Hospital In Uganda Research Articles

Neonatal sepsis at Mulago national referral hospital in Uganda: Etiology, antimicrobial resistance, associated factors and case fatality risk.

BackgroundSepsis is the third most common cause of death among neonates, with about 225,000 newborns dying every year globally. Data concerning the microbial etiology of neonatal sepsis and antimicrobial resistance profiles of its causative agents are necessary to inform targeted and effective treatment and prevention strategies.ObjectiveTo determine the proportion of newborns with symptoms and signs of sepsis who had a positive blood culture, its bacterial etiology, the antimicrobial resistance patterns as well as the factors associated with culture-positivity and case fatality at Mulago national referral hospital in Uganda.MethodsWe conducted a cross-sectional study among 359 neonates with symptoms and signs of sepsis who presented to the pediatric emergency care unit of Mulago national referral hospital from mid-January to end of December 2018. We performed blood culture and antimicrobial susceptibility testing, and conducted polymerase chain reaction to identify methicillin-resistant Staphylococcus aureus (MRSA) isolates. We used multivariable logistic regression to estimate the association between potential risk factors and culture-positive neonatal sepsis.FindingsOf the 359 neonates recruited, 46 (12.8%; 95% CI 9.5%, 16.7%) had a positive blood culture. The predominant isolated bacteria were Staphylococcus aureus in 29 (63.0%), Escherichia coli in seven (15.2%), and Klebsiella pneumoniae in five (10.9%). Of the 46 pathogens, 73.9% were resistant to ampicillin, 23.9% to gentamicin and 8.7% to ceftriaxone. We isolated MRSA from the blood specimens of 19 (5.3%) of the 359 neonates, while 3 (0.8%) grew extended spectrum beta lactamase producers. The case fatality risk among neonates with neonatal sepsis was 9.5% (95% CI: 6.6%, 13.0%). Cesarean section delivery was strongly associated with culture-positive sepsis (adjusted odds ratio 3.45, 95% CI: 1.2, 10.1).ConclusionOne in eight neonates with clinical signs of sepsis grew a likely causative bacterial pathogen. S. aureus was the main pathogen isolated and a third of these isolates were MRSA. A significant proportion of the isolated bacterial pathogens were resistant to the first and second line antibiotics used for the treatment of neonatal sepsis. There is need to revisit the current treatment guidelines for neonatal sepsis.

Gravidity-dependent associations between interferon response and birth weight in placental malaria

BackgroundMaternal malarial infection leads to poor perinatal outcomes, including low birth weight from preterm delivery and/or fetal growth restriction, particularly in primigravidas. In placental malaria, Plasmodium falciparum-infected red blood cells cause an inflammatory response that can interfere with maternal–fetal exchange, leading to poor growth. The type I interferon (IFN-I) pathway plays an immunomodulatory role in viral and bacterial infections, usually by suppressing inflammatory responses. However, its role in placental malaria is unknown. This study examines the cytokine responses in placental tissue from subsets of malaria-infected and uninfected women, and attempts to correlate them with particular birth outcomes.Methods40 whole placental biopsy samples were obtained from pregnant women at least 16 years of age recruited to a larger prospective chemoprevention trial against malaria. These were patients at Tororo District Hospital in Uganda, an area of high malaria endemicity where approximately 40% of women have evidence of malaria infection at delivery. They were regularly followed at a local clinic and monitored for fever, with blood smears performed then and at time of delivery to diagnose malaria infection. Placenta biopsies were taken for histological diagnosis of placental malaria, as well as quantitative PCR analysis of genes in the IFN-I pathway (IFN-β, IL-10 and MX-1). Parameters such as infant birth weight and gestational age were also recorded.ResultsHistological analysis revealed placental malaria in 18 samples, while 22 were found to be uninfected. RT-PCR analysis showed a four-fold increase in IFN-β and IL-10 expression in multigravidas with placental malaria when compared to gravidity-matched, uninfected controls. This effect was not observed in primigravidas. Interestingly, linear regression analysis showed a positive association between IFN-β levels and higher birth weights (β = 101.2 g per log2-fold increase in IFN-β expression, p = 0.042). This association was strongest in primigravidas with placental malaria (β = 339.0, p = 0.006).ConclusionsThese results demonstrate differential regulation of the IFN-I pathway in placental malaria according to gravidity, with the greatest anti-inflammatory response seen in multigravidas. The association between IFN-β levels and higher birth weight also suggests a protective role for IFN-I against fetal growth restriction in placental malaria.

