Rural Kenyan Hospital Research Articles

Recurrent Symptomatic Renal Stones Managed by Repeat Open Nephrolithotomy in a Rural Kenyan Hospital

Kidney stone disease (nephrolithiasis, urolithiasis, and renal calculi) is characterized by the formation of both symptomatic and asymptomatic obstructive and non-obstructive calculi in the urinary tract. Calcium oxalate stones are the most common type, related to the consumption of large amounts of oxalate-rich foods. Other stones are made of calcium phosphate, hydroxyapatite, uric acid, cystine, and struvite. Urolithiasis is increasingly being reported in both urban and rural Kenya. Minimally invasive surgical treatment of symptomatic stones is the current standard of care, but open nephrolithotomy remains a viable option in selected patients. Nonetheless, the rates of stone recurrence remain high, increasing from 15% at 1 year to 50% at 10 years due to multifactorial risk factors. In this study, we report the case of a rural Kenyan patient who underwent the third open nephrolithotomy in 10 years for recurrent symptomatic stones and whose biochemical analysis has guided subsequent preventative dietary efforts against stone recurrence.

A Case of End-stage Post-Covid-19 Pulmonary Fibrosis in a Kenyan Hospital

Post-COVID-19 pulmonary fibrosis (PC19-PF) is one of the severe manifestations of the “long COVID syndrome,” with a prevalence of about 7%, and is characterized by the presence of persistent fibrotic lung changes (on a CT scan of the lungs) associated with impairment of pulmonary function. Some of the risk factors for PC19-PF include advanced age, the occurrence of acute respiratory distress syndrome (ARDS), the need for supplemental oxygen, mechanical ventilation, smoking, etc. Antifibrotic agents, e.g., pirfenidone and nintedanib, are increasingly being used in the management of PC19-PF with good outcomes, but larger studies on efficacy and benefit are needed. In this study, we present the case of a young woman in a rural Kenyan hospital found to have end-stage PC19-PF needing long-term oxygen therapy to highlight the reality of PC19-PF in the post-COVID-19 clinical era.

Transient Hyperthyroidism of Hyperemesis Gravidarum: A Case Report from Rural Kenya

Purpose: The aim of the study was to assess the transient hyperthyroidism of hyperemesis gravidarum: A case report from rural Kenya.
 Materials and Methods: This study adopted a desk methodology. A desk study research design is commonly known as secondary data collection. This is basically collecting data from existing resources preferably because of its low cost advantage as compared to a field research. Our current study looked into already published studies and reports as the data was easily accessed through online journals and libraries.
 Findings: Hyperthyroidism complicates 0.2-0.4% of pregnancies. It may be diagnosed in the setting of hyperemesis gravidarum and can be pathological or transient. Untreated pathological hyperthyroidism has adverse maternal and fetal outcomes. Transient hyperthyroidism of hyperemesis gravidarum (THHG) affects up to 60% of women with hyperemesis, is self-limiting, and needs no antithyroid drug treatment. A diagnosis of THHG (rather than overt pathological hyperthyroidism) should be made when hyperthyroidism occurs in the setting of hyperemesis gravidarum and in the absence of pre-pregnancy hyperthyroidism, clinical findings compatible with maternal hyperthyroidism, and a negative antithyroid autoimmune profile. THHG resolves by the end of the first trimester without adverse pregnancy outcomes. We present a case from a rural Kenyan hospital to highlight the clinical profile and management of THHG for the primary care physician.
 Implications to Theory, Practice and Policy: Assessment of thyroid functions is indicated in hyperemesis gravidarum, where there are clinical features of hyperthyroidism. THHG is a self-limiting benign condition that may inappropriately lead to unnecessary drug treatment for pathological hyperthyroidism in pregnancy. A diagnosis of THHG should be made when a laboratory picture of hyperthyroidism occurs in the setting of hyperemesis gravidarum in the absence of pre-pregnancy hyperthyroidism, compatible physical findings, and a negative antithyroid autoantibody profile.

