Examining need and capacity for the development of a pediatric liver transplantation program in Kenya.

BACKGROUND: In Africa, pediatric liver transplantation (PLT) is currently only performed in Egypt and South Africa, leaving those who require treatment in Kenya to travel abroad. The aim of this study was to determine whether sufficient capacity and need exists in Kenya to establish a safe and sustainable PLT program. METHODS: A descriptive analysis of the intensive care unit (ICU) beds, surgical workforce, current hepatobiliary volume, and estimated prevalence of pediatric liver disease (PLD) was conducted across 17 hospitals in Kenya between July and September 2020. Data were collected from medical superintendents, directors of surgical departments, or nominated proxies at Kenyan Level 5 and 6 hospitals via a web-based survey. RESULTS: A total of 165 ICU beds were reported at 17 facilities, with 15 facilities reporting five or more beds. About 39% of general surgeons at responding hospitals performed hepatobiliary procedures, and 30% performed pediatric surgeries. Only 10% of surgeons had pediatric training. Over half (57%) of hospitals performed hepatobiliary procedures; at the maximum, 1-5 cases were performed per week including cholecystectomy to Kasai portoenterostomy and hepatectomy. Across 13 hospitals, there were an estimated 192-570 cases of PLD seen per month. The most common PLDs were hepatitis B, neonatal hepatitis, cirrhosis, and acute hepatic failure. Overall, two hospitals possessed the minimum workforce and resources to attempt PLT. CONCLUSIONS: In Kenya, ICU bed availability, pediatric surgical training, and hepatobiliary volume are limited. However, the high prevalence of PLD demonstrated a significant need for PLT across all Kenyan hospitals.

Facilitation as a component of evidence implementation: a multinational perspective.

BACKGROUND: Facilitation is a key component of JBI's approach to evidence implementation along with context analysis and evaluation of process and outcomes. Although the role of facilitation is recognized as a critical component of evidence implementation, what constitutes effective facilitation is poorly understood. AIM: This article presents a descriptive exploration of facilitation as it occurs in evidence implementation initiatives conducted in various healthcare and geographical contexts. All projects used the JBI approach to evidence implementation. METHODS: To provide a multinational perspective on how facilitation was operationalized to promote positive changes in clinical practice and health outcomes, five case studies of evidence implementation projects are presented. RESULTS: The cases highlighted that facilitation is a multifaceted process that can be met through a variety of roles that address aspects of education and capacity building, partnerships, action planning, problem solving and evaluation. Facilitation in all cases appeared to be collaborative, with multiple 'players' within and outside of the health organization being involved in the process. Although there are similarities in activities, facilitation involved some level of local contextualization where there were unique or additional activities performed to accommodate the local needs and requirements of the health organization involved in each case. Numerous contextual factors influenced the success of the implementation initiative. CONCLUSION: The cases emphasized the complex nature of facilitation as a strategy for evidence implementation, indicating that contextual attributes and features define the range of knowledge, skills, and activities that should take place in order for facilitation to be effective. Although there appears to be some core components, tailoring and adaptation of the facilitation process (or roles) is required.

Needle and syringe programs for reducing blood-borne diseases among people who inject drugs in sub-Saharan Africa: a scoping review protocol.

OBJECTIVE: This review will identify, explore, and map the literature on the characteristics and implementation modalities of needle and syringe programs for reducing blood-borne diseases among people who inject drugs in sub-Saharan Africa compared with the recommended standards by the World Health Organization and AIDS Projects Management Group. INTRODUCTION: Sub-Saharan Africa bears a disproportionate burden of infectious diseases and HIV/AIDS. Needle and syringe programs have been shown to be effective in preventing transmission of infections among those who inject drugs by providing them with sterile injection equipment. The programs may also serve as avenues for addressing other issues that affect this population. INCLUSION CRITERIA: This review will consider published and unpublished studies on needle and syringe programs as a method of preventing blood-borne infections among people who inject drugs in sub-Saharan Africa. The review will consider quantitative, qualitative, and mixed methods study designs, as well as systematic reviews and text and opinion papers. METHODS: The electronic databases to be searched include MEDLINE, African Journals Online, CINAHL, the Cochrane Library, Embase, and TRoPHI. We will also search sources of unpublished studies and gray literature (conference abstracts, theses, etc). The search will be restricted to studies in English, with no date limit. Data extraction will be done by two independent reviewers, guided by an extraction tool developed by the reviewers. Key information, such as author, reference, and findings relevant to the review questions, will be obtained. The results will be presented as graphs, figures, and tables accompanied by a narrative summary.

