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Objectives : To determine the epidemiology of acute coronary syndromes (ACS) in sub-Saharan Africa. Methods : A prospective survey was carried out of all patients with a diagnosis of ACS who were admitted to the critical care unit of a tertiary teaching hospital over a 25-month period. Demographics, presentation, management and outcomes were subsequently recorded. Results : A total of 111 (5.1% of all hospitalisations) patients were recruited, with 56% presenting with ST-elevation myocardial infarction (STEMI) and the rest non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA). Chest pain was the most common presenting symptom, and up to one-third of all STEMI patients did not receive any form of reperfusion therapy, primarily due to late presentation. As in the developed world, diabetes, hypertension and cigarette smoking still account for the most common predisposing risk-factor profile, and the mortality associated with ACS is about six to 10% in our unit. Conclusions : ACS, contrary to common belief, is increasingly more prevalent in sub-Saharan Africa, with similar risk profiles to that in the developed world. Late presentation to hospital is common and accounts for the increased mortality associated with this condition.

Background Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital for acute HF (AHF) and are used routinely throughout admission to assess the severity of disease and response to therapy. Methods and Results The data were collected in The Sub-Saharan Africa Survey on Heart Failure (THESUS-HF) study, a prospective, multicenter, observational survey of AHF from 9 countries in sub-Saharan Africa. A total of 1006 patients, ≥12 years of age, hospitalized for AHF were recruited. Symptoms and signs of HF and changes in dyspnea and well-being, relative to admission, were assessed at entry and on days 1, 2, and 7 (or on discharge if earlier) and included oxygen saturation, degree of edema and rales, body weight, and level of orthopnea. The patient determined dyspnea and general well-being, whereas the physician determined symptoms and signs of HF, as well as improvements in vital sign measurement, throughout the admission. After multivariable adjustment, baseline rales and changes to day 7 or discharge in general well-being predicted death or HF hospitalization through day 60, and baseline orthopnea, edema, rales, oxygen saturation, and changes to day 7 or on discharge in respiratory rate and general well-being were predictive of death through day 180. Conclusions In AHF patients in sub-Saharan Africa, symptoms and signs of HF improve throughout admission, and simple assessments, including edema, rales, oxygen saturation, respiratory rate, and asking the patient about general well-being, are valuable tools in patients' clinical assessment.

Introduction The prevalence of non-communicable diseases (NCDs) is rising in low- and middle-income countries, including Kenya, disproportionately to the rest of the world. Our objective was to quantify patient payments to obtain NCD screening, diagnosis, and treatment services in the public and private sector in Kenya and evaluate patients’ ability to pay for the services. Methods and findings We collected payment data on cardiovascular diseases, diabetes, breast and cervical cancer, and respiratory diseases from Kenyatta National Hospital, the main tertiary public hospital, and the Kibera South Health Center—a public outpatient facility, and private sector practitioners and hospitals. We developed detailed treatment frameworks for each NCD and used an itemization cost approach to estimate payments. Patient affordability metrics were derived from Kenyan government surveys and national datasets. Results compare public and private costs in U.S. dollars. NCD screening costs ranged from $4 to $36, while diagnostic procedures, particularly for breast and cervical cancer, were substantially more expensive. Annual hypertension medication costs ranged from $26 to $234 and $418 to $987 in public and private facilities, respectively. Stroke admissions ($1,874 versus $16,711) and dialysis for chronic kidney disease ($5,338 versus $11,024) were among the most expensive treatments. Cervical and breast cancer treatment cost for stage III (curative approach) was about $1,500 in public facilities and more than $7,500 in the private facilities. A large proportion of Kenyans aged 15 to 49 years do not have health insurance, which makes NCD services unaffordable for most people given the overall high cost of services relative to income (average household expenditure per adult is $413 per annum). Conclusions There is substantial variation in patient costs between the public and private sectors. Most NCD diagnosis and treatment costs, even in the public sector, represent a substantial economic burden that can result in catastrophic expenditures.

