UPESI: Swahili translation of the FAST acronym for stroke awareness campaigns in East Africa.

Introduction: Despite stroke being a leading cause of death and disability in sub-Saharan Africa, stroke awareness remains a major hurdle to early stroke response and care in the region. To improve stroke awareness, we endeavoured to borrow a leaf from initiatives in high-income countries, beginning with the translation and dissemination of the acronym, FAST (Face, Arms, Speech, Time) to Swahili. Methods: We formed a translation group consisting of two stroke physicians, one nurse and two professional translators, all native Swahili speakers. Forward translation of the original document from English to Swahili was done by one Swahili translator; followed by a backward translation by another translator. Clinician reviews and cognitive reviews were then done, and a final translation was developed. Results: We developed the acronym UPESI, a Swahili translation of the word, FAST. The acronym stands for U so kupooza upande mmoja; P ooza mkono/mguu (au kupoteza hisia); ugumu ku- E leza/kuongea; SI mu upesi translating to face drooping, arm/leg paralysis, difficulty in speaking/explaining and fast to the phone. Conclusion: The result of this process is a Swahili translation of the FAST tool for stroke awareness campaigns. The translation will improve communication during stroke campaigns and increase awareness of stroke.

Stroke Epidemiology, Care, and Outcomes in Kenya: A Scoping Review.

Background: Stroke is a leading cause of death and disability in sub-Saharan Africa with increasing incidence. In Kenya, it is a neglected condition with a paucity of evidence despite its need for urgent care and hefty economic burden. Therefore, we reviewed studies on stroke epidemiology, care, and outcomes in Kenya to highlight existing evidence and gaps on stroke in Kenya. Methods: We reviewed all published studies on epidemiology, care, and outcomes of stroke in Kenya between 1 January 1990 to 31 December 2020 from PubMed, Web of Science, EBSCOhost, Scopus, and African journal online. We excluded case reports, reviews, and commentaries. We used the Newcastle-Ottawa scale adapted for cross-sectional studies to assess the quality of included studies. Results: Twelve articles were reviewed after excluding 111 duplicates and 94 articles that did not meet the inclusion criteria. Five studies were of low quality, two of medium quality, and five of high quality. All studies were hospital-based and conducted between 2003 and 2017. Of the included studies, six were prospective and five were single-center. Stroke patients in the studies were predominantly female, in their seventh decade with systemic hypertension. The mortality rate ranged from 5 to 27% in-hospital and 23.4 to 26.7% in 1 month. Conclusions: Our study highlights that stroke is a significant problem in Kenya, but current evidence is of low quality and limited in guiding policy development and improving stroke care. There is thus a need for increased investment in hospital- and community-based stroke care and research.

Mortality and functional outcomes after a spontaneous subarachnoid haemorrhage: A retrospective multicentre cross-sectional study in Kenya.

INTRODUCTION: Despite a reduction in poor outcomes in recent decades, spontaneous subarachnoid haemorrhage (SAH) remains associated with severe disability and high mortality rates. The exact extent of these outcomes is however unknown in Africa. This study aimed to determine the mortality and functional outcomes of patients with SAH in Kenya. METHODS: We conducted a retrospective multicentre cross-sectional study involving patients admitted with SAH to three referral hospitals in Nairobi. All patients with a confirmed (primary) discharge diagnosis of first-time SAH between January 2009 and November 2017 were included (n = 158). Patients who had prior head trauma or cerebrovascular disease (n = 53) were excluded. Telephone interviews were conducted with surviving patients or their next of kin to assess out-of-hospital outcomes (including functional outcomes) based on modified Rankin Scale (mRS) scores. Chi-square and Fisher's exact tests were used to assess associations between mortality and functional outcomes and sample characteristics. RESULTS: Of the 158 patients sampled, 38 (24.1%) died in hospital and 42 (26.6%) died within 1 month. In total, 87 patients were discharged home and followed-up in this study, of which 72 reported favourable functional outcomes (mRS ≤2). This represented 45.6% of all patients who presented alive, pointing to high numbers of unfavourable outcomes post SAH in Kenya. CONCLUSIONS: Mortality following SAH remains high in Kenya. Patients who survive the initial ictus tend to do well after treatment, despite resource constraints. LIMITATIONS: The study findings should be interpreted with caution because of unavoidable limitations in the primary data. These include its retrospective nature, the high number of patients lost to follow up, missing records and diagnoses, and/or possible miscoding of cases.

Isolated septic non-otogenic lateral sinus thrombosis complicating nasopharyngitis in a 2-month-old infant: a case report.

Nasopharyngeal infections are among the commonest diagnosed infections in infants. Largely treated supportively, these infections are considered harmless. These can however lead to serious complications from local spread and septicemia. With local extension, inflammatory neck masses (abscesses) can swiftly lead to life-threatening complications including mediastinitis, airway compromise and sinovenous thrombosis. Here, we report a 2-month-old infant with initial rhinopharyngitis and subsequent extensive deep neck abscesses with consequent dural sinus thrombosis successfully managed with antibiotics, anticoagulants and drainage. While such cases have been presented before, it is the pathophysiology and extent of sinus thrombosis in our case that is eccentric.