Sociocultural determinants and patterns of healthcare utilization for epilepsy care in Uganda

ObjectiveEpilepsy is a global public health concern, with the majority of cases occurring in lower- and middle-income countries where the treatment gap remains formidable. In this study, we simultaneously explore how beliefs about epilepsy causation, perceived barriers to care, seizure disorder characteristics, and demographics influence the initial choice of healthcare for epilepsy and its impact on attaining biomedical care (BMC). MethodsThis study utilized the baseline sample (n = 626) from a prospective cohort study of people with epilepsy (PWE) attending three public hospitals in Uganda (Mulago National Referral Hospital, Butabika National Referral Mental Hospital, and Mbarara Regional Referral Hospital) for epilepsy care. Patient and household demographics, clinical seizure disorder characteristics, and sociocultural questionnaires were administered. Logistic regression and principal component analyses (PCA) were conducted to examine associations with the choice of primary seizure treatment. ResultsThe sample was 49% female, and 24% lived in rural settings. A biomedical health facility was the first point of care for 355 (56.7%) participants, while 229 (36.6%) first sought care from a traditional healer and 42 (6.7%) from a pastoral healer. Preliminary inspection of candidate predictors using relaxed criteria for significance (p < 0.20) identified several factors potentially associated with a greater odds of seeking BMC first. Demographic predictors included older caredriver (decision-maker for the participant) age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: [0.99, 1.02], p-value: 0.09), greater caredriver education level (OR = 1.21, 95% CI: [1.07, 1.37], p-value = 0.003), and lower ratio of sick to healthy family members (OR = 0.77 [0.56, 1.05], P = 0.097). For clinical predictors, none of the proposed predictors associated significantly with seeking BMC first. Self-report causation predictors associated with a greater odds of seeking BMC first included higher belief in biological causes of epilepsy (OR = 1.31 [0.92, 1.88], P = 0.133) and lower belief in socio-spiritual causes of epilepsy (OR = 0.68 [0.56, 0.84], P < 0.001). In the multivariate model, only higher caredriver education (OR = 1.19 [1.04, 1.36], P = 0.009) and lower belief in socio-spiritual causes of epilepsy (OR = 0.69 [0.56, 0.86], P < 0.01) remained as predictors of seeking BMC first. Additionally, PCA revealed a pattern which included high income with low beliefs in nonbiological causes of epilepsy as being associated with seeking BMC first (OR = 1.32 [1.12, 1.55], p = 0.001). Despite reaching some form of care faster, individuals seeking care from traditional or pastoral healers experienced a significant delay to eventual BMC (P < 0.001), with an average delay of more than two years (traditional healer: 2.53 years [1.98, 3.24]; pastoral care: 2.18 [1.21, 3.91]). ConclusionsCoupled with low economic and educational status, belief in spiritual causation of epilepsy is a dominant determinant of opting for traditional or pastoral healing over BMC, regardless of concurrent belief in biological etiologies. There is a prolonged delay to eventual BMC for PWE who begin their treatment seeking with nonallopathic providers, and although nonallopathic healers provide PWE with benefits not provided by BMC, this notable delay likely prevents earlier administration of evidence-based care with known efficacy. Based on these findings, initiatives to increase public awareness of neurobiological causes of epilepsy and effectiveness of biomedical drug treatments may be effective in preventing delays to care, as would programs designed to facilitate cooperation and referral among traditional, faith-based, and biomedical providers.This article is part of the Special Issue “The Intersection of Culture, Resources, and Disease: Epilepsy Care in Uganda”

Re-thinking antimicrobial resistance transmission dynamics: a meta-analysis of cross-sectional studies at referral hospitals in Uganda