Background: Preoperative anxiety is a common perioperative complication seen in approximately 11-80% of adults undergoing surgery. One of the goals of the preanaesthesia clinic is to allay anxiety. A preanaesthesia clinic evaluation has been shown to reduce anxiety however current studies on anxiety and the preanaesthesia clinic have not quantified this reduction. Objective: To determine the reduction in anxiety in patients evaluated in the clinic versus those evaluated in the ward. Methods: Fifty one adult patients with 28 patients in anaesthesia clinic (AC) group and 23 in the ward (W) group were sequentially recruited from both the surgical, gynaecology and antenatal outpatient clinics and the wards. The patient’s State Trait Anxiety Index (STAI) was taken once the patient was booked for theatre. The patients then had a preanaesthesia evaluation either in the preanaesthesia outpatient clinic (PAC) or in the wards. Another STAI score was taken in the preoperative area in theatre on the day of surgery. The difference in the change of STAI scores in both groups was then analysed. Results: Fifty one adult patients were recruited with 28 in the AC group and 23 in the W group. The majority of patients were female (n=38). Statistically significant difference was seen in the reduction of the anxiety scores between the clinic group 2.143 (C.I=1.384-2.902) and ward group 0.74(C.I=0.17-1.31) with a p value=0.0051.There was also significant difference in reduction in anxiety scores within ward group in the patients with no prior anaesthetic experience having a greater reduction than those with prior anaesthetic experience. There were no other significant differences between the two groups. Conclusion: Patients evaluated in the anaesthesia clinic had a greater reduction in their anxiety but it was not as much as hypothesised which may be due to the multi-factorial nature of preoperative anxiety. A larger multicenter study is recommended to increase generalizability to the population. Keywords: Preanaesthesia clinic, consultation on adult patient anxiety, cohort study , Kenya

The impact of gender on the clinical characteristics, risk factors, co-morbidities, etiology, treatment and outcome of acute heart failure in sub-Saharan Africa has not been described before. The aim of this study was to evaluate the sex differences in acute heart failure in sub-Saharan Africa using the data from The sub-Saharan Africa Survey of Heart Failure (THESUS-HF).1,006 subjects were recruited into this prospective multicenter, international observational heart failure survey. The mean age of total population was 52.4 years (54.0 years for men and 50.7 years for women). The men were significantly older (p = 0.0045). Men also presented in poorer NYHA functional class (III and IV), p = 0.0364). Cigarette smoking and high blood pressure were significantly commoner in men (17.3 vs. 2.6% and 60.0 vs. 51.0% respectively). On the other hand, atrial fibrillation and valvular heart disease were significantly more frequent in women. The mean hemoglobin concentration was lower in women compared to men (11.7 vs. 12.6 g/dl, p ≤ 0.0001), while the blood urea and creatinine levels were higher in men (p0.0001). LV systolic dysfunctional was also seen more in men. Men also had higher E/A ratio indicating higher LV filling pressure. Outcomes were similar in both sexes.Although the outcome of patients admitted for AHF in sub-Saharan regions is similar in men and women, some gender differences are apparent suggesting that in men more emphasis should be put on modifiable life risk factors, while in women prevention of rheumatic heart diseases and improved nutrition should be addressed vigorously.

The Multi-Track System is a simplified double-balloon technique for percutaneous mitral valvuloplasty. Here we describe the technique and report the results obtained using it. The Multi-Track catheter has a short distal tip for connection to the guidewire. This leaves the rest of guidewire free to receive other catheters. Various catheters can be introduced over the same guidewire. The balloons are introduced one after the other allowing a smaller size of vascular access and transseptal passage. Furthermore, simultaneous pressure measurements in the left atrium and left ventricle are possible through a simple venous access, allowing avoidance of arterial puncture. We used this technique worldwide between June 1994 and February 2000 for the treatment of 153 patients with mitral stenosis worldwide. In 12 cases, the procedure was done using the exclusive venous approach. The mean mitral valve area increased from 0.75 ± 0.22 to 2 ± 0.33 cm2and the mean left atrial pressure dropped from 27 ± 8 to 11 ± 4 mmHg. Four patients had a significant increase in mitral regurgitation, requiring surgical treatment in two patients. There was no mortality. The Multi-Track system is a valid user-friendly and cost-effective alternative for the treatment of mitral stenosis. It is a rapid and effective procedure associated with low risks.

We developed the Multi-Track System for percutaneous mitral valvotomy and described the preliminary results in 1995. Here we report the first 100 consecutive cases after the original publication. Two separate balloon catheters are positioned on a single guidewire. The first catheter, with only a distal guidewire lumen, is introduced into the vein and then advanced into the mitral orifice. Subsequently, a rapid exchange balloon catheter running on the same guidewire is inserted and lined up with the first catheter so the two are positioned side by side. Both balloons are then inflated simultaneously. Age of the patients was 31 ± 12.8 years and weight 50 ± 14 kg. Valve area increased 0.75 ± 0.22 cm2 to 2.00 ± 0.32 cm2and mean left atrial pressure dropped from 27 ± 8 to 11 ± 5 mm Hg. One patient had significant mitral insufficiency after dilatation, which did not require surgery. The Multi-Track System is a valid alternative to the existing procedures for the treatment of mitral stenosis and uses simpler and less costly catheters. Cathet. Cardiovasc. Intervent. 48:178–183, 1999. © 1999 Wiley-Liss, Inc.