Endometrial tuberculosis compounding polycystic ovary syndrome in a subfertile woman: a case report.

BACKGROUND: Asymptomatic female genital tuberculosis can impair tubal and endometrial function and later present as subfertility. A majority of the patients with genital tuberculosis in endemic regions present with subfertility and the delay in presentation, coupled with the potential the disease has in mimicking other gynecological conditions, renders it elusive. In addition to the challenge of diagnosing genital tuberculosis, fertility outcomes after treatment are not impressive. This is particularly so in the background of another confounding subfertility factor to which interventional efforts may initially be directed, at the expense of undiagnosed genital tuberculosis. We therefore present a case of subfertility due to endometrial tuberculosis, but confounded by other subfertility factors notably polycystic ovary syndrome. To the best of our knowledge this case report is the first of its kind in the literature. CASE PRESENTATION: This is a case report of a 42-year-old woman of African descent who presented to our fertility clinic with a 10-year history of primary subfertility and amenorrhea of 6 years duration. She was a nurse in a medical ward and had no prior history of tuberculosis. She had undergone a diagnostic laparoscopy 8 years prior which demonstrated dense pelvic adhesions and an impression of tubal factor subfertility was made. At presentation, her gonadal hormone profile and pelvic ultrasound were consistent with polycystic ovary syndrome. A negative response to a progesterone challenge test prompted a hysteroscopic evaluation which revealed endometrial atrophy. Endometrial biopsies confirmed histological features consistent with tuberculosis. Normal endometrial function was not restored despite adequate treatment and her options were limited to surrogacy or adoption. CONCLUSIONS: Genital tuberculosis is elusive in presentation and clinicians should consider it in patients with amenorrhea and/or tubal disease from tuberculosis-endemic regions. Due to the attendant high cost of fertility treatment and associated poor fertility outcomes, it is prudent to explore options to diagnose it early. A routine endometrial biopsy in a patient with subfertility in a tuberculosis-endemic area would be pragmatic. An alternative algorithm in management would be risk stratification prior to endometrial biopsy.

Protracted refractory pain post-TEVAR: post-implantation syndrome?

Aortic dissection is a life-threatening condition and has one of the highest mortality rates of cardiovascular diseases. It remains a devastating disease; with multiple unanswered questions concerning treatment modalities. The role of thoracic endovascular aortic repair (TEVAR) in these patients; especially those with uncomplicated acute aortic Type B dissections (AAD-B) is especially controversial although it has been shown to have better long-term outcomes compared to medical therapy alone. For those who have TEVAR, up to 60% may develop an acute, transient systemic inflammatory response syndrome that remains vaguely defined. The role of local inflammation in this post-implantation syndrome (PIS) has not been highlighted. We present a case of a 57-year-old male patient with an uncomplicated AAD-B who developed an 'atypical' PIS post-TEVAR with severe refractory abdominal pains; leukocytosis and raised C-reactive protein. The role of local inflammation in PIS is highlighted.

Conservative Management of an Iatrogenic Esophageal Tear in Kenya.

Since its description over 250 years ago, diagnosis of esophageal perforation remains challenging, its management controversial, and its mortality high. This rare, devastating, mostly iatrogenic, condition can quickly lead to severe complications and death due to an overwhelming inflammatory response to gastric contents in the mediastinum. Diagnosis is made with the help of esophagograms and although such tears have traditionally been managed via aggressive surgical approach, recent reports emphasize a shift in favor of nonoperative care which unfortunately remains controversial. We here present a case of an iatrogenic esophageal tear resulting from a routine esophagoscopy in a 50-year-old lady presenting with dysphagia. The esophageal tear, almost missed, was eventually successfully managed conservatively, thanks to a relatively early diagnosis.

Complicated malaria and a covert ruptured spleen: a case report.

Spontaneous splenic rupture in complicated malaria is an uncommon cause of hemoperitoneum in the tropics. The exact incidence of splenic rupture is unknown, largely due to under-reporting, but has been estimated at ∼2%. Its pathophysiology is linked to the formation of a subcapsular hematoma. Upon rupture, patients present with features of shock and peritonitis and in most cases (95%), computed tomography (CT) scan detects the splenic injury. Patients should be managed conservatively with splenectomy reserved for patients with shock and hemoperitoneum due to risk of post-splenectomy sepsis. We report the case of a 38-year-old man with severe malaria who presented with fever, chills and abdominal pains. A CT scan abdomen failed to reveal splenic parenchymal injury or any splenic extravasation of contrast. Conservative management was unsuccessful. Exploratory laparatomy confirmed the spleen as the site of bleeding necessitating a splenectomy.

The prevalence of smoking and the knowledge of smoking hazards and smoking cessation strategies among HIV- positive patients in Johannesburg, South Africa.