Cutaneous Furuncular Myiasis in a Rural Kenyan Hospital: A Case Report

Myiasis is a neglected tropical disease caused by infestation by the larval stages (maggots) of many species of flies, which occur worldwide but are more prevalent in the tropical and subtropical regions. The two main types of flies causing human myiasis are Dermatobia hominis (bot fly) and Cordylobia anthropophaga (tumbu fly). Cases of human myiasis in Kenya are not well documented, but some epidemiological studies show the tumbu fly to be the most prevalent. Transmission and infestation occur in cases of poor personal and environmental hygiene, especially in spaces shared with wild and domestic animals. Cutaneous myiasis, presenting as a furuncular, wound, and migratory disease, is the most common clinical phenotype that may be associated with secondary pyogenic infection and cellulitis, especially when not treated promptly. In this study, we present a case of cutaneous furuncular myiasis in a patient from rural Kenya. We share our experience managing the patient and also provide a literature review on the clinical case management of myiasis, with a call for more epidemiological and clinical work to be done to better understand this neglected disease.

Chalasia Cardia in Pregnancy Presenting as Hyperemesis Gravidarum in A Rural Kenyan Hospital: A Case Report and Literature Review

Achalasia cardia is a motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter (LES) during swallowing, resulting in dysphagia, regurgitation symptoms, vomiting, fluid losses, and malnutrition. Achalasia cardia is rare in pregnancy and is often misdiagnosed as hyperemesis gravidarum due to similar symptomatology, usually with significant morbidity and mortality. Definitive management is by surgical myotomy, which should be delayed until after delivery due to concerns about maternal and fetal safety. In this study, we present a case of achalasia cardia in a young primigravida in rural Kenya in the third trimester of pregnancy.

Prevalence of Antimicrobial Resistance and Association with Patient Outcomes in a Rural Kenyan Hospital.

Data on antimicrobial resistance (AMR) and association with outcomes in resource-variable intensive care units (ICU) are lacking. Data currently available are limited to large, urban centers. We attempted to understand this locally through a dual-purpose, retrospective study. Cohort A consisted of adult and pediatric patients who had blood, urine, or cerebrospinal fluid cultures obtained from 2016 to 2020. A total of 3,013 isolates were used to create the Kijabe Hospital's first antibiogram. Gram-negative organisms were found to be less than 50% susceptible to third- and fourth-generation cephalosporins, 67% susceptible to piperacillin-tazobactam, 87% susceptible to amikacin, and 93% susceptible to meropenem. We then evaluated the association between AMR and clinical characteristics, management, and outcomes among ICU patients (Cohort B). Demographics, vital signs, laboratory results, management data, and outcomes were obtained. Antimicrobial resistance was defined as resistance to one or more antimicrobials. Seventy-six patients were admitted to the ICU with bacteremia during this time. Forty complete paper charts were found for review. Median age was 34 years (interquartile range, 9-51), 26 patients were male (65%), and 28 patients were older than 18 years (70%). Septic shock was the most common diagnosis (n = 22, 55%). Six patients had AMR bacteremia; Escherichia coli was most common (n = 3, 50%). There was not a difference in mortality between patients with AMR versus non-AMR infections (P = 0.54). This study found a prevalence of AMR. There was no association between AMR and outcomes among ICU patients. More studies are needed to understand the impact of AMR in resource-variable settings.

A Blended Learning Approach to Emergency Airway Training in a Low Resource Environment

Introduction:Global Emergency Care Skills (GECS) is a charity which delivers medical training to health care professionals in low and middle income countries. Teaching airway management both didactically and through simulation training is a key component of the GECS Emergencies and Trauma Course. In 2022, a team of doctors delivered an intensive, five-day teaching course with a strong emphasis on airway management and airway emergencies at St. Joseph’s Nyabondo Mission Hospital in rural Kenya. This course was delivered to a group of doctors, nurses and clinical officers. At the conclusion of this course we collected qualitative feedback from course participants. The aim of this study was to assess airway knowledge and skills acquisition, as well as real-world application and potential for ongoing teaching of acquired airway skills.Method:A questionnaire was distributed to course participants to ascertain their experience of didactic airway teaching, airway skills stations, and airway simulation. Each question offered a binary response. To continue to enhance course content, we invited participants to submit qualitative feedback at the end of the questionnaire.Results:Questionnaires were returned by 19 of a total 24 participants. 53% were registered nurses, 21% were clinical officers, 5% were medical officers and 21% did not respond to this question. Median post graduate clinical experience was four years (2.75-5.25). 37% indicated that they had not heard of simulation training for medical education before undertaking this course. 58% had no previous airway training although 63% had prior exposure to clinical situations which required emergency airway management. 100% reported feeling more confident in their airway skills and potential for training colleagues following this course.Conclusion:The results indicate that participants gained knowledge, skills, and confidence when approaching airway emergencies. Furthermore, results showed increased perceived competence by participants at providing airway training to colleagues.