R A L A B ST R A C T S Methods: We collected injection dates of benzathine penicillin G for all patients from 80 clinics from 2012 – 2014 (36 months). Injection data were matched against a database of RHD patients diagnosed through screening and commenced on SAP from 2006 – 2012. The observation period was adjusted for known migration mortality and cessation of treatment. Patients with 12 months of observation were included. We calculated the proportion of recommended injections received per individual, and the proportion of patients receiving adequate SAP to prevent disease progression (defined as 80% of injections). Risk factors for complete non-adherence (zero injections) were identified on bivariate analysis, and multivariate linear regression was used to identify factors associated with adherence in patients with 1 injection. Results: 495 patients were included (mean age 13.9 years, SD 2.89). Overall, 41.2% of the cohort received no injections, and 6.3% received adequate SAP. There were significant associations between complete non-adherence and age (p1⁄40.003) and the number of years since diagnosis (p

Background. Helicobacter pylori is associated with several upper gastrointestinal conditions including chronic gastritis, peptic ulcer disease, and gastric malignancy. Proton pump inhibitor-based triple therapies are considered the standard regimens for H. pylori eradication, but the optimal duration of therapy is controversial. To prevent infection and complications, local studies should be undertaken to evaluate H. pylori eradication rates in a country.Objectives. We compared 7-day and 14-day regimens to determine the optimum duration of triple therapy for H. pylori eradication.Methods. We undertook a prospective randomised comparative trial of 7-day and 14-day triple therapy regimen for H. pylori eradication at the Aga Khan University Hospital, Nairobi; 120 patients with dyspepsia and H. pylori infection were randomised to receive esomeprazole, amoxicillin and clarithromycin for either 7 days (EAC 7) or 14 days (EAC 14). Compliance and side-effects were assessed 2 weeks after the start of therapy and H. pylori eradication was assessed by stool antigen tests 4 weeks after treatment.Results. Both the intention-to-treat (ITT; N=120) and per protocol (PP; N=97) analyses showed no significant differences between the eradication rates of EAC 7 (ITT 76.7%; PP 92%) and EAC 14 (ITT 73.3%; PP 93.6%) (ITT p=0.67; PP p=0.76). Poor compliance was reported in one patient in the EAC 14 group. The incidence of adverse events was comparable in the two groups.Conclusion. One-week and 2-week triple treatments for H. pylori eradication are similar in terms of efficacy, safety and patient compliance.S Afr Med J 2012;102(6):368-371.

Introduction Scant data exist on the epidemiology and clinical characteristics of atrial fibrillation in Kenya. Traditionally, atrial fibrillation (AF) in sub-Saharan Africa is as a result of rheumatic valve disease. However, with the economic transition in sub-Saharan Africa, risk factors and associated complications of this arrhythmia are likely to change. Methods A retrospective observational survey was carried out between January 2008 and December 2010. Patients with a discharge diagnosis of either atrial fibrillation or flutter were included for analysis. The data-collection tool included clinical presentation, risk factors and management strategy. Follow-up data were obtained from the patients’ medical records six months after the index presentation. Results One hundred and sixty-two patients were recruited (mean age 67 ± 17 years, males 56%). The distribution was paroxysmal (40%), persistent (20%) and permanent AF (40%). Associated co-morbidities included hypertension (68%), heart failure (38%) diabetes mellitus (33%) and valvular abnormalities (12%). One-third presented with palpitations, dizziness or syncope and 15% with a thromboembolic complication as the index AF presentation. Rate-control strategies were administered to 78% of the patients, with beta-blockers and digoxin more commonly prescribed. Seventy-seven per cent had a CHA2DS2VASC score ≥ 2, but one-quarter did not receive any form of oral anticoagulation. At the six-month follow up, 6% had died and 12% had been re-admitted at least once. Of the high-stroke risk patients on anticoagulation, just over one-half were adequately anticoagulated. Conclusion Hypertension and diabetes mellitus, not rheumatic valve disease were the more common co-morbidities. Stroke risk stratification and prevention needs to be emphasised and appropriately managed.

With the advent of highly active antiretroviral therapy, there has been a significant change in the epidemiology of pulmonary disease in HIV/AIDS. The relative prevalence of non-infectious manifestations is likely to rise. HIV associated pulmonary hypertension (HIV-PH), albeit low prevalence, is associated with significant morbidity and mortality. Presently, despite having scanty evidence on the management modalities of HIV-PH, evidence extrapolated from idiopathic pulmonary hypertension is being utilised to effectively manage some of these patients. Efforts should therefore be made to screen, diagnose and treat these patients. A case of a thirty year old female with HIV disease and severe pulmonary hypertension is presented. East African Medical Journal Vol. 85 (11) 2008: pp. 564-568