Background: Antimicrobial resistance threatens the achievements of modern medicine as well as the sustainability of effective global public health responses to the threat posed by infectious diseases. Extended-spectrum β-lactamase production in bacteria provides the main mechanism of resistance in gram-negative bacteria, particularly those belonging to the Enterobacteriaceae family as well as gram-positive bacteria. This study hence aimed at providing insights into the potential role of in-patients, their immediate hospital environments, out-patients, and their communities in the transmission of antimicrobial resistance via identifying gram-negative and gram-positive bacteria commonly isolated in samples collected from each of these patients/sites as well as their antimicrobial susceptibility profiles using extended-spectrum β-lactamase production in the same as the basis. Methods: Our study reviewed four cross-sectional studies conducted at national and regional referral hospitals in Uganda. Data on bacterial aetiology and antimicrobial susceptibility testing retrieved from the studies was imported into Microsoft Excel, cleaned, sand then exported to IBM SPSS statistics (version 16) for statistical analysis. The databases used were PubMed and Embase. Results: We report that; Escherichia coli and Klebsiella pneumoniae are the most prevalent Enterobacteriaceae species in the samples that were collected in the studies reviewed; these species account for the highest proportions of extended-spectrum β-lactamase producers; Staphylococcus aureus is the most prevalent of the gram-positive bacteria isolated from the same samples, and accounts for the highest proportions of extended-spectrum β-lactamase producers in the gram-positive bacteria isolated, and similar Enterobacteriaceae species and gram-positive bacteria, are predominant in samples from in-patients, their immediate hospital environments, and out-patients. Conclusion: The insights provided indicate antimicrobial resistance transmission dynamics be re-thought and more comprehensive studies aimed at investigating the same be done to ascertain the source and transmission routes of antimicrobial-resistant bacteria in clinical settings.

Identifying women giving birth preterm and care at the time of birth: a prospective audit of births at six hospitals in India, Kenya, Pakistan and Uganda

BackgroundGlobally, 15 million infants are born preterm each year, and 1 million die due to complications of prematurity. Over 60% of preterm births occur in Sub-Saharan Africa and south Asia. Care at birth for premature infants may be critical for survival and long term outcome. We conducted a prospective audit to assess whether women giving birth preterm could be identified, and to describe cord clamping and neonatal care at hospitals in Africa and south Asia.MethodsThis prospective audit of livebirths was conducted at six hospitals in Uganda, Kenya, India and Pakistan. Births were considered preterm if between 28+ 0 and 33+ 6 weeks gestation and/or the birthweight was 1.00 to 1.99 kg. A pre-specified audit plan was agreed with each hospital. Livebirths before 28 weeks gestation with birthweight less than 1.0 kg were excluded. Data were collected on estimated and actual gestation and birthweight, cord clamping, and neonatal care.ResultsOf 4149 women who gave birth during the audit, data were available for 3687 (90%). As 107 were multiple births, 3781 livebirths were included, of which 257 (7%) were preterm. Antenatal assessment correctly identified 148 infants as ‘preterm’ and 3429 as ‘term’, giving a positive predictive value of 72% and negative predictive value of 97%. For term births, cord clamping was usually later at the two Ugandan hospitals, median time to clamping 50 and 76 s, compared with 23 at Kenyatta (Kenya), 7 at CMC (India) and 12 at FBH/LNH (Pakistan). At the latter two, timing was similar between term and preterm births, and between vaginal and Caesarean births. For all the hospitals, the cord was clamped quickly at Caesarean births, with Mbale (Uganda) having the highest median time to clamping (15 s ‘term’, 19 ‘preterm’). For preterm infants temperature on admission to the neonatal unit was below 35.5 °C for 50%, and 59 (23%) died before hospital discharge.ConclusionsAntenatal identification of preterm birth was good. Timing of cord clamping varied between hospitals, although at each there was no difference between ‘term’ and ‘preterm’ births. For premature infants hypothermia was common, and mortality before hospital discharge was high.

