critical COVID-19. METHODS: A retrospective cohort study was carried out on all eligible patients admitted to the Aga Khan University Hospital, Nairobi, with critical COVID-19 between 1st March 2020 and 31st December 2021. The intervention of interest was corticosteroids quantified as the average daily dose in milligrams of dexamethasone. A steroid dose of six milligrams once a day was compared to high dose steroid dosing, which was defined as any dose greater than this. The primary outcome measure was ICU mortality and secondary outcomes included occurrence of dysglycaemias, superadded infections and duration of critical care admission. RESULTS: The study included 288 patients. The median age was 61.2 years (IQR: 49.7, 72.5), with 71.2% of patients being male. The most common comorbidities were diabetes mellitus (60.7%), hypertension (58%), and heart disease (12.2%). The average oxygen saturation and C-reactive protein at admission were 82% [IQR: 70.0-89.0]and 113.0 [IQR: 54.0-186.0], respectively. Fifty-eight percent of patients received a standard dose (6mg) of steroids. The mortality rate was higher in the high-dose group compared to the standard-dose group; however, the difference was not statistically significant (47.9% vs 43.7% p = 0.549). The two most common steroid associated adverse effects were uncomplicated hyperglycemia (62.2%) and superimposed bacterial pneumonia (20.1%). The high-dose group had a higher incidence of uncomplicated hyperglycemia compared to the standard-dose group (63.6% vs 61.1%). However, the incidence of diabetic ketoacidosis was lower in the high dose group (0.6% vs 6.6%). Oxygen saturation at admission was associated with survival where it was lower among non-survivor patients with critical COVID-19. CONCLUSION: The study found that high-dose steroids in the treatment of critically ill patients with COVID-19 pneumonia did not confer any mortality benefit and were associated with an increased risk of dysglycemia and superimposed infections.

Association Between CA 15-3 and 18F-FDG PET/CT Findings in Recurrent Breast Cancer Patients at a Tertiary Referral Hospital in Kenya.

The tumor marker cancer antigen 15-3 (CA 15-3) is that most commonly used to monitor metastatic breast cancer during active therapy and surveillance for disease recurrence after treatment. The association of CA 15-3 and 18F-FDG PET/CT findings can be considered complementary, since any significant rise may indicate the presence of disease and imaging is able to map the tumor sites. Although current guidelines do not recommend the routine performance of CA 15-3 in asymptomatic patients being followed up after definitive breast cancer treatment, most oncologists perform serial assessment of the tumor markers as part of routine follow-up of patients. The aim of this study was to evaluate the correlation between CA 15-3 levels and 18F-FDG PET/CT scan findings in patients with recurrent breast cancer. Methods: This was a cross-sectional study with data collected retrospectively. Patients being evaluated for breast cancer recurrence with 18F-FDG PET/CT imaging and CA 15-3 level were included. Evaluation of the association between CA 15-3 levels and 18F-FDG PET/CT scan findings was then done. Results: In total, 154 cases were included in this study; 62 patients had recurrence (positive) on the 18F-FDG PET/CT scans, whereas 92 patients had normal (negative) findings on follow-up 18F-FDG PET/CT scans. There was an association between CA 15-3 levels and the presence or absence of recurrence on 18F-FDG PET/CT scans, with 84.4% (27/32) of patients who had elevated CA 15-3 levels having disease recurrence on 18F-FDG PET/CT and 84.4% (27/32) of patients who had elevated CA 15-3 levels having disease recurrence on 18F-FDG PET/CT as well as a correlation with the burden of metastases. Most patients with disease recurrence on 18F-FDG PET/CT, however, had normal CA 15-3 levels. Conclusion: Higher CA 15-3 levels correlate with breast cancer recurrence on 18F-FDG PET/CT as well as with burden of metastasis. Notably, CA 15-3 levels within the reference range do not exclude breast cancer disease recurrence since more than half of patients with recurrence had normal CA 15-3 levels. 18F-FDG PET/CT should therefore be considered in patients with suspected breast cancer recurrence but normal CA 15-3 levels.

Factors Associated With Non-Uptake of Implantable Cardioverter-Defibrillator (ICD) Among Eligible Patients at a Tertiary Hospital in Kenya.