Diagnostic accuracy of [-2]proPSA versus Gleason score and Prostate Health Index versus Gleason score for the determination of aggressive prostate cancer: a systematic review.

OBJECTIVE: The objective of this review was to determine the diagnostic accuracy of [-2]proPSA (p2PSA) and the Prostate Health Index compared to the Gleason score in determining the aggressiveness of prostate cancer. INTRODUCTION: Prostate cancer is the most commonly diagnosed cancer in men. However, the utility of currently available biomarkers for determining the aggressive form of the disease remains unknown. This review sought to determine the diagnostic accuracy of two new biomarkers in determining the aggressive form of prostate cancer. INCLUSION CRITERIA: Diagnostic accuracy studies that enrolled men of any age and any prostate specific antigen (PSA) level with histologically confirmed prostate cancer in which Prostate Health Index and p2PSA were assessed in comparison to Gleason score for the determination of aggressive prostate cancer were considered for inclusion. There was no time limitation on study inclusion. METHODS: A three-step search strategy was utilized to identify both published and unpublished studies in the English language in the following sources: PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, Google Scholar, MedNar, and SIGLE. Databases were searched from inception to January 2019. Study selection, critical appraisal, data extraction, and data synthesis were done according to the approach recommended by JBI. RESULTS: A total of 12 studies (n = 8462) that recruited men with aggressive prostate cancer were considered in this review. The majority of included subjects had a total PSA level of 2 to 10ng/mL. The sensitivity of the Prostate Health Index ranged from 67% to 97% while specificity ranged from 6% to 64%. At a Prostate Health Index threshold of 25 and below (three studies, n = 3222), pooled sensitivity was 97% (95% confidence interval [CI], 95% to 98%) and specificity was 10% (95% CI, 6% to 16%). At a Prostate Health Index threshold of between 26 and 35 (six studies, n = 6030), pooled sensitivity was 87% (95% CI, 8% to 91%) and specificity was 45% (95% CI, 39% to 50%). At a Prostate Health Index threshold of 36 and above (five studies, n = 1476), pooled sensitivity was 72% (95% CI, 64% to 79%) and specificity was 74% (95% CI, 68% to 80%). Only one study assessed p2PSA. Sensitivity ranged from 80% to 95%, and specificity ranged from 9.9% to 27.9% with increasing threshold values from 7.9 to 10.9ng/mL. CONCLUSIONS: Overall, both Prostate Health Index and p2PSA have acceptable accuracy for the determination of the likelihood of aggressive prostate cancer. However, the inverse relationship between sensitivity and specificity makes it difficult to determine an optimum cut-off value for positivity. Further research is warranted to determine their utility in the management of prostate cancer.

Prevalence of burnout among nurses in sub-Saharan Africa: a systematic review.

OBJECTIVE: The objective of this review was to determine the prevalence rates for burnout among nurses working in countries within the sub-Saharan Africa region. INTRODUCTION: Burnout is a response to chronic work-related stress. While there is ample information on its prevalence and risk factors in well-resourced settings in high-income countries, it remains poorly studied in the low- and middle-income countries of sub-Saharan Africa, which bear the larger share of the global burden of disease. INCLUSION CRITERIA: This review considered studies from sub-Saharan Africa that identified the prevalence of burnout among nurses using standard measurement tools. METHODS: A three-step search strategy was utilized to identify both published and unpublished studies in English. Databases (MEDLINE, Embase, CINAHL, and others) were searched from inception to January 2019. Study selection, critical appraisal, data extraction, and data synthesis were conducted according to JBI methodology. RESULTS: A total of 12 studies (n = 2543 nurses) from seven African countries were included in this review. Eight of these studies were cross-sectional by design while the others were either exploratory, longitudinal, surveys, or descriptive. Ten studies were deemed to be at low risk of bias. According to the Maslach Burnout Inventory (seven studies, n = 1923), the prevalence of emotional exhaustion was 66% (95% confidence interval [CI], 37% to 89%), 60% (95% CI, 31% to 85%) for depersonalization, and 49% (95% CI, 19% to 80%) for low personal achievement. The overall prevalence of burnout among studies that utilized the Professional Quality of Life Scale (three studies, n = 337) was 87% (95% CI, 54% to 100%). One study reported a prevalence of 51% (95% CI, 44% to 57%) using the Copenhagen Burnout Inventory (n = 237), and the final study reported a prevalence of 33% (95% CI, 21% to 47%) using an unspecified measuring tool (n = 46). CONCLUSIONS: Regardless of the measuring tool used, nurses in sub-Saharan Africa experience high levels of burnout in all its dimensions.