Prescription of Levofloxacin and Moxifloxacin in Select Hospitals in Uganda: A Pilot Study to Assess Guideline Concordance.

Background: In Uganda, national tuberculosis (TB) treatment guidelines were revised to include the newer generation fluoroquinolones among the second-line treatment options for multidrug-resistant TB. This study was designed to analyze if the prescription of these quinolones is compliant with country recommendations. Methods: This was an observational retrospective study of consumption data for 2017 and 2018 across four selected regional referral hospitals. The sources of consumption data were hospital pharmacy stock cards and the dispensing register. The medical files of patients who had been prescribed fluoroquinolones were also assessed to study compliance with the Uganda Clinical Guidelines and the British National Formulary (BNF). Results: None of the 371 levofloxacin prescriptions analyzed complied with the Uganda Clinical Guidelines, although 250 (67.3%) were prescribed for indications included in the BNF. According to WHO prescription indicators, only 220 (59.3%) prescriptions were appropriate. Conclusion: The prescription of levofloxacin and moxifloxacin increased in the hospitals studied, but in a high proportion of cases, they were not compliant with country recommendations. The findings call for the strengthening of national antimicrobial stewardship programs.

Mixed-method analysis of barriers to surgical care in Uganda

Introduction: Barriers to surgical care in low- and middle-income countries have roots in theoretical frameworks, but are often left undefined and understudied. On the basis of the Access Evaluation Framework and Healthcare Barrier Model, this study implemented 2 consumer decision tools and a qualitative interview to elucidate significant barriers to seeking surgical care in Uganda. Methods: Participants were recruited from a convenience sample within the surgical wards of 1 national referral hospital and 1 regional referral hospital in Uganda. Individuals selected for the study answered a brief questionnaire and a ranking and rating exercise followed by an in-depth, semi-structured interview. The questionnaire evaluated demographic, economic, transportation, and care-seeking characteristics, while the ranking and rating exercises assessed potential barriers to surgical care. Descriptive statistics were used to assess characteristics of the sample. Ranking and rating medians were compared between the 2 exercises for each barrier. Results: Among the 214 participants, cost of surgery, distance to hospital, and transportation to hospital were identified as the most significant barriers to care. Language barrier, no control over decision making, and no caretaker available at the hospital were identified as the least significant barriers to care. Mulago National Referral Hospital had significantly greater costs and transportation times, indicating larger scale barriers to care than Jinja Regional Referral Hospital, even though top barriers were similar. Conclusions: Cost was the most significant barrier to surgical care among care-seekers in Uganda. Transportation to the hospital and distance from the hospital remain large barriers that need to be considered as well. These complementary analysis tools provide evidence that future policies and research need to consider mitigating cost, distance, and transportation issues for patients that need a surgical intervention. Next steps in determining more granular level differences between barriers will improve understanding on how best to address these issues.

Dysregulation of angiopoietin-Tie-2 axis in ugandan children hospitalized with pneumonia

ObjectivePneumonia is the leading cause of death in children under 5, with the highest burden in resource-limited countries. Endothelial activation occurs in pneumonia and can be assessed using quantitative levels of biomarkers angiopoietin (Ang)-1 and Ang-2. We examined admission levels of Ang-1 and Ang-2 in pediatric pneumonia and their association with disease severity and outcome. MethodsProspective cohort study of children with hypoxemic pneumonia admitted to two hospitals in Uganda. Clinical, radiographic, and microbiologic characteristics were measured at admission. Disease severity was assessed using the Respiratory Index of Severity in Children (RISC). Plasma levels of Ang-1 and Ang-2 were quantified by enzyme-linked immunosorbent assay. Vital signs, oxygen supplementation, and mortality were assessed prospectively. ResultsWe included 65 patients (43% female) with median age 19 months (IQR 8–24). Admission Ang-2/Ang-1 ratio directly correlated with RISC (ρ = 0.32, p = 0.008) and lactate level (ρ = 0.48, p < 0.001). Ang-2/Ang-1 ratio was higher in pneumococcal pneumonia than viral RTI (0.19 [IQR: 0.076–0.54] vs. 0.078 [IQR: 0.027–0.11]; p = 0.03). Elevated Ang-2/Ang-1 ratio (>0.084) was associated with prolonged tachypnea (HR 0.50 (95%CI 0.29–0.87), p = 0.02), fever (HR 0.56 (95%CI 0.33 to 0.96), p = 0.02), longer duration of oxygen therapy (HR 0.59 (95%CI 0.35–0.99), p = 0.04), and hospital stay (HR 0.43 (95%CI 0.25–0.74), p = 0.001). The Ang-2/Ang-1 ratio at admission was higher in fatal cases relative to survivors (0.36 [IQR: 0.17–0.58] vs. 0.077 [IQR: 0.025–0.19]; p = 0.05) ConclusionEndothelial activation in hypoxemic pediatric pneumonia, reflected by high plasma Ang-2/Ang-1 ratio, is associated with disease severity, prolonged recovery time, and mortality.