Background: Efficacy of Implantable Cardioverter-Defibrillator (ICD) implantation in both primary and secondary prevention of Sudden Cardiac Death (SCD) in at-risk population is well established. ICD implantation rates remain low particularly in Africa with a paucity of data regarding factors associated with non-uptake. Objectives: The primary study objective was to determine the factors associated with non-uptake of ICD among heart failure (HF) patients with reduced ejection fraction (EF<35%). Reasons for ICD refusal among eligible patients were reviewed as a secondary objective. Methods: This was a retrospective study among HF patients eligible for ICD implantation evaluated between 2018 to 2020. Comparison between ICD recipient and non-recipient categories was made to establish determinants of non-uptake. Results: Of 206 eligible patients, only 69 (33.5%) had an ICD. Factors independently associated with non-uptake were lack of private insurance (42.3% vs 63.8%; p = 0.005), non-cardiology physician (16.1% vs 5.8%; p = 0.045) and non-ischemic cardiomyopathy (54.7% vs 36.4% p = 0.014). The most common (75%) reason for ICD refusal was inability to pay for the device. Conclusion: ICDs are underutilized among eligible HF with reduced EF patients in Kenya. The majority of patients without ICD had no private insurance, had non-ischemic cardiomyopathy and non-cardiology primary physician. Early referral of HF with reduced EF patients to HF specialists to optimize guideline-directed medical therapy and make ICD recommendation is needed.

Clinical presentation and outcomes of care in adults with diabetic ketoacidosis pre-COVID-19 and during-COVID-19 at a tertiary, referral hospital in Nairobi, Kenya.

BACKGROUND: Prognosis of DKA has improved over time with the availability of evidence-based protocols and resources. However, in Kenya, there are limited resources for the appropriate diagnosis and management of DKA, mostly limited to tertiary-level referral facilities. This study aimed to review the clinical presentation, management, and outcomes of adult patients admitted with DKA and assess differences in these parameters before and during the COVID-19 pandemic. METHODS: This was a retrospective study of DKA admissions from January 2017 to December 2021. Patient data were retrieved from the medical records department using ICD-10 codes, and individual details were abstracted on clinical presentation, management, and outcomes of DKA. Comparisons were made between pre-COVID-19 and during COVID-19 durations. RESULTS: 150 patients admitted with DKA were included (n = 48 pre- COVID-19, n = 102 during COVID-19 (n = 23 COVID-19 positive, n = 79 COVID-19 negative)). Median age was 47 years (IQR 33.0, 59.0), median HbA1C was 12.4% [IQR 10.8, 14.6]), and most patients had severe DKA (46%). Most common DKA precipitants were infections (40.7%), newly diagnosed diabetes (33.3%) and missed medication (25.3%). There was a significant difference in pulmonary infections as a DKA precipitant, between the pre- COVID and during COVID-19 pandemic (21.6% during COVID-19 versus 6.3% pre- COVID-19; p = 0.012). Median total insulin dose used was 110.0 units [IQR 76.0, 173.0], and a 100% of patients received basal insulin. Median length of hospital stay was 4.0 days [IQR 3.0, 6.0] and time to DKA resolution was 30.0 h [IQR 24.0, 48.0]. There were 2 deaths (1.3%), none directly attributable to DKA. Severity of DKA significantly differed between pre- COVID-19, COVID-19 positive and COVID-19 negative DKA (52.2% of COVID-19 positive had moderate DKA compared to 26.6% of COVID-19 negative and 22.9% of Pre-COVID-19 (p = 0.006)). CONCLUSION: Even in developing regions, good outcomes can be achieved with the appropriate facilities for DKA management. Clinician and patient education is necessary to ensure early detection and prompt referral to avoid patients presenting with severe DKA. Exploratory studies are needed to assess reasons for prolonged time to DKA resolution found in this study.

The Shortfalls of Mental Health Compartment Models: A Call to Improve Mental Health Investment Cases in Developing Countries.

OBJECTIVES: There are irregularities in investment cases generated by the Mental Health Compartment Model. We discuss these irregularities and highlight the costing techniques that may be introduced to improve mental health investment cases. METHODS: This analysis uses data from the World Bank, the World Health Organization Mental Health Compartment Model, the United Nations Development Program, the Kenya Ministry of Health, and Statistics from the Kenyan National Commission of Human Rights. RESULTS: We demonstrate that the Mental Health Compartment Model produces irrelevant outcomes that are not helpful for clinical settings. The model inflated the productivity gains generated from mental health investment. In some cases, the model underestimated the economic costs of mental health. Such limitation renders the investment cases poor in providing valuable intervention points from the perspectives of both the users and the providers. CONCLUSIONS: There is a need for further calibration and validation of the investment case outcomes. The current estimated results cannot be used to guide service provision, research, and mental health programming comprehensively.