Open abdomen management and outcomes: two case reports from western Kenya and a review of literature from Africa.

The open abdomen (OA) is clinically indicated for attenuating the effects of select intra-abdominal insults that may lead to high intra-abdominal pressure with fascial closure. Despite the high incidence of conditions warranting OA in Africa, there are few reports on its use and outcomes. A retrospective chart review was performed for two patients managed with an OA at the Moi Teaching and Referral Hospital. For comparison, a literature review on related studies from Africa was performed. One patient had an anastomotic leak, while the other had a perforated gastric ulcer. A Bogotá bag was used for temporary abdominal content containment. There was no mortality in our series and fascial closure was achieved in one patient. Upon review of studies from Africa, overall mortality stood at 44%, while 25% of surviving patients underwent fascial closure. The use of OA in Africa is associated with high mortality and low rates of fascial closure. Our limited experience shows this technique is a viable treatment option in an attempt to bridge a patient to abdominal closure during critical illness.

Clinicopathologic Features and Early Surgical Outcome of Astrocytomas in Eldoret, Kenya.

BACKGROUND: Astrocytomas are primary central nervous system tumors arising from astrocytes and accounting for up to 37.8% of all brain tumors seen in hospital-based studies from Africa. Despite being common, their patterns and short-term outcomes remain poorly studied in Kenya. MATERIALS AND METHODS: A prospective, descriptive study involving consecutive patients with a histological diagnosis of astrocytoma seen in three hospitals located in Eldoret, Kenya. Clinicopathologic characteristics and outcomes were recorded and patients followed up for 12 weeks. RESULTS: Thirty-one patients were recruited over a 1-year period. Majority of them were female (51.6%). Headache (83.9%) and focal neurological deficits (64.5%) were the most common presenting features. Among patients with high-grade tumors, mean duration of illness was 106.03 ± 162.16 days, median functional status was Karnofsky performance status (KPS) score 50, mean tumor size was 110.22 ± 46.16 cm3, and median magnetic resonance imaging (MRI) score was 17. Among patients with low-grade astrocytomas, mean duration of illness was 213.03 ± 344.93 days, median functional status was KPS score 40, mean tumor size was 53.49 ± 54.96 cm3 and median MRI score was 9. Glioblastoma multiforme (GBM) (71%) and diffuse astrocytoma (22.6%) were the predominant histological subtypes. The median Ki-67 proliferative index was 6% for pilocytic astrocytoma, 1.6% for diffuse astrocytoma, and 60% for GBM. Systemic and regional surgical complications occurred in 6.5% and 38.7% of patients, respectively. In-hospital mortality was 19.4% and increased to 25.8% at 12 weeks. The KPS score at discharge was 50 and improved to 60 at 12 weeks. Only 9.7% of patients had acceptable functional status at 12 weeks follow-up. CONCLUSIONS: In this locality, headache, focal neurological deficits, and reduced functional status are the most common presenting features of astrocytomas while GBM is the most common histological subtype. Tumors are highly proliferative and in the short-term, both surgical and functional outcome are suboptimal.

Diagnostic accuracy of the [-2]Pro-PSA and Prostate Health Index versus the Gleason score for determining the aggressiveness of prostate cancer: a systematic review protocol.

REVIEW QUESTIONS.

Treatment of Madura foot: a systematic review.