We developed a simple and versatile new technique (Multi-Track) for percutaneous mitral valvotomy using two two separate balloon catheters positioned on a single guidewire. The first catheter, with only a distal guidewire lumen and a proximal balloon, is introduced over the guidewire into the vein and then advanced into the mitral valve orifice. Subsequently, a normal balloon catheter running on the same guidewire is inserted and lined up with the first catheter so the two are positioned side by side. The balloons are then inflated simultaneously. The technique was applied in 12 patients between 10 and 44 years of age (mean, 27.1) and weighing 24-80 kg (mean, 50.3). Valve area increased from 0.66 cm2 (range, 0.3-0.9 cm2) to 1.97 cm2 (range, 1.3-3.1 cm2) and mean left atrial pressure dropped from 31 mmHg (range, 18-52 mmHg) to 12 mmHg (range, 5-22 mmHg). Mitral dilatation with the Multi-Track system gives results comparable to those with previously described techniques and uses simpler and less costly catheters.

Background: Acute heart failure (AHF) in sub-Saharan Africahasnotbeenwellcharacterized.Therefore,wesought todescribethecharacteristics,treatment,andoutcomesof patients admitted with AHF in sub-Saharan Africa. Methods: The Sub-Saharan Africa Survey of Heart Failure (THESUS–HF) was a prospective, multicenter, observational survey of patients with AHF admitted to 12 university hospitals in 9 countries. Among patients presenting with AHF, we determined the causes, treatment, and outcomes during 6 months of follow-up. Results: From July 1, 2007, to June 30, 2010, we enrolled1006patientspresentingwithAHF.Mean(SD)age was 52.3 (18.3) years, 511 (50.8%) were women, and the predominantracewasblackAfrican(984of999[98.5%]). Mean (SD) left ventricular ejection fraction was 39.5% (16.5%). Heart failure was most commonly due to hypertension (n=453 [45.4%]) and rheumatic heart disease (n=143 [14.3%]). Ischemic heart disease (n=77 [7.7%]) was not a common cause of AHF. Concurrent renal dysfunction (estimated glomerular filtration rate, 30 mL/ min/173m 2 ),diabetesmellitus,anemia(hemoglobinlevel, 10g/dL),andatrialfibrillationwerefoundin73(7.7%), 114(11.4%),147(15.2%),and184cases(18.3%),respectively;65of500patientsundergoingtesting(13.0%)were seropositive for the human immunodeficiency virus. The medianhospitalstaywas7days(interquartilerange,5-10), with an in-hospital mortality of 4.2%. Estimated 180-day mortality was 17.8% (95% CI, 15.4%-20.6%). Most patients were treated with renin-angiotensin system blockers but not -blockers at discharge. Hydralazine hydrochloride and nitrates were rarely used. Conclusions: In African patients, AHF has a predominantly nonischemic cause, most commonly hypertension.Theconditionoccursinmiddle-agedadults,equally in men and women, and is associated with high mortality. The outcome is similar to that observed in nonAfrican AHF registries, suggesting that AHF has a dire prognosis globally, regardless of the cause.

Background An advance directive (AD) is a written or verbal document that legally stipulates a person’s health care preference while they are competent to make decisions for themselves and is used to guide decisions on life-sustaining treatment in the event that they become incapacitated. AD can take the form of a living will, a limitation of care document, a do-not-resuscitate order, or an appointment of a surrogate by durable power of attorney. The completion rate of AD varies from region to region, and it is influenced by multiple factors. The objectives of this study were to determine the proportion of terminally ill patients with AD and to identify the factors that influence the completion of AD amongst terminally ill patients at a tertiary hospital in Kenya. Methods The study was a retrospective survey. All available records of terminally ill patients seen at Aga Khan University Hospital, Nairobi, between July 2010 and December 2015, and that met the inclusion criteria were included in the study. Results In total, 216 records of terminally ill patients were analyzed: 89 records were of patients that had AD and 127 records were of patients that did not have AD. The proportion of terminally ill patients that had completed AD was 41.2%. The factors that were associated with the completion of AD on bivariate analysis were history of ICU admission, history of endotracheal intubation, functional status of the patient, the medical specialty taking care of the patient, patient’s caregiver discussing the AD with the patient, and a palliative specialist review. On multivariate regression analysis, discussion of AD with a caregiver and patient’s functional impairment were the factors with statistically significant association with completion of AD. Conclusions The proportion of terminally ill patients that had AD in their medical records was significant. However, most terminally ill patients did not have AD. Our data, perhaps the first on the subject in East Africa, suggest that most of the factors associated with AD completion mirrored those seen in other regions of the world. Discussion between patient and their physician and patient’s functional impairment were the factors independently associated with completion of AD. Therefore, physicians need to be aware of the importance of discussions of AD with their patients.