Knowledge on ionizing radiation among non-radiologist clinicians at Kenyatta National Hospital – Kenya

Background: Low dose ionizing radiation used in diagnostic imaging has the potential to cause detrimental health effects. Knowledge of the requesting clinician on ionizing radiation will deter inappropriate and unjustifiable imaging requests.Objective: To document the knowledge of ionizing radiation (IR) among the teaching hospital non-radiologist clinicians.Design: Cross-sectional survey.Setting: Kenyatta National Hospital (KNH), the largest teaching and referral hospital in Nairobi, Kenya.Subjects: A total of 170 non-radiology hospital clinicians were recruited into the study after ethical approval and informed consent using simple random sampling method over a six-week period in August -October 2013.Results: Health workers with ionizing radiation (IR) training were more likely to correctly identify all the imaging modalities that use IR compared to those without IR training (50.9% versus 27.5%; OR = 2.83, 95% CI 1.35-5.91). There was significant heterogeneity in knowledge across the cadres (p < 0.0001). Those with formal IR training were able to identify that an abdominal CT has the highest radiation dose compared to those with no formal training (69.8% vs 37.1% p= < 0.001). Length of professional experience, field of clinical training, and formal training in IR of the clinicians had no influence on their knowledge of IR doses. With respect to organ sensitivity only 42% of participants correctly rated bone marrow as a very sensitive organ.Conclusions: The results from this study show that health workers lack the basic knowledge on ionizing radiation doses and its harmful effects. This is likely to impact negatively on their attitude and practice. The implications here are serious for the patient as they are possibly being exposed to unnecessary radiation and its attendant risks which include carcinogenesis.Recommendations: To bridge this knowledge gap, there is need to increase awareness about ionizing radiation through continuous medical education,development of imaging referral guidelines and incorporating modules on medical radiation and its risks during the clinicians’ training programs

The Cerebro-placental Ratio as a Prognostic Factor of Foetal Outcome in Patients with Third Trimester Hypertension

Background: Hypertensive disorders of pregnancy can cause complications in both the maternal and fetal circulations resulting in poor fetal outcome. These circulations can be safely and non-invasively assessed using arterial Doppler indices of the umbilical and middle cerebral arteries to obtain the cerebro-placental ratio. The study objective was to determine the role of the cerebro-placental ratio as a prognostic factor of fetal outcome in patients with hypertensive states of pregnancy delivered at least 32 weeks of gestation by dates.Methods: This was a prospective cohort study undertaken at Kenyatta National Hospital, a tertiary referral hospital in Nairobi. A total of 160 gravid patients of median age 28 years and at least 32 weeks gestations were recruited from labor ward over a 9 month study period by consecutive sampling method. Doppler ultrasound analyses of the foetal umbilical and cerebral arteries were done and the cerebro-placental ratio calculated.Results: At sonography, the average ultrasound age was 31 weeks. The median gestation at admission was 34 weeks. Twenty nine percent had an abnormal Cerebro-placental ratio (<1.0).125/160 (78%) delivered via caesarean section and 35/160(22%) delivered vaginally.51/160(32%)  severe pre-eclamptic toxaemia out of which 39% had cerebroplacental ratio<1.0 109/160(68%) had mild pre-eclamptic toxaemia out of which 24% had cerebroplacental ratio <1.0 Still births were 12.5 times more likely in mothers with cerebroplacental ratio <1.0 than those with CPR 1.0 (p value 0.05). A foetal birth score < 7 was 66 times more often in  mothers with cerebro-placental ratio< 1.0 than mothers with CPR 1.0. (P 0.05). Low birth weight was 4.7 times more likely among mothers with cerebroplacental ratio < 1.0.as compared to those with mothers with CPR1.0 (95% CI 2, 11.1; p0.001). A foetal birth score < 7 was 66 times more likely among neonates delivered vaginally as compared to those born via caesarean section(95% CI 1.3, 23; p=0.02). Still births were 14.5 times more often than among neonates born vaginally as compared to those born via caesarean section (95% CI 3, 84; p0.001). The prognostic Odds Ratio for cerebro-placental ratio was 12.5 for live births (95% CI 2, 74; p=0.005), 66 for fetal birth score <7 (95% Confidence interval 13, 340; p< 0.001) and 4.7 for low birth weight (95% CI 2, 11.1; p< 0.001) and 1.1 (95% CI 0.9, 1.4; p=0.327).Conclusion: Cerebro-placental ratio is significantly predictive of adverse perinatal outcome when used to monitor mothers with hypertensive states of pregnancy. Cerebroplacental ratio.Key words: Cerebro-placental Ratio, Prognostic Factor, Foetal Outcome, Third Trimester, Hypertensio