REVIEW QUESTION/OBJECTIVE: The objective of this review was to determine the best available evidence on the most effective treatment of Madura foot. INTRODUCTION: Madura foot or mycetoma is a chronic granulomatous soft-tissue infection that is endemic to several regions of Africa and Asia. It may be of fungal (eumycetoma) or bacterial (actinomycetoma) origin, warranting therapy with either antifungal or antibacterial medication as well as surgery. Without timely intervention, it often results in lifelong disability. However, it is unclear what regimes are most effective for treatment. INCLUSION CRITERIA: This review considered studies that included individuals of all ages with Madura foot (actinomycetoma or eumycetoma) as confirmed by microbiological or histological studies. Studies that evaluated antibiotic and antifungal regimens (any drug, dosage, frequency, duration) as well as surgical interventions (wound debridement, advanced excision or limb amputation) for Madura foot were included. Outcomes of interest were disease resolution (as determined by complete healing of mycetoma lesion after treatment), recurrence (return of mycetoma lesion after successful treatment) and mortality. Although this review considered both experimental and epidemiological study designs for inclusion, only case series and individual case reports were identified and were therefore included in the review. METHODS: A three-step search strategy, involving an initial search, a second more comprehensive search using identified keywords and a third search involving the reference lists of included articles, was utilized. Ten databases were searched. An additional 13 sources were searched for gray and/or unpublished literature. Included studies were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute. Disagreements were resolved through discussion or with a third reviewer. A data extraction tool was used to extract data on interventions, populations, study designs and outcomes of significance to the review question. Statistical pooling was not possible, therefore a narrative synthesis was performed. RESULTS: Thirty-one studies were included in the review (27 case reports and four case series). A total of 47 patients with Madura foot were analyzed. Twenty-five had eumycetoma, 21 actinomycetoma and one had both. Therapy involved varying dosages of sulfa drugs (co-trimoxazole and dapsone), amikacin and tetracyclines administered for the therapy of actinomycetoma with resolution of disease in all affected patients. The azole derivatives (itraconazole, ketoconazole, voriconazole, fluconazole and miconazole) as well as co-trimoxazole were the most commonly employed drugs for eumycetoma, with resolution of disease in 88% of included patients. Surgery was performed in a total of 21 patients with resolution of disease in all cases. The overall resolution rate following therapy was 95.7%. CONCLUSION: Therapy for Madura foot is informed by case series and case reports which provide low level evidence for practice. Antimicrobials in conjunction with surgery lead to resolution of disease.

Burden of brain tumors in low- and middle-income countries: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to determine the best available evidence on the burden of brain tumors in low- and middle-income countries (LAMICs). More specifically, the objective is to determine the incidence and prevalence rates for brain tumors in LAMICs.

Antimalarial drugs and the prevalence of mental and neurological manifestations: A systematic review and meta-analysis.

Background: Antimalarial drugs affect the central nervous system, but it is difficult to differentiate the effect of these drugs from that of the malaria illness. We conducted a systematic review to determine the association between anti-malarial drugs and mental and neurological impairment in humans.  Methods: We systematically searched online databases, including Medline/PubMed, PsychoInfo, and Embase, for articles published up to 14th July 2016. Pooled prevalence, heterogeneity and factors associated with prevalence of mental and neurological manifestations were determined using meta-analytic techniques.  Results: Of the 2,349 records identified in the initial search, 51 human studies met the eligibility criteria. The median pooled prevalence range of mental and neurological manifestations associated with antimalarial drugs ranged from 0.7% (dapsone) to 48.3% (minocycline) across all studies, while it ranged from 0.6% (pyrimethamine) to 42.7% (amodiaquine) during treatment of acute malaria, and 0.7% (primaquine/dapsone) to 55.0% (sulfadoxine) during prophylaxis. Pooled prevalence of mental and neurological manifestations across all studies was associated with an increased number of antimalarial drugs (prevalence ratio= 5.51 (95%CI, 1.05-29.04); P=0.045) in a meta-regression analysis. Headaches (15%) and dizziness (14%) were the most common mental and neurological manifestations across all studies. Of individual antimalarial drugs still on the market, mental and neurological manifestations were most common with the use of sulphadoxine (55%) for prophylaxis studies and amodiaquine (42.7%) for acute malaria studies. Mefloquine affected more domains of mental and neurological manifestations than any other antimalarial drug.  Conclusions: Antimalarial drugs, particularly those used for prophylaxis, may be associated with mental and neurological manifestations, and the number of antimalarial drugs taken determines the association. Mental and neurological manifestations should be assessed following the use of antimalarial drugs.

Effective treatment of Madura foot: a systematic review protocol.