Associated Factors and Outcomes of Acute Kidney Injury in COVID-19 Patients in Kenya.

Background: Corona Virus Disease 2019 (COVID-19), an infection caused by the SARS-CoV-2 virus, has been the largest global pandemic since the turn of the 21st century. With emerging research on this novel virus, studies from the African continent have been few. Corona Virus Disease 2019 has been shown to affect various organs including the lungs, gut, nervous system, and the kidneys. Acute kidney injury (AKI) is an independent risk factor for mortality and increases the health care burden for patients with persistent kidney dysfunction and maintenance dialysis. Sub-Saharan Africa has a high number of poorly controlled chronic illnesses, economic inequalities, and health system strains that may contribute to higher cases of kidney injury in patients with COVID-19 disease. Objectives: The objective of this study was to determine the incidence, associated factors, and outcomes of AKI in patients hospitalized with COVID-19 in Kenya. Methods: This retrospective cohort study included 1366 patients with confirmed COVID-19 illness hospitalized at the Aga Khan University Hospital in Nairobi, Kenya, between April 1, 2020 and October 31, 2021. Data were collected on age, sex, the severity of COVID-19 illness, existing pregnancy and comorbid conditions including human immunodeficiency virus (HIV), diabetes mellitus, hypertension, and functioning kidney transplant patients. Univariate analysis was carried out to determine the association of clinical and demographic factors with AKI. To determine independent associations with AKI incidence, a logistic regression model was used and the relationship was reported as odds ratios (ORs) with a 95% confidence interval (CI). The outcomes of AKI including the in-hospital mortality rate, renal recovery rate at hospital discharge, and the duration of hospital stay were reported and stratified based on the stage of AKI. Results: The median age of study patients was 56 years (interquartile range [IQR] = 45-68 years), with 67% of them being male (914 of 1366). The AKI incidence rate was 21.6% (n = 295). Patients with AKI were older (median age = 64 years vs 54 years; P < .001), majority male (79% of men with AKI vs 63.6% without AKI; P < .001), and likely to have a critical COVID-19 (OR = 8.03, 95% CI = 5.56-11.60; P < .001). Diabetes and hypertension, with an adjusted OR of 1.75 (95% CI = 1.34-2.30; P < .001) and 1.68 (95% CI = 1.27-2.23; P < .001), respectively, were associated with AKI occurrence in COVID-19. Human immunodeficiency virus, pregnancy, and a history of renal transplant were not significantly associated with increased AKI risk in this study. Patients with AKI had significantly higher odds of mortality, and this effect was proportional to the stage of AKI (OR = 11.35, 95% CI = 7.56-17.03; P < .001). 95% of patients with stage 1 AKI had complete renal recovery vs 33% of patients with stage 3 AKI. Of the patients with stage 3 AKI (n = 64), 10 underwent hemodialysis, with 1 recovery in renal function and 3 patients requiring ongoing dialysis after discharge. Conclusions: This study was conducted at a single private tertiary-level health care facility in Kenya and only up to the time of hospital discharge. It is one of the first large studies from sub-Saharan Africa looking at the associated factors and outcomes of AKI in COVID-19 and forms a foundation for further analysis on the long-term consequences of COVID-19 on the kidneys. A major limitation of the study is the lack of baseline pre-admission creatinine values for most patients; thus, the impact of chronic kidney disease/baseline creatinine values on the incidence of AKI could not be established.

Surgical site infections post cesarean section and associated risk factors: a retrospective case-control study at a tertiary hospital in Kenya.