Universal Definition of Loss to Follow-Up in HIV Treatment Programs: A Statistical Analysis of 111 Facilities in Africa, Asia, and Latin America

Background: Although patient attrition is recognized as a threat to the long-term success of antiretroviral therapy programs worldwide, there is no universal definition for classifying patients as lost to follow-up (LTFU). We analyzed data from health facilities across Africa, Asia, and Latin America to empirically determine a standard LTFU definition. Methods and Findings: At a set ''status classification'' date, patients were categorized as either ''active'' or ''LTFU'' according to different intervals from time of last clinic encounter. For each threshold, we looked forward 365 d to assess the performance and accuracy of this initial classification. The best-performing definition for LTFU had the lowest proportion of patients misclassified as active or LTFU. Observational data from 111 health facilities - representing 180,718 patients from 19 countries - were included in this study. In the primary analysis, for which data from all facilities were pooled, an interval of 180 d (95% confidence interval [CI]: 173–181 d) since last patient encounter resulted in the fewest misclassifications (7.7%, 95% CI: 7.6%–7.8%). A secondary analysis that gave equal weight to cohorts and to regions generated a similar result (175 d); however, an alternate approach that used inverse weighting for cohorts based on variance and equal weighting for regions produced a slightly lower summary measure (150 d). When examined at the facility level, the best-performing definition varied from 58 to 383 d (mean = 150 d), but when a standard definition of 180 d was applied to each facility, only slight increases in misclassification (mean = 1.2%, 95% CI: 1.0%–1.5%) were observed. Using this definition, the proportion of patients classified as LTFU by facility ranged from 3.1% to 45.1% (mean = 19.9%, 95% CI: 19.1%–21.7%). Conclusions: Based on this evaluation, we recommend the adoption of $180 d since the last clinic visit as a standard LTFU definition. Such standardization is an important step to understanding the reasons that underlie patient attrition and establishing more reliable and comparable program evaluation worldwide

Estimating Loss to Follow-Up in HIV-Infected Patients on Antiretroviral Therapy: The Effect of the Competing Risk of Death in Zambia and Switzerland

BACKGROUND: Loss to follow-up (LTFU) is common in antiretroviral therapy (ART) programmes. Mortality is a competing risk (CR) for LTFU; however, it is often overlooked in cohort analyses. We examined how the CR of death affected LTFU estimates in Zambia and Switzerland. METHODS AND FINDINGS: HIV-infected patients aged ≥18 years who started ART 2004-2008 in observational cohorts in Zambia and Switzerland were included. We compared standard Kaplan-Meier curves with CR cumulative incidence. We calculated hazard ratios for LTFU across CD4 cell count strata using cause-specific Cox models, or Fine and Gray subdistribution models, adjusting for age, gender, body mass index and clinical stage. 89,339 patients from Zambia and 1,860 patients from Switzerland were included. 12,237 patients (13.7%) in Zambia and 129 patients (6.9%) in Switzerland were LTFU and 8,498 (9.5%) and 29 patients (1.6%), respectively, died. In Zambia, the probability of LTFU was overestimated in Kaplan-Meier curves: estimates at 3.5 years were 29.3% for patients starting ART with CD4 cells <100 cells/µl and 15.4% among patients starting with ≥350 cells/µL. The estimates from CR cumulative incidence were 22.9% and 13.6%, respectively. Little difference was found between naïve and CR analyses in Switzerland since only few patients died. The results from Cox and Fine and Gray models were similar: in Zambia the risk of loss to follow-up and death increased with decreasing CD4 counts at the start of ART, whereas in Switzerland there was a trend in the opposite direction, with patients with higher CD4 cell counts more likely to be lost to follow-up. CONCLUSIONS: In ART programmes in low-income settings the competing risk of death can substantially bias standard analyses of LTFU. The CD4 cell count and other prognostic factors may be differentially associated with LTFU in low-income and high-income settings