REVIEW QUESTION/OBJECTIVE: The objective of this review is to determine the best available evidence on the effective treatment of Madura foot. More specifically, the objectives are to identify.

Early management of traumatic brain injury in a Tertiary hospital in Central Kenya: A clinical audit.

BACKGROUND: Traumatic brain injury (TBI) is a major cause of death and disability worldwide and is mostly attributed to road traffic accidents in resource-poor areas. However, access to neurosurgical care is poor in these settings and patients in need of neurosurgical procedures are often managed by general practitioners or surgeons. MATERIALS AND METHODS: A retrospective clinical audit of the initial management of patients with TBI in Thika Level 5 Hospital (TL5H), a Tertiary Hospital in Central Kenya. Seventeen audit criteria divided into five clinical domains were identified and patient case notes reviewed for compliance with each criterion. Data were analyzed separately for those below 13 years owing to differences in response to brain trauma in those below this age. RESULTS: Overall, there was poor compliance with audit criteria in both groups. Among those below 13 years of age, only 3 out of 17 criteria achieved compliance and 4 out of 17 criteria achieved compliance for those above 13 years of age. Assessment for the need for a cervical radiograph (7.1% and 8.8% compliance) and administration of oxygen (21.4% and 20.6% compliance) had the worst performance in both groups. CONCLUSION: Poor compliance to audit criteria indicates the low quality of care for patients with TBI in TL5H. Quality improvement strategies with follow-up audits are needed to improve care. There is a need to develop and enforce evidence-based protocols and guidelines for use in the management of patients with TBI in sub-Saharan Africa.

Caecal volvulus in an adolescent African male: a case report and brief review of the literature.

Caecal volvulus is an infrequent clinical condition caused by an axial twist of ascending colon, caecum and terminal ileum around the mesenteric pedicle. This article presents the case of a 16-year old African male from Kenya who presented to the emergency department with acute onset right sided lower abdominal pain diagnosed intra-operatively as caecal volvulus. The rare nature of the condition, the need for a high index of suspicion and surgical management are highlighted.

Accuracy of clinical stroke scores for distinguishing stroke subtypes in resource poor settings: A systematic review of diagnostic test accuracy.

BACKGROUND: Stroke is the second leading cause of death globally. Computerized tomography is used to distinguish between ischemic and hemorrhagic subtypes, but it is expensive and unavailable in low and middle income countries. Clinical stroke scores are proposed to differentiate between stroke subtypes but their reliability is unknown. MATERIALS AND METHODS: We searched online databases for studies written in English and identified articles using predefined criteria. We considered studies in which the Siriraj, Guy's Hospital, Besson and Greek stroke scores were compared to computerized tomography as the reference standard. We calculated the pooled sensitivity and specificity of the clinical stroke scores using a bivariate mixed effects binomial regression model. RESULTS: In meta-analysis, sensitivity and specificity for the Siriraj stroke score, were 0.69 (95% CI 0.62-0.75) and 0.83 (95% CI 0.75-0.88) for ischemic stroke and 0.65 (95% CI 0.56-0.73) and 0.88 (95% CI 0.83-0.91) for hemorrhagic stroke. For the Guy's hospital stroke score overall sensitivity and specificity were 0.70 (95% CI 0.53-0.83) and 0.79 (95% CI 0.68-0.87) for ischemic stroke and 0.54 (95% CI 0.42-0.66) and 0.89 (95% CI 0.83-0.94) for hemorrhagic stroke. CONCLUSIONS: Clinical stroke scores are not accurate enough for use in clinical or epidemiological settings. Computerized tomography is recommended for differentiating stroke subtypes. Larger studies using different patient populations are required for validation of clinical stroke scores.

Assessment of cardiovascular risk and target organ damage among adult patients with primary hypertension in Thika Level 5 Hospital, Kenya: a criteria-based clinical audit.