Background: Surgical site infection is a common healthcare-associated infection that affects maternal health, yet it can be prevented or controlled. Caesarian sections are most likely to develop surgical site infections. The rates of delivery by caesarian section in reported to be higher that the acceptable rates in some healthcare facilities. Risk factors for surgical site infections can be identified and modified to reduce the occurrence of surgical site infections. This study aims to determine the risk factors that contribute to surgical site infections post caesarian section in a tertiary teaching hospital in Kenya. Methods: This was a retrospective case-control (1:2 matched) study conducted between 1st November 2021 to 31st October 2022 at a tertiary hospital in Nairobi. Data was extracted on surgical site risk factors as per World Health Organization's recommended preoperative measures, for both cases and controls. Descriptive statistics was used to summarize the variables and the Chi-squared test and Fisher's Exact test were used for group comparisons. Results: A total of 1,262 caesarian deliveries were performed, 2.1% (27/1262) of which developed surgical site infections post caesarian section. The risk factors identified were not significantly associated with surgical site infection development (gestational age P=0.152, body mass index P=0.615, premature rupture of membranes P=0.253, and antibiotic prophylaxis P=0.108). Conclusions: There was no significant association of exposure to surgical site infection risk factors with surgical site infection despite a positive trend. Other prospective methods should also be used in addition to chart reviews to determine the level of effect each risk factor has on surgical site infection.

Religious, Cultural, and Sex Influences on Advance Care Directives in Patients Admitted to a Tertiary Care Center in Kenya.

INTRODUCTION: Advance care directives (AD) are instructions from patients regarding the care they would prefer if they could not make medical decisions in the future. It is widely recognized that racial and ethnic as well as sex differences, particularly in the West, can influence AD. However, to the best of our knowledge, there is limited understanding of how these factors impact AD in sub-Saharan Africa. METHODS: This prospective cross-sectional study was conducted at the Aga Khan University Hospital, Nairobi. We enrolled patients above the age of 18 years who were admitted to the general medical wards. The data were collected using a structured questionnaire that consisted of questions based on demographics and AD. Descriptive statistics were used to summarize the data, including frequencies and percentages, as well as medians and interquartile ranges. RESULTS: The study involved 286 participants, with a median age of 44.0 years (IQR: 37.0 - 52.0). Roughly half of the participants were male (51.7%), and the majority identified themselves as Christians (77.3%) and of African ethnicity (78.3%). Upon further analysis, it was discovered that only 35.3% had an awareness of AD. Notably, individuals from the Hindu religion and Asian ethnicity demonstrated significantly higher knowledge of AD. Furthermore, more males reported having a living will and believed that AD are crucial for patients who could not make independent medical decisions compared to females. CONCLUSION: This study indicated a lower awareness and knowledge of AD among the participants. Hindus and Asians exhibited higher levels of awareness regarding AD. Considering the diverse religious and cultural backgrounds in our setting, there is a pressing need for strategies to increase awareness surrounding AD.

High acceptability, convenience and reduced carbon emissions of tele-neurology outpatient services at a regional referral centre in Kenya.

Background: There is severe shortage of neurologists in sub-Saharan Africa. Tele-neurology consultations (TNC) can bridge this service gap, but there is very little published evidence on TNC in our setting, which we addressed through our study. Methods: We prospectively enrolled patients at our neurology outpatients from October 2020 to October 2021. We administered a post-TNC questionnaire which captured satisfaction/acceptability using Likert scales. A sub-group of participants who also did in-person consultations (IPC) were additionally administered post-IPC questionnaires. Statistical comparisons were made using the paired student t-test, and descriptive data expressed as median (inter-quartile range). Results: From 219 enrolled patients, 66.7% participants responded: 74.0% had both IPC and TNC; 63.0% were female; age was 40.9 (30.6-55.2) years; and 2.7% were from neighbouring countries. The commonest presentations were headache (30.8%), seizures (26.0%) and neurodegenerative disorders (15.1%). For TNC, >90% found it: (i) as comfortable as IPC (p = 0.35); (ii) didn't violate their privacy; (iii) saved time [3.0 (2.0-4.0) hours], travel [11.0 (7.2-21.1) km] and cost [$9.09 (4.55-18.18)]; and (iv) addressed their concerns satisfactorily such that they would use TNC again. Conversely, 15.1% didn't agree with TNC being as effective as IPC, and felt the neurologist did not satisfactorily identify all of their health problems (p = 0.03). In total, our TNC service saved our patients $6167, 1143 h, and 25,506 km of travel, translating to 3.5 t (equivalent to 21 newly-planted trees) of carbon dioxide emissions. Conclusions: Our study demonstrates that TNC is an acceptable, efficient, effective, and environmentally-sustainable care delivery model.

12-month substance use disorders among first-year university students in Kenya.