Abstract A32: Postoperative analgesia in a Ugandan population

Abstract Introduction: Opioid dependence is a major problem in the Western world. There have been significant efforts seeking to optimize pain control pathways and minimize risk of dependence on opioid pain relievers. However, little is known in low- to middle-income countries regarding current practices in postoperative pain control and its efficacy. This study evaluates subjective pain scores of patients following head and neck surgeries in a Ugandan hospital. These patients are unique in that most are opioid naive. We hope to contribute to the understanding of adequate postoperative pain control in opioid naive patients. Methods: Twenty-five patients without chronic opioid use underwent head and neck surgery during a semiannual surgical outreach trip. Ages ranged from 4-77 years (mean 38). The most common procedures performed were hemithyroidectomy (5), total thyroidectomy (3), parotidectomy (3), tonsillectomy (2), and cystic hygroma removal (2). Charts were reviewed retrospectively for daily subjective pain scores assessed on a numerical scale of 0-5, length of hospital stay, postoperative medications given for pain, surgery type, and postoperative analgesic medications administered, including dosage and frequency. Wilcoxon analysis was used to compare medians between groups receiving paracetamol alone or in combination with opioids or other analgesics. Results: All patients received IV paracetamol postoperatively; 16% of patients also requested opioids, and 8% requested another nonopioid analgesic. Average age for the 6 patients receiving paracetamol and either opioids or another nonopioid analgesic was 49.17 years compared to 34.47 years in the group that received paracetamol only (p=0.26; 95% CI -12.5, 42.9). For the whole study population, there was a reduction in the median pain score of -1.9 points (p&amp;lt;0.005; 95% CI -2.5, -1.01). Patients who received only paracetamol showed a reduction in median pain score from 3 to 2 (p&amp;lt;0.05; 95% CI (1.01 - 2.5)) compared to a reduction from 2.5 to 2 (p=0.37) in patients who received paracetamol and any another class of analgesic. Individually the group of patients who received paracetamol and opioids reported a reduction in the median pain score from 3 to 2.5 (p=1), and the group of patients who received paracetamol and another nonopioid analgesic reported a reduction in median pain score from 1.5 to 1 (p=1). Conclusion: Despite language and cultural barriers, we were able to assess postoperative pain scores in a Ugandan population. Intravenous paracetamol alone was effective and adequate for postoperative pain management for the majority of patients in this study. Although this study was limited in sample size, there was no significant improvement observed in pain score for patients using opioids or nonopioid analgesics other than paracetamol compared to paracetamol only. Opioids or additional analgesics were requested by a minority of patients, who tended to be older and/or have undergone more extensive procedures. Citation Format: Sara Maskal, Nilam Patel, Claudia Cabrera, Akina Tamaki, Fiona Kabagenyi, Ian Bwete, Isaac Mukiibi, Edrisa Kabazzi, Katrina Harrill, Jeffrey Otiti, Jason Thuener, Chad Zender. Postoperative analgesia in a Ugandan population [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; 2019 Apr 29-30; Austin, TX. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(12_Suppl_2):Abstract nr A32.

A yield and cost comparison of tuberculosis contact investigation and intensified case finding in Uganda.