WANDERING SPLEEN: CASE REPORT

Wandering spleens are rare clinical entities found more commonly in women aged 20-40 years. We report one such case found in a 24-year-old nulliparous woman who presented with low abdominal pains of sudden onset and splenomegaly. An emergency abdominal CT scan showed an enlarged spleen located in the right lumbar region and extending into the pelvis. There was a long splenic pedicle containing tortuous vessels. A review of literature and the postulated aetiological factors and associationsare discussed

Determining the elastography strain ratio cut off value for differentiating benign from malignant breast lesions: systematic review and meta-analysis

Background: Elastography is an addition to grey-scale ultrasonic examination that has gained substantial traction within the last decade. Strain ratio (SR) has been incorporated as a semiquantitative measure within strain elastography, thus a potential imaging biomarker. The World Federation for Ultrasound in Medicine and Biology (WFUMB) published guidelines in 2015 for breast elastography. These guidelines acknowledge the marked variance in SR cut-off values used in differentiating benign from malignant lesions. The objective of this review was to include more recent evidence and seek to determine the optimal strain ratio cut off value for differentiating between benign and malignant breast lesions. Methods: Comprehensive search of MEDLINE and Web of Science electronic databases with additional searches via Google Scholar and handsearching set from January 2000 to May 2020 was carried out. For retrieved studies, screening for eligibility, data extraction and analysis was done as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Diagnostic Test Accuracy (PRISMA-DTA) Statement guidelines of 2018. Quality and risk of bias assessment of the studies were performed using the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Results: A total of 424 articles, 412 from electronic database and 12 additional searches were retrieved and 65 studies were included in the narrative synthesis and subgroup analysis. The overall threshold effect indicated significant heterogeneity among the studies with Spearman correlation coefficient of Logit (TPR) vs Logit (FPR) at − 0.301, p-value = 0.015. A subgroup under machine model consisting seven studies with 783 patients and 844 lesions showed a favourable threshold, Spearman’s correlation coefficient,0.786 (p = 0.036). Conclusion: From our review, currently the optimal breast SR cut-off point or value remains unresolved despite the WFUMB guidelines of 2015. Machine model as a possible contributor to cut-off value determination was suggested from this review which can be subjected to more industry and multi-center research determination

Land suitability evaluation for the production of the major crops in the southwestern part of the Uluguru Mountains, Morogoro rural district, Tanzania

Land evaluation study was conducted on the southwestern slopes of the Uluguru Mountains in Morogoro Rural District, Tanzania to assess the potentials and constraints of the various land units for the production of low input rainfed cabbage, round potato and arabica coffee. The study area is located between latitudes 7 o 0000 and 7 o 1123.5S and longitudes 37 o 3000 and 37 o 3836.6E covering the villages of Kibaoni, Langali, Bunduki, Bumu, Kikeo, Luale, Mwarazi, Nyandira, Kibuko and Tchenzema. The areal extent is 419.64 km 2 (41,964 ha) with an average elevation ranging between 900 - 2700 m a.s.l. The mean annual rainfall in the study area ranges from 1065 mm to 2450 mm. The rainfall distribution pattern is monomodal with the rainy season starting from December to May. The peak rainfall occurs in April in most places of the study area. The high altitude areas receive more rainfall than the lower areas. In some areas rainfall distribution tends more to be bimodal with two peaks occurring in October and in April. There is considerable temperature variability in the study area with the mean monthly temperature ranging from 17.4 o C (July) to 22.4 o C (December). At high elevations temperatures are much cooler. The shortest reference length of growing period is 180 days while the longest is 270 days. The geology of the study area consists of a mixture of banded pyroxene granulites with occasional biotite-rich bands, foliated mica gneisses, hornblende gneisses and granulites and some iron-rich meta-anorthositic rocks, all belonging to the Usagaran system. In some places alluvial deposits and kaolinitic clays of Neogene age are found. The study area consists of strongly dissected mountains with very steep plateau and ridge slopes of about 30-60% and narrow valleys and incisions. Lukwangule plateau is the highest peak in the study area reaching an altitude of 2,623 m a.s.l. The Lukwangule plateau is only slightly dissected and the surface forms quite a mature relief. Two distinct drainage patterns exist in the study area. A sub-radial pattern which is related to the horse-shoe of high mountains from Mkumbaku through Lukwangule and Magari to Lupanga, which is currently represented by some of the larger rivers such as Mngazi, Mbakana and, in part, the Mgeta. A rectilinear pattern is exhibited where secondary streams and many main rivers show adjustment to geological structure and rock type. The pattern of the minor rivers follows the geological structure more closely and has resulted in river capture, reversed drainage and wind gaps. The edge of the meta-anorthosite is marked by the Mgeta, Mfunesi and Lukangazi river valleys for about two-thirds of its circumference, and this weakness is presumably the cause of the spiral course of the Mgeta River as it cuts back along the junction of rocks, capturing successively all the radial drainage from the north and west of the high level plateaux