OBJECTIVES: The period of entry into university represents one of vulnerability to substance use for university students. The goal of this study is to document the 12-month prevalence of substance use disorders among first year university students in Kenya, and to test whether there is an association between substance use disorders and mental disorders. METHODS: This was a cross-sectional online survey conducted in 2019 and 2020 as part of the World Health Organization's World Mental Health International College Student (WMH-ICS) survey initiative. A total of 334 university students completed the survey. Descriptive statistics were used to summarize the demographic characteristics of the participants. Multivariate logistic regression was used to assess the association between substance use disorder and mental disorders after adjusting for age and gender. RESULTS: The 12-month prevalence for alcohol use disorder was 3.3%, while the 12-month prevalence for other substance use disorder was 6.9%. Adjusting for age and gender, there was an association between any substance use disorder and major depression, generalized anxiety disorder, bipolar 1 disorder, intermittent explosive disorder, social anxiety disorder, suicidal ideation, suicide attempt, and non-suicidal self-injury. CONCLUSION: These findings highlight the need to institute policies and interventions in universities in Kenya that address substance use disorders and comorbid mental disorders among first-year students.

An electronic health record system implementation in a resource limited country-lessons learned.

Electronic health records have revolutionized the medical world by improving medical care, refining provider documentation, standardizing care, and minimizing sentinel events. Successful implementation of electronic health records remains a daunting task and requires careful strategic planning and buy-in from key stakeholders. Much has been published in resource-rich settings and high-income countries about implementations of electronic health records. However, little is known about the experience in resource-limited settings where challenges remain unique and distinct from other parts of the world. Our intention is to share lessons learned during implementation of a web-based electronic health record at a tertiary care center in Kenya.

Stop-bang questionnaire for screening obstructive sleep apnea syndrome among hypertensive patients in Kenya.

INTRODUCTION: Obstructive sleep apnea (OSA) is a type of breathing problem during sleep caused by the blockage of the upper airway, which can cause cessation of airflow. There is limited research on the prevalence of OSA in hypertensive patients in sub-Saharan Africa (SSA). The study aimed to describe the prevalence and clinical characteristics of OSA among hypertensive patients at a tertiary hospital in Nairobi, Kenya. METHODS: This cross-sectional study was conducted at the Aga Khan University Hospital in Nairobi, Kenya. Two hundred and fifty-one hypertensive patients were screened for OSA risk using the STOP-Bang questionnaire (SBQ). Patients with a SBQ score of ≥ 4 were categorized as high risk for OSA. Descriptive statistics were employed to describe both categorical and continuous variables and binary logistic regression to assess factors associated with the high risk of OSA. RESULTS: The study reported that 78.5% of the participants had high-risk OSA. The median age and body mass index (BMI) were 57.0 years (IQR: 50.0-64.0) and 28.3 kg/m2, respectively. Age, neck circumference, gender, and BMI were significantly higher in the high-risk OSA group as compared to the low-risk group. CONCLUSION: The study highlights the importance of screening hypertensive patients for OSA using the SBQ in clinical settings, particularly in low-and middle-income countries (LMICs). Healthcare providers can use patient characteristics such as age, gender, neck circumference, and BMI to identify those at greater risk of developing OSA. Further research could focus on developing effective OSA prevention and treatment interventions in hypertensive patients.

Use of mobile technology to identify behavioral mechanisms linked to mental health outcomes in Kenya: protocol for development and validation of a predictive model.

OBJECTIVE: This study proposes to identify and validate weighted sensor stream signatures that predict near-term risk of a major depressive episode and future mood among healthcare workers in Kenya. APPROACH: The study will deploy a mobile application (app) platform and use novel data science analytic approaches (Artificial Intelligence and Machine Learning) to identifying predictors of mental health disorders among 500 randomly sampled healthcare workers from five healthcare facilities in Nairobi, Kenya. EXPECTATION: This study will lay the basis for creating agile and scalable systems for rapid diagnostics that could inform precise interventions for mitigating depression and ensure a healthy, resilient healthcare workforce to develop sustainable economic growth in Kenya, East Africa, and ultimately neighboring countries in sub-Saharan Africa. This protocol paper provides an opportunity to share the planned study implementation methods and approaches. CONCLUSION: A mobile technology platform that is scalable and can be used to understand and improve mental health outcomes is of critical importance.

Metastatic breast cancer in Kenya: survival, prognosis and management at a tertiary referral centre.