IntroductionResource constraints in Low and Middle-Income Countries (LMICs) limit tuberculosis (TB) contact investigation despite evidence its benefits could outweigh costs, with increased efficiency when compared with intensified case finding (ICF). However, there is limited data on yield and cost per TB case identified. We compared yield and cost per TB case identified for ICF and Tuberculosis-Contact Investigation (TB-CI) in Uganda.MethodsA retrospective cohort study based on data from 12 Ugandan hospitals was done between April and September 2017. Two methods of TB case finding (i.e. ICF and TB-CI) were compared. Regarding ICF, patients either self-reported their signs and symptoms or were prompted by health care workers, while TB-CI was done by home-visiting and screening contacts of TB patients. Patients who were presumed to have tuberculosis were requested to produce a sample for examination. TB yield was defined as a ratio of diagnoses to tests, and this was computed per method of diagnosis. The cost per TB case identified (medical, personnel, transportation and training) for each diagnosis method were computed using the activity-based approach, from the health care perspective. Cost data were analyzed using Windows Excel.Results454 index TB cases and 2,707 of their household contacts were investigated. Thirty-one per cent of contacts (840/2707) were found to be presumptive TB cases. A total of 7,685 tests were done, 6,967 for ICF and 718 for TB-CI. The yields were 18.62% (1297/6967) and 5.29% (38/718) for ICF and TB-CI, respectively. It cost US$ 120.60 to diagnose a case of TB using ICF compared to US$ 877.57 for TB-CI.ConclusionThe yield of TB-CI was found to be four-times lower and seven-times costlier compared to ICF. These findings suggest that ICF can improve TB case detection at a low cost, particularly in high TB prevalent settings.

An Attitude Survey and Assessment of the Feasibility, Acceptability, and Usability of a Traumatic Brain Injury Decision Support Tool in Uganda

Traumatic brain injury (TBI) prognostic models are potential solutions to severe human and technical shortages. Although numerous TBI prognostic models have been developed, none are widely used in clinical practice, largely because of a lack of feasibility research to inform implementation. We previously developed a prognostic model and Web-based application for in-hospital TBI care in low-resource settings. In this study, we tested the feasibility, acceptability, and usability of the application with potential end-users. We performed our feasibility assessment with providers involved in TBI care at both a regional and national referral hospital in Uganda. We collected qualitative and quantitative data on decision support needs, application ease of use, and implementation design. We completed 25 questionnaires on potential uses of the app and 11 semistructured feasibility interviews. Top-cited uses were informing the decision to operate, informing the decision to send the patient to intensive care, and counseling patients and relatives. Participants affirmed the potential of the application to support difficult triage situations, particularly in the setting of limited access to diagnostics and interventions, but were hesitant to use this technology with end-of-life decisions. Although all participants were satisfied with the application and agreed that it was easy to use, several expressed a need for this technology to be accessible by smartphone and offline. We elucidated several potential uses for our app and important contextual factors that will support future implementation. This investigation helps address an unmet need to determine the feasibility of TBI clinical decision support systems in low-resource settings.

Retention in HIV Care Among HIV-Seropositive Pregnant and Postpartum Women in Uganda: Results of a Randomized Controlled Trial.

We tested an intervention that aimed to increase retention in antiretroviral therapy (ART) among HIV-positive pregnant and postpartum women, a population shown to be vulnerable to poor ART outcomes. 133 pregnant women initiating ART at 2 hospitals in Uganda used real time-enabled wireless pill monitors (WPM) for 1month, and were then randomized to receive text message reminders (triggered by late dose-taking) and data-informed counseling through 3months postpartum or standard care. We assessed "full retention" (proportion attending all monthly clinic visits and delivering at a study facility; "visit retention" (proportion of clinic visits attended); and "postpartum retention" (proportion retained at 3months postpartum). Intention-to-treat and per protocol analyses found that retention was relatively low and similar between groups, with no significant differences. Retention declined significantly post-delivery. The intervention was unsuccessful in this population, which experiences suboptimal ART retention and is in urgent need of effective interventions.