BACKGROUND: While the detrimental effects of smoking among HIV-positive patients have been well documented, there is a paucity of data regarding cigarette smoking prevalence among these patients in South Africa (SA). OBJECTIVES: To establish the frequency, demographics, knowledge of harmful effects, and knowledge of smoking cessation strategies among HIV-positive patients in Johannesburg, SA. METHODS: We conducted a prospective cross-sectional survey using a structured questionnaire to interview HIV-positive patients attending the HIV Clinic at the Charlotte Maxeke Johannesburg Academic Hospital between 1 July and 31 October 2011. RESULTS: Of 207 HIV-positive patients attending an antiretroviral therapy (ART) roll-out clinic, 31 (15%) were current smokers (23.2% of males and 7.4% of females) and a further 45 (21.7%) were ex-smokers. Most of the current smokers (30/31 patients) indicated their wish to quit smoking, and among the group as a whole, most patients were aware of the general (82.1%) and HIV-related (77.8%) risks of smoking and of methods for quitting smoking. Despite this, however, most (62.3%) were not aware of who they could approach for assistance and advice. CONCLUSIONS: Given the relatively high prevalence of current and ex-smokers among HIV-positive patients, there is a need for the introduction of smoking-cessation strategies and assistance at ART roll-out clinics in SA.

Pilot study of sternal plating for primary closure of the sternum in cardiac surgical patients.

OBJECTIVE: Postoperative sternal wound complications are a significant problem in high-risk patients. In addition to closure with conventional wires, several systems involving rigid fixation with metal plates are currently available. The rapid sternal closure system (Talon) is approved for stabilization and fixation of the anterior chest wall. Anecdotal evidence suggests that use of the Talon may result in improved postoperative recovery. METHODS: Fifty-one cardiac surgical patients at higher risk for sternal wound complications were enrolled at two sites. Subjects were randomized to insertion of Talons (n = 28) or wires only (control, n = 23) for sternal closure. The primary endpoint was a comparison between study groups of the percent of baseline incentive spirometry volume through postoperative day 7. Secondary endpoints included other measures of quality of recovery, sternal wound infection, and nonunion. RESULTS: The percentage of preoperative incentive spirometry volume achieved was higher in the Talon arm (67% ± 32%) versus control (58% ± 24%); however, this was not statistically significant (P = 0.41). Use of the Talon was associated with decreased use of opiates (21.3 ± 11.8 vs. 25.4 ± 21.6 mg, P = 0.44), increased ability to ambulate 1000 ft on postoperative day 5 (25% vs. 13%, P = 0.28), and decreased duration of mechanical ventilation (median 0.5 vs 1.0 days, P = 0.24) and hospital length of stay (4.5 ± 3.2 vs. 5.3 ± 4.0 days, P = 0.40). One superficial sternal wound infection was observed in each study arm. There were no cases of nonunion. CONCLUSIONS: In this pilot study, the primary endpoint was not statistically different between the treatment groups. Use of the Talon was associated with trends toward benefit in endpoints consistent with enhanced postoperative recovery, highlighting a need for additional data from larger randomized trials.

Implementation of the thin layer agar method for diagnosis of smear-negative pulmonary tuberculosis in a setting with a high prevalence of human immunodeficiency virus infection in Homa Bay, Kenya.

The objective of this study was to evaluate the performance of a low-cost method, the thin layer agar (TLA) method, for the diagnosis of smear-negative patients. This prospective study was performed in Homa Bay District Hospital in Kenya. Out of 1,584 smear-negative sputum samples, 212 (13.5%) were positive by culture in Löwenstein-Jensen medium (LJ) and 220 (14%) were positive by the TLA method. The sensitivities of LJ and TLA were 71% and 74%, respectively. TLA could become an affordable method for the diagnosis of smear-negative tuberculosis in resource-limited settings, with results available within 2 weeks.

A prospective, double-blind, randomized clinical feasibility trial of controlling the storage age of red blood cells for transfusion in cardiac surgical patients.

BACKGROUND: Recent evidence demonstrates an association between duration of storage of red blood cells (RBC) and morbidity and mortality after cardiac surgery. We studied the feasibility of two different schemes for categorizing and randomizing age of RBC units transfused in cardiac surgical patients. STUDY DESIGN AND METHODS: In Phase 1, 20 subjects were randomly assigned to standard of care (SOC) versus no RBCs with more than 21 days' storage duration. In Phase 2, 23 subjects were randomized to RBCs of 7 +/- 4 versus 21 +/- 4 days' storage duration. The age of study RBC units was masked. RESULTS: In Phase 1, no patients received RBCs 31 days or older in SOC, and there was overlap in storage age shared in both arms so the predefined feasibility criteria were not met. In Phase 2, it was feasible to deliver specified age RBCs to the 7-day arm (achieved in 100% of subjects), but feasibility was not demonstrated for the 21-day arm (only 50% of subjects transfused with target age RBCs). Significant differences, however, were observed between the 7 +/- 4- and 21 +/- 4-day arms with respect to age of all RBC units (6 +/- 2 vs. 18 +/- 7, p = 0.0002) and maximum age (7 +/- 2 vs. 20 +/- 7, p < 0.0001). CONCLUSION: Given the current storage age distribution of available RBC inventory, use of a SOC arm in future studies is unlikely to result in a large exposure to "old" blood. It is feasible to randomize patients to "younger" RBCs (3-11 days) but design strategies are needed to provide "intermediate-aged" or "old" blood as a comparator.