There has been an increase in breast cancer in Africa with up to 77% of patients diagnosed with advanced disease. However, there is little data on survival outcomes and prognostic factors affecting survival in patients with metastatic breast cancer (MBC) in Africa. The study objective was to establish the survival of patients with MBC at a single tertiary health facility, the clinical and pathological characteristics affecting survival and describe the treatment modalities used. This was a retrospective descriptive study conducted at Aga Khan University Hospital, Nairobi of patients diagnosed with MBC between 2009 and 2017. Survival data was collected on metastatic free survival, survival time between diagnosis of first metastasis and death and overall survival. Data on patient's age, menopausal status and stage at diagnosis, tumour grade, receptor status, site of metastasis and treatment given was also collected. The Kaplan-Meier Estimator was used to estimate survival. Prognostic factors for survival outcomes were analysed using univariate analysis. Standard descriptive statistics were used to describe patient characteristics. A total of 131 patients were included in the study. The median survival was 22 months. The 3 and 5-year survivals were 31.3% and 10.7%, respectively. On univariate analysis, the Luminal A molecular subtype was a significant positive prognostic factor hazard ratios (HR 0.652 95% confidence interval (CI) 0.473-0.899) while metastasis to the liver or brain were significant negative prognostic factors (HR 0.615 95% CI 0.413-0.915 and HR 0.566 95% CI 0.330-0.973, respectively). A large proportion (87.0%) received some treatment for metastatic disease. Our study concluded that survival rates for patients diagnosed with MBC were lower compared to studies from Western countries but higher than in studies from Sub-Saharan Africa. Luminal A molecular subtype was found to be a positive prognostic factor and metastasis to the liver or brain were found to be negative prognostic factors. Improved access to adequate treatment for MBC is required in the region.

Discrimination and Abuse Among Healthcare Workers from Patients and their Relatives at a Tertiary Hospital in Kenya.

Discrimination and abuse of healthcare workers (HCWs) by patients and their relatives remains a pressing and prevalent problem in various healthcare settings, negatively affecting professional outcomes. Despite this, little has been reported about discrimination and abuse in many low- and middle-income countries such as Kenya. We conducted a cross-sectional survey study between May - August 2021 among healthcare workers at a hospital in Kenya. Email invitations were sent, and the survey was in English, and the data was collected through and online survey. Discrimination based on gender was reported by 24.9% of all HCWs; 39.9% of doctors, 17.2% of nurses, and 10.9% of allied staff whereas racial discrimination was reported by 28.8% of all HCWs; 49.0% of doctors, 18.9% of nurses, and 8.9% of allied staff. Verbal or emotional abuse was the most common form of abuse and was reported by 56.8% of all HCWs while physical abuse was reported by 4.9% of all HCWs. For those that reported discrimination based on gender, 77.4% reported patient and their family members as the main source, whereas 81.2% of those that reported discrimination based on race reported the main source was from patient and their family members. Despite strict laws against discrimination and abuse, a significant portion of healthcare providers suffer from discrimination and abuse primarily from patients and their family members. In addition to education programs and policies to curb such behavior in the work environment, coping mechanisms should be actively sought to help healthcare providers deal with such actions.

Developing and testing a clinical care bundle incorporating caffeine citrate to manage apnoea of prematurity in a resource-constrained setting: a mixed methods clinical feasibility study protocol.

BACKGROUND: Apnoea of prematurity (AOP) is a common condition among preterm infants. Methylxanthines, such as caffeine and aminophylline/theophylline, can help prevent and treat AOP. Due to its physiological benefits and fewer side effects, caffeine citrate is recommended for the prevention and treatment of AOP. However, caffeine citrate is not available in most resource-constrained settings (RCS) due to its high cost. Challenges in RCS using caffeine citrate to prevent AOP include identifying eligible preterm infants where gestational age is not always known and the capability for continuous monitoring of vital signs to readily identify apnoea. We aim to develop an evidence-based care bundle that includes caffeine citrate to prevent and manage AOP in tertiary healthcare facilities in Kenya. METHODS: This protocol details a prospective mixed-methods clinical feasibility study on using caffeine citrate to manage apnoea of prematurity in a single facility tertiary-care newborn unit (NBU) in Nairobi, Kenya. This study will include a 4-month formative research phase followed by the development of an AOP clinical-care-bundle prototype over 2 months. In the subsequent 4 months, implementation and improvement of the clinical-care-bundle prototype will be undertaken. The baseline data will provide contextualised insights on care practices within the NBU that will inform the development of a context-sensitive AOP clinical-care-bundle prototype. The clinical care bundle will be tested and refined further during an implementation phase of the quality improvement initiative using a PDSA framework underpinned by quantitative and qualitative clinical audits and stakeholders' engagement. The quantitative component will include all neonates born at gestation age < 34 weeks and any neonate prescribed aminophylline or caffeine citrate admitted to the NBU during the study period. DISCUSSION: There is a need to develop evidence-based and context-sensitive clinical practice guidelines to standardise and improve the management of AOP in RCS. Concerns requiring resolution in implementing such guidelines include diagnosis of apnoea, optimal timing, dosing and administration of caffeine citrate, standardisation of monitoring devices and alarm limits, and discharge protocols. We aim to provide a feasible standardised clinical care bundle for managing AOP in low and middle-income settings.