Land suitability evaluation for the production of the major crops in the southwestern part of the Uluguru Mountains, Morogoro rural district, Tanzania

Land evaluation study was conducted on the southwestern slopes of the Uluguru Mountains in Morogoro Rural District, Tanzania to assess the potentials and constraints of the various land units for the production of low input rainfed cabbage, round potato and arabica coffee. The study area is located between latitudes 7 o 0000 and 7 o 1123.5S and longitudes 37 o 3000 and 37 o 3836.6E covering the villages of Kibaoni, Langali, Bunduki, Bumu, Kikeo, Luale, Mwarazi, Nyandira, Kibuko and Tchenzema. The areal extent is 419.64 km 2 (41,964 ha) with an average elevation ranging between 900 - 2700 m a.s.l. The mean annual rainfall in the study area ranges from 1065 mm to 2450 mm. The rainfall distribution pattern is monomodal with the rainy season starting from December to May. The peak rainfall occurs in April in most places of the study area. The high altitude areas receive more rainfall than the lower areas. In some areas rainfall distribution tends more to be bimodal with two peaks occurring in October and in April. There is considerable temperature variability in the study area with the mean monthly temperature ranging from 17.4 o C (July) to 22.4 o C (December). At high elevations temperatures are much cooler. The shortest reference length of growing period is 180 days while the longest is 270 days. The geology of the study area consists of a mixture of banded pyroxene granulites with occasional biotite-rich bands, foliated mica gneisses, hornblende gneisses and granulites and some iron-rich meta-anorthositic rocks, all belonging to the Usagaran system. In some places alluvial deposits and kaolinitic clays of Neogene age are found. The study area consists of strongly dissected mountains with very steep plateau and ridge slopes of about 30-60% and narrow valleys and incisions. Lukwangule plateau is the highest peak in the study area reaching an altitude of 2,623 m a.s.l. The Lukwangule plateau is only slightly dissected and the surface forms quite a mature relief. Two distinct drainage patterns exist in the study area. A sub-radial pattern which is related to the horse-shoe of high mountains from Mkumbaku through Lukwangule and Magari to Lupanga, which is currently represented by some of the larger rivers such as Mngazi, Mbakana and, in part, the Mgeta. A rectilinear pattern is exhibited where secondary streams and many main rivers show adjustment to geological structure and rock type. The pattern of the minor rivers follows the geological structure more closely and has resulted in river capture, reversed drainage and wind gaps. The edge of the meta-anorthosite is marked by the Mgeta, Mfunesi and Lukangazi river valleys for about two-thirds of its circumference, and this weakness is presumably the cause of the spiral course of the Mgeta River as it cuts back along the junction of rocks, capturing successively all the radial drainage from the north and west of the high level plateaux

Evolution of a programme to engage school students with health research and science in Kenya.

Facilitating mutually-beneficial educational activities between researchers and school students is an increasingly popular way for research institutes to engage with communities who host health research, but these activities have rarely been formally examined as a community or public engagement approach in health research. The KEMRI-Wellcome Trust Research Programme (KWTRP) in Kilifi, Kenya, through a Participatory Action Research (PAR) approach involving students, teachers, researchers and education stakeholders, has incorporated 'school engagement' as a key component into their community engagement (CE) strategy. School engagement activities at KWTRP aim at strengthening the ethical practice of the institution in two ways: through promoting an interest in science and research among school students as a form of benefit-sharing; and through creating forums for dialogue aimed at promoting mutual understanding between researchers and school students. In this article, we provide a background of CE in Kilifi and describe the diverse ways in which health researchers have engaged with communities and schools in different parts of the world. We then describe the way in which the KWTRP school engagement programme (SEP) was developed and scaled-up. We conclude with a discussion about the challenges, benefits and lessons learnt from the SEP implementation and scale-up in Kilifi, which can inform the establishment of SEPs in other settings