BACKGROUND: Appropriate management of hypertension reduces the risk of death from stroke and cardiac disease and includes routine assessment for target organ damage and estimation of cardiovascular risk. However, implementation of evidence-based hypertension management guidelines is unsatisfactory. We explore the use of audit and feedback as a quality improvement (QI) strategy for reducing the knowledge practice gap in hypertension care in a resource poor setting. AIMS: The aim of this study is to determine the level of compliance to evidence-based guidelines on assessment of cardiovascular risk and target organ damage among patients with hypertension in Thika Level 5 Hospital in central Kenya and to implement best practice with regard to evidence utilisation among clinicians in the hospital. METHOD: A retrospective clinical audit done in three phases spread over 5 months. Phase one involved identifying five audit criteria on assessment of cardiovascular risk and target organ damage in patients with hypertension and conducting a baseline audit in which compliance to audit criteria, blood pressure control and drug prescription practices were assessed. Phase two involved identifying barriers to compliance to audit criteria and strategies to overcoming these barriers. The third phase was a follow-up audit. RESULTS: There was no use of a cardiovascular risk assessment tool in both audits (0% vs. 0%; P = 1.00). Testing urine for haematuria and proteinuria reduced from 13% to 8% (P = 0.230) while taking a blood sample for measuring blood glucose, electrolytes and creatinine levels improved from 11% to 17% (P = 0.401). Performance of fundoscopy and electrocardiography remained unchanged at 2% and 8%, respectively (P = 0.886 and P = 0.898). High patient load was identified as the biggest barrier to implementation of best practice. Blood pressure control improved from 33% to 70% (P ≤ 0.001), whereas the proportion of patients on two or more recommended antihypertensive drugs rose from 59% to 72% (P = 0.158). CONCLUSION: In Thika Level 5 Hospital, audit and feedback has a poor impact on assessment of cardiovascular risk and target organ damage but positive impact on blood pressure control and prescription practices. Time and sample size may have affected observed results. Additional audits and alternative QI strategies are warranted.

Antiepileptic properties of quinine: A systematic review.

EXECUTIVE SUMMARY: Background: Quinine has been found to have anti-epileptic properties in animals. However, in humans this has not been systematically investigated. If quinine has antiepileptic properties in humans, it may reduce the neurological sequelae associated with acute seizures in severe malaria and promote its choice over other antimalarial drugs in treating severe falciparum malaria. OBJECTIVE: The review objective was to examine available research evidence on the effects of quinine on seizures in adults or children who present with seizures or who develop seizures in the course of treatment. INCLUSION CRITERIA: Participants: This review considered adult and child patients who were prescribed using quinine for malaria, arthritis, nocturnal leg cramps, arrhythmia and systemic lupus erythematosus. INTERVENTION: This review evaluated the use of quinine in comparison to other drugs used for malaria, arthritis, nocturnal leg cramps, arrhythmia and systemic lupus erythematosus. OUTCOMES: The primary outcome of interest for this review was the proportion of participants who had seizures after the administration of quinine, compared with those who were not given quinine.Types of Studies: This review considered randomised controlled trials. SEARCH STRATEGY: We searched online databases for published and unpublished studies written in English and identified articles using predefined criteria.Methodological Quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. DATA EXTRACTION/SYNTHESIS: The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. A standardized data extraction tool was used. A random effects model was used to statistically pool data in meta-analysis, in order to determine the effect of quinine on prevalence of seizures in comparison to other drugs. RESULTS: We identified six randomized controlled trials on severe malaria. Quinine was compared to the artemisinin derivatives in all trials. A total of 8,244 patients were included. In the meta-analysis, there was no significant effect of quinine on the prevalence of seizures (Odds ratio=0.90 95% Confidence Interval=0.63-1.30). There was significant heterogeneity (Chi-squared=17.44, p=0.008). DISCUSSION: This is the first review on the antiepileptic effect of quinine in humans. However, this effect is not demonstrated in patients with malaria. A dose-response effect may be responsible for the absence of antiepileptic properties of quinine in humans. The results of the review are confounded by the fact that all the studies reviewed were conducted in patients with malaria, and quinine was only compared against artemisinin compounds which may have neurological effects. Further, incidence of seizures could not be assessed in this review. CONCLUSIONS: There is not sufficient evidence to conclude that quinine has any antiepileptic properties. A dose-response effect may be responsible for the absence of antiepileptic properties of quinine in humans with severe malaria. IMPLICATIONS FOR PRACTICE: This review provides data that may influence choice of antimalarial drugs in resource poor settings. IMPLICATIONS FOR RESEARCH: This review identifies the need for further studies on the antiepileptic properties of quinine with sufficient power, designed to capture seizure prevalence and incidence as outcomes, that have the ability to control for confounders appropriately and that can explore the dose-response effect of quinine on seizures.