The diagnostic accuracy of an initial point-of-care lactate at the emergency department as a predictor of in-hospital mortality among adult patients with sepsis and septic shock.

Background: In patients with sepsis, elevated lactate has been shown to be a strong predictor of in-hospital mortality. However, the optimal cutoff for rapidly stratifying patients presenting to the emergency department at risk for increased in-hospital mortality has not been well defined. This study aimed to establish the optimal point-of-care (POC) lactate cutoff that best predicted in-hospital mortality in adult patients presenting to the emergency department. Methods: This was a retrospective study. All adult patients who presented to the emergency department at the Aga Khan University Hospital, Nairobi, between 1 January 2018 and 31 August 2020 with suspected sepsis or septic shock and were admitted to the hospital were included in the study. Initial POC lactate results (GEM 3500® blood gas analyzer) and demographic and outcome data were collected. A receiver operating characteristic (ROC) curve for initial POC lactate values was plotted to determine the area under the curve (AUC). An optimal initial lactate cutoff was then determined using the Youden Index. Kaplan-Meier curves were used to determine the hazard ratio (HR) for the identified lactate cutoff. Results: A total of 123 patients were included in the study. They had a median age of 61 years [interquartile range (IQR) 41.0-77.0]. Initial lactate independently predicted in-hospital mortality [adjusted odds ratio (OR) 1.41 95% confidence interval (CI 1.06, 1.87) p = 0.018]. Initial lactate was found to have an area under the curve (AUC) of 0.752 (95% CI, 0.643 to 0.86). Additionally, a cutoff of 3.5 mmol/L was found to best predict in-hospital mortality (sensitivity 66.7%, specificity 71.4%, PPV 70%, NPV 68.2%). Mortality was 42.1% (16/38) in patients with an initial lactate of ≥ 3.5 mmol/L and 12.7% (8/63) in patients with an initial lactate of <3.5 mmol/L (HR, 3.388; 95% CI, 1.432-8.018; p < 0.005). Discussion: An initial POC lactate of ≥ 3.5 mmol/L best predicted in-hospital mortality in patients presenting with suspected sepsis and septic shock to the emergency department. A review of the sepsis and septic shock protocols will help in the early identification and management of these patients to reduce their in-hospital mortality.

Factors associated with depressive symptoms in patients with benign prostatic enlargement.

BACKGROUND: Depression is a common condition that may lead to suicide at its worst. It is considered one of the primary causes of morbidity globally. Among the urological causes of depression is benign prostatic enlargement (BPE). AIM: To determine the prevalence and factors associated with depressive symptoms among BPE patients. SETTING: This study was conducted in the Urology and Family Medicine Clinic at the Aga Khan University Hospital, Nairobi and Urology clinic at the Aga Khan Hospital Mombasa. METHODS: The study was a cross-sectional design recruiting 308 males above the age of 40. Patient Health Questionnaire-9 and International Prostate Symptom Score (IPSS) were used to assess depressive symptoms and lower urinary tract symptoms (LUTS), respectively. Association between depressive symptoms and LUTS was determined. Factors associated with depressive symptoms were analysed by logistic regression. RESULTS: Prevalence of depressive symptoms among patients with symptomatic benign prostatic enlargement (sBPE) was 42.90%. Factors associated with depressive symptoms included comorbid conditions, medication side effects, reduced libido, alcohol use, disturbed sleep at night and anxiety in regard to the prostate condition. CONCLUSION: There is a high prevalence of depressive symptoms among men with BPE. Assessment and early intervention for depressive symptoms among men with BPE should be initiated before clinical depression sets in.Contribution: The study has created a knowledge base on factors associated with depressive symptoms among men with sBPE in the African context.