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Objective: To study patient determinants that may affect completion of the diagnostic process in tuberculosis control, highlighting the role of counselling., Design: Cross-sectional study., Subjects: TB patients., Setting: Rhodes Chest Clinic, Nairobi, City Council., Results: Ninety five percent of the suspects delivered three sputum samples but only 27% consented to a HIV test; several determinants for none consenting were mentioned. On average US$2.27 was spent for one clinic visit and U.S. $8.62 for following the entire diagnostic process. Cost factors included transport, loss of income and food., Conclusion: Individual pre-test counselling seems important for obtaining three sputum specimens. It takes time and for settings with a large number of suspects, alternative methods may be required. To obtain consensus for a HIV test in a TB clinic is complicated. Costs spent on transport and loss in income are important determinants and may contribute to poor patient adherence to the diagnostic process.

Objectives: To determine the prevalence of smoking and investigate factors that may influence smoking behaviour in secondary school students in Nairobi., Design: Cross-sectional survey in which a self-administered questionnaire was issued to the students., Setting: Sampled public and private secondary schools in Nairobi., Participants: All the students in the selected secondary schools were included in the study., Results: Five thousand, three hundred and eleven (74.1%) secondary school students were covered. There were 3658 boys and 1653 girls in the study. The mean age was 16.7 years SD +/- 1.48. The study covered 3065 (77.3%) and 2246 (70.1%) of the public and private school students respectively. A total of 1709 (32.2%) were ever-smokers. The overall rate of ever-smoking by gender among the students was 38.6% of males and 17.9% of the females. Experimentation with smoking started at five years and regular smoking at 10 years but majority of students (72.2%) started at between age 12 and 16 years. Parents' and teachers' smoking habits influenced initiation of smoking by young children while peer pressure, advertising and type of school influenced older children to smoking. About 67% of the ever-smokers stopped the habit giving various reasons. There was a strong relationship between age of smoking initiation and stoppage. Majority of the students smoked either to enhance their personalities or for stimulation. Most students smoked less than five cigarettes per day. General shops, kiosks and cigarette stalls which sell cigarettes in both packets and single sticks were the main source to students. Students smoked mostly in the evening and at night. Most student smokers were not discouraged by health warnings on the cigarette packets and awareness of the dangers of smoking. Enforceable legislation that would ban advertising and make smoking illegal was the main recommendation from the students., Conclusions: Smoking is a problem among Kenyan students. The habit starts quite early in life. Peer pressure, advertising, type of school and age influenced smoking among the students. Banning the sale of cigarettes in single sticks is recommended. Anti-smoking campaigners and specially trained school teachers should encourage attitude shaping among school children towards self confidence and adequacy.

Exercise-induced bronchospasm (EIB), a common feature of asthma in children, has been used as the outcome measure in community-based surveys of childhood asthma to circumvent difficulties arising from relative lack of objectivity in the use of questionnaires in communities with different cultural and language orientations. We report here the results of the first community-based study of childhood asthma in Kenya using EIB as the outcome measurement. The data was collected in a pilot study to develop methodology for a larger subsequent study. The survey targeted grade four children in five Nairobi City Council school each representing a neighbourhood social economic status (SES). Out of 597 eligible, 408 children took part in the study (68% participation rate). EIB defined as decline in FEV1 of 15% or more, post-exercise was found in 10.5% (95% CI; 10.3, 10.7) of the children studied, the highest rate reported so far in Africa. While boys were more likely to exhibit EIB compared to girls, the prevalence of EIB tended to decrease with age, especially among children residing in low SES neighbourhoods where the EIB prevalence rates tended to be lower compared to those among children from higher SES neighbourhoods. However, none of these differences was statistically significant. This study confirms the feasibility of undertaking exercise challenge tests in the African context and we recommend that additional studies of similar nature be carried out in other populations of Africa to explore the potential of using an exercise test as a marker of asthma in epidemiologic studies.

An open study to assess the efficacy and safety of 50 micrograms inhaled Salmeterol (Serevent) administered twice daily as maintenance therapy for asthma was undertaken by the Respiratory Diseases Research Unit (RDRU) in Nairobi between August and October, 1992. Salmeterol (Hydroxynaphthoate) is a long acting selective beta-2-agonist. Seventy-three adult patients recruited at Kenyatta National Hospital underwent a two weeks treatment period during which they were assessed over three visits. At Visit 1, eligibility was confirmed, baseline lung function indices measured, the study drug introduced and all the previous medications withdrawn. After treatment for one week (Visit 2) and two weeks (Visit 3), lung function indices were measured again and subjective patients' and physicians' assessments of efficacy documented. Patients with obstructive ventilatory defect (OVD) at baseline had significant improvement in their lung function compared to those without at the end of the treatment period. A significant number of patients reported decreased number of nocturnal awakenings and increased tolerance to physical activity. Cough, headache and itchy throat were adverse events possibly related to the use of Salmeterol. The patients treated with Salmeterol gained improved control of their asthma symptoms. The drug offers a convenient dose schedule and we recommend its use for maintenance therapy for mild to moderate asthma.

Forty adult patients with acute severe asthma were assessed for arterial blood gases and acid-base changes at presentation at the Casualty Unit, Kenyatta National Hospital, Nairobi, Kenya. Marked degrees of hypoxaemia (mean P(a)O2 of 8.02 kP(a)), hypocapnia (mean P(a)CO2 of 4.62kP(a)) with apparently normal pH (mean 7.384) were documented in the majority of these patients. Based on these findings, a significant number of the patients (68.5%) were either candidates (5.3%) or potential candidates (63.2%) for artificial ventilation. Records at this hospital suggest an increasing trend in asthma admissions and mortality. Additionally, Intensive Care Unit (ICU) admissions for asthma are associated with high mortality (54.4%). Pulsus paradoxicus emerged as the most significant (p = 0.002) clinical correlate to asthma severity. Central cyanosis was detected in none of the study patients suggesting that it is an unusual finding in the common presentation of acute severe asthma at this hospital. Its clinical detection would therefore imply an ominous clinical state. It is recommended that clinicians should take every opportunity to adequately assess their asthma patients before prescribing medications. They are also encouraged to more frequently request for blood gas studies in acute asthma. Those in charge of clinical teaching should direct appropriate efforts towards improved understanding of the pathophysiology and interpretation of acid-base disorders.