CT without borders: Comparison of diagnoses for abdominal pain from a teaching hospital in rural Kenya and a US academic medical center.

Radiology global health opportunities are expanding as more hospitals in low- and middle-income countries utilize CT. This creates opportunities for global health program building, education, service, and research. This study determines the diagnostic yield and variety of abdominopelvic CT diagnoses for abdominal pain in a US academic medical center (UW) compared to a rural Kenyan teaching hospital (Tenwek). A retrospective, cross-sectional sequential sample of 750 adults from both hospitals who underwent abdominopelvic CT for abdominal pain from February 2019 through July 2020was obtained. Exclusion criteria were trauma, cancer staging, and recent hospitalization or surgery. Patient age, sex, comparisonstudies, use of contrast, known cancerdiagnosis, and CT diagnoses were compared. Negative examrate, acute abdomendiagnosis, and new cancer diagnosis were recorded. Statistical analysis was performed using R. 750 UW patients met inclusion criteria (mean age 53.3 ± 20years; 442 women) and 750 Tenwekpatients met inclusion criteria (mean age 52.5 ± 18years; 394 women). 72% of UW patients had comparison imaging compared to 6% of Tenwek patients. 11% (83/750) of UW patients had a known cancer diagnosis compared to 1% (10/750) of Tenwek patients. 39% of UW patients had a negative exam compared to 23% of Tenwek patients (p < 0.001). 58% of UW patients had an acute abdomen diagnosis compared to 38% of Tenwek patients (p < 0.001). 10 of the 15 topacute abdomen diagnoses were shared, but in different order of frequency. Diagnoses unique to UW were diverticulitis, constipation, stercoral colitis, and epiploicappendagitis. Diagnoses unique to Tenwek were tuberculosis and hydatidosis. 3% of UW patients received a new cancer diagnosis (7/19 metastatic), compared to 40% of Tenwek patients (153/303 metastatic) (p < 0.001). For adults undergoing CT for abdominal pain, there are differences in the prevalence of abdominal pain diagnoses, new cancer diagnosis, and negative exam rate between the rural Kenyan teaching hospital and the US academic medical center.

Perceptions of barriers and facilitators to disinfection of basic neonatal resuscitation equipment in a rural hospital in Kenya: A qualitative study

Perceptions of barriers and facilitators to disinfection of basic neonatal resuscitation equipment in a rural hospital in Kenya: A qualitative study

Implementation of a Surgical Critical Care Service Reduces Failure to Rescue in Emergency Gastrointestinal Surgery in Rural Kenya.

We aimed to evaluate the implementation of a dedicated Surgical critical care service (SCCS) on failure to rescue (FTR) rates in rural Kenya. FTR adversely impacts perioperative outcomes. In the resource-limited contexts of low- and middle-income countries, emergency gastrointestinal surgery carries high morbidity and mortality rates. Quality improvement initiatives that decrease FTR rates are essential for improving perioperative care. All patients who underwent emergency gastrointestinal surgery between January 2016 and June 2019 at Tenwek Hospital in rural Kenya were reviewed. Critical care capabilities were constant throughout the study period. A supervised surgical resident was dedicated to the daily care of critically ill surgical patients beginning in January 2018. The impact of the SCCS initiation on the outcome of FTR was evaluated, controlling for patient complexity via the African Surgical Outcomes Study Surgical Risk Score. A total of 484 patients were identified, consisting of 278 without and 206 with an active SCCS. A total of 165 (34.1%) patients experienced postoperative complications, including 49 mortalities (10.1%) yielding an FTR rate of 29.7%. The FTR rate decreased after SCCS implementation from 36.8% (95% CI: 26.7%-47.8%) to 21.8% (95% CI: 13.2%-32.6%) ( P = 0.035) despite an increase in the average patient African Surgical Outcomes Study score from 14.5 (95% CI, 14.1-14.9) to 15.2 (95% CI, 14.7-15.7) ( P =0.03). The implementation of an SCCS in rural Kenya resulted in decreased rates of FTR despite an increase in patient complexity and severity of critical illness.

Get Me a Mask! The Challenge of Equipment Supply Chains.

Get Me a Mask! The Challenge of Equipment Supply Chains.

Coping with COVID: Developing a Rapid-cycle Frontline Quality-improvement Process to Support Employee Well-being and Drive Institutional Responsiveness in a Tertiary Care Faith-based Hospital in Rural Kenya.

ABSTRACT.The coronavirus disease 2019 (COVID-19) pandemic has demanded rapid institutional responses to meet the needs of patients and employees in the face of a serious new disease. To support the well-being of frontline staff, a series of debriefing sessions was used to drive a rapid-cycle quality-improvement process. The goals were to confidentially determine personal coping strategies used by staff, provide an opportunity for staff cross-learning, identify what staff needed most, and provide a real-time feedback loop for decision-makers to create rapid changes to support staff safety and coping. Data were collected via sticky notes on flip charts to protect confidentiality. Management reviewed the data daily. Institutional responses to problems identified during debrief sessions were tracked, visualized, addressed, and shared with staff. More than 10% of staff participated over a 2-week period. Feedback influenced institutional decisions to improve staff schedules, transportation, and COVID-19 training.

Deployment and testing of an automated medical equipment service communication and documentation system at a rural hospital in Kenya.

BackgroundThe Medical Equipment Network Documentation System (MENDS) provides a simple communication network for equipment servicing from failure to restoration. It is a text messaging-based platform, designed to use existing technologies in place in low- and middle-income settings. The system gathers and relays information about equipment service requests and reports and automatically saves them to an online database.MethodsMENDS was deployed at a high volume, rural, charity medical facility in Kijabe, Kenya for a 3-mo pilot test.ResultsThe results show MENDS more than tripled documentation and enhanced ease and speed of communication.ConclusionsComprehensive data provided by MENDS created more accurate measures of equipment performance, which can be used to decrease the time that equipment is out of service and improve the efficiency of repairs, equipment quality and procurement.

Clinical features to distinguish meningitis amongst infants aged

Clinical features to distinguish meningitis amongst infants aged <60 days admitted at a rural Kenyan hospital

Referral Patterns of Burn Injury in Rural Kenya.

Burn injury represents a substantial burden of disease in resource-limited settings. Kenya has no formal trauma system and referral practices for burn injuries are not well understood. The purpose of this study was to determine the factors associated with burn injury referrals in rural Kenya. A retrospective chart review was conducted for patients with burn injury from January 1, 2014 to December 31, 2017 at a 300-bed faith-based, teaching hospital in southwest Kenya. Bivariate analysis compared referred and non-referred patients. Multivariable logistic regression was used to assess the association between burn severity and odds of referral adjusting for age, sex, insurance, time from injury to arrival, and estimated travel time from home to hospital. The study included 171 patients with burn injury; 11 patients were excluded due to missing referral data. Of the 160 patients, 31.9% (n = 51) were referred. Referral patients had higher average total body surface area burn (23.1 ± 2.4% vs 11.1 ± 1.2%, P < .001), were more likely to have full-thickness burns (41.3% vs 25.5%, P = .05), and less likely to present to the referral hospital within 24 hours after injury (47.8% vs 73.0%, P = .005). Referral patients had longer travel time to hospital (90+ min: 52.9% vs 22.0%, P < .001). Odds of referral increased 1.62 times (95% confidence interval: 1.19-2.22) for every 10% increase in total body surface area burn. Without a coordinated trauma system, referrals represent a substantial portion of burn injury patients at a hospital in rural Kenya. Referred patients present with more severe burns and experience delays to presentation.

Operative Self-Confidence, Hesitation, and Ability Assessment of Surgical Trainees in Rural Kenya

BackgroundThe education of surgical trainees is ideally designed to produce surgeons with both confidence and competence. This involves the development of autonomy in the operating room. Factors associated with autonomy and entrustment have been studied in high-resource settings. In a resource-limited context, where autonomy is solely at the discretion of faculty, and there are fewer external constraints to restrict it, we hypothesized that assessment of a trainee’s performance would be dependent upon reported confidence levels of both faculty and trainees in those trainees’ abilities. Materials and methodsAt a teaching hospital in rural Kenya, operative experience surveys were administered to eleven general surgery trainees (PGY1-5) and six faculty paired dyads immediately following operative procedures in May 2016 to elicit self-reported assessments of confidence, hesitation, and ability as measured by the Zwisch Scale. We examined factors related to learning and used dyadic structural equation models to understand factors related to the assessment of ability. ResultsThere were 107 paired surveys among 136 trainees and 130 faculty evaluations. Faculty scrubbed into 76 (72%) cases. In comparison to trainees, faculty were more likely to give a higher average score for confidence (4.08 versus 3.90; P value: 0.005), a lower score for hesitation (2.67 versus 2.84; P value: 0.001), and a lower score for the ability to perform the operation independently (2.73 versus 3.02; P value: 0.01). Faculty and trainee perceptions of hesitation influenced their ability scores. Trainee hesitation (OR 12.1; 1.2-127.6, P = 0.04) predicted whether trainees reported experiencing learning. ConclusionsBetween trainees and faculty at a teaching program in rural Kenya, assessment scores of confidence, hesitation, and ability differ in value but remain fairly correlated. Hesitation is predictive of ability assessment, as well as self-reported learning opportunities. Focus upon identifying when trainees hesitate to proceed with a case may yield important educational opportunities.

Clinical features to distinguish meningitis among young infants at a rural Kenyan hospital

BackgroundDetection of meningitis is essential to optimise the duration and choice of antimicrobial agents to limit mortality and sequelae. In low and middle-income countries most health facilities lack laboratory capacity...

Multi-level perceptions of barriers and facilitators to reprocessing of basic neonatal resuscitation equipment in a resource-limited, rural hospital in Kenya

Multi-level perceptions of barriers and facilitators to reprocessing of basic neonatal resuscitation equipment in a resource-limited, rural hospital in Kenya

Establishing exclusive breastfeeding among in-patient malnourished infants in a rural Kenyan hospital: mothers\u2019 experiences of a peer supporter intervention

BackgroundThe 2013 WHO guidelines for nutritional rehabilitation of hospitalized and non-hospitalized malnourished infants under six months (u6m) recommend the re-establishment of exclusive breastfeeding. However, in most low-income settings these recommendations are not consistently applied. A recently concluded pilot study on the effects of implementing these guidelines among hospitalized malnourished infants u6m of age in Kilifi, Kenya introduced breastfeeding peer supporters (BFPS) to the inpatient setting to support guideline implementation. Here we report a sub-study investigating mothers’ experiences and perceptions of the process of re-establishing exclusive breastfeeding during their infant’s admission to hospital.MethodsInterviews were conducted with mothers just prior to their infant’s discharge to explore their experiences and perceptions of the breastfeeding support process. A trained social science researcher conducted the interviews in Kiswahili language using a structured interview guide with open questions. Interviews were tape recorded, transcribed and translated into English for analysis. Data were managed and organized using NVIVO version 10 and analyzed using a framework approach.ResultsTwenty mothers were interviewed. While some mothers found re-establishing breastfeeding challenging, they all reported improved knowledge on the relationships between maternal nutrition, stress management, hygiene practices and breastmilk production. They also reported gaining skills in breast care, breastfeeding techniques, hand expression and handling of expressed breastmilk. The breastfeeding peer supporters were said to have provided technical, social and emotional support which facilitated the process of re-establishing exclusive breastfeeding. The mothers identified the key characteristics of an effective and trustworthy BFPS as well as gaps in support.ConclusionBFPS are able share knowledge and skills in a way that is understood and appreciated by the mothers of inpatient malnourished infants u6m of age, enhancing the reestablishment of exclusive breastfeeding. Central to the success of BFPS is their ability to develop close and supportive relationships with the mothers based on shared social and cultural backgrounds. Future studies should focus on evaluating the long-term impact of inpatient breastfeeding support strategies on the quality of breastfeeding and growth, as well as on understanding where, when and how BFPS might be incorporated into routine hospital settings.

Liz Grant: prioritising palliative care and planetary health

At a rural hospital in Kenya in the late 1990s, Liz Grant saw diseases like cancer and HIV/AIDS destroy lives. “Patients were dying in severe pain, chewing paracetamol—there wasn't sufficient morphine…The voice of one woman still lives with me: ‘I want to go to sleep and wake up dead’”, says Grant, who has worked tirelessly ever since to improve access to palliative care in low-income and middle-income countries (LMICs). The low priority given to end-of-life care means “it has been an uphill struggle”, says Grant, Assistant Principal and Professor of Global Health and Director of the Global Health Academy at the UK's University of Edinburgh. But she's clear: “We must strive to deliver good palliative care in poverty.”