The Relationship Between Self-fulfilling Prophecies and Social Reintegration Among Obstetric Fistula Patients in Different Repair Categories at St. Joseph Kitovu Hospital, Uganda

Background: Obstetric fistula is a debilitating childbirth injury. Patients live in despair and self-stigmatize. Studies highlight beliefs and perceptions about the cause of the disease and how it can be cured. Experiences among both treated and untreated patients are also discussed vastly but there is limited information on negative perceptions and beliefs among obstetric fistula patients towards their spouses, families, and communities and how these affect social reintegration. This study determined the relationship between self-fulfilling prophecies and social reintegration among obstetric fistula patients in different repair categories. Methods: A cross-sectional mixed-methods survey was done among the obstetric fistula patients (n=398) at St. Joseph Kitovu Hospital in Uganda. Also, 12 key informants participated. A semi-structured questionnaire and an in-depth interview were used to get data from the patients. The interviews covered patients’ expectations and beliefs on reacceptance, interaction, self-satisfaction and comfort with others. The hypothesis: “there was a significant relationship between self-fulfilling prophecies and social reintegration among obstetric fistula patients in different repair categories” was tested by Pearson chi-square at a 95% confidence interval. Results: Accordingly, 51.5%, 14.4% and 9.0% of the 398 participants felt that their spouses, communities, and parents respectively would not reaccept them. Again, 33.6% were not satisfied with their lives and 47.7% felt uncomfortable around others. A major difference was observed in the relationship between their self-perceived stigma, sense of loss, self-worth, achievement, the expectation of reacceptance, perception of others’ attitudes towards them, labeling, moods, self-satisfaction, comfort with others and social reintegration. A relationship with the patients’ repair category was noted across all variables: P-values less than 0.001 at a 95% confidence interval. Conclusion: A relationship was found between the patient’s negative beliefs, perceptions, and social reintegration. Negative beliefs and expectations could be transformed into positive ones through the promotion of personal hygiene and comprehensive counseling.

HIV infection is associated with higher mortality in individuals presenting with reduced level of consciousness to a referral hospital in Uganda. (5067)

HIV infection is associated with higher mortality in individuals presenting with reduced level of consciousness to a referral hospital in Uganda. (5067)

Estimating prognosis for traumatic brain injury patients in a low-resource setting: how do providers compare to the CRASH risk calculator?

Traumatic brain injury (TBI), a burgeoning global health concern, is one condition that could benefit from prognostic modeling. Risk stratification of TBI patients on presentation to a health facility can support the prudent use of limited resources. The CRASH (Corticosteroid Randomisation After Significant Head Injury) model is a well-established prognostic model developed to augment complex decision-making. The authors' current study objective was to better understand in-hospital decision-making for TBI patients and determine whether data from the CRASH risk calculator influenced provider assessment of prognosis. The authors performed a choice experiment using a simulated TBI case. All participant doctors received the same case, which included a patient history, vitals, and physical examination findings. Half the participants also received the CRASH risk score. Participants were asked to estimate the patient prognosis and decide the best next treatment step. The authors recruited a convenience sample of 28 doctors involved in TBI care at both a regional and a national referral hospital in Uganda. For the simulated case, the CRASH risk scores for 14-day mortality and an unfavorable outcome at 6 months were 51.4% (95% CI 42.8%, 59.8%) and 89.8% (95% CI 86.0%, 92.6%), respectively. Overall, participants were overoptimistic when estimating the patient prognosis. Risk estimates by doctors provided with the CRASH risk score were closer to that score than estimates made by doctors in the control group; this effect was more pronounced for inexperienced doctors. Surgery was selected as the best next step by 86% of respondents. This study was a novel assessment of a TBI prognostic model's influence on provider estimation of risk in a low-resource setting. Exposure to CRASH risk score data reduced overoptimistic prognostication by doctors, particularly among inexperienced providers.

Pattern of Peri-Operative Antibiotic Use among Surgical Patients in a Regional Referral and Teaching Hospital in Uganda.

Background: Prolonged surgical antimicrobial prophylaxis (SAP) to prevent surgical site infection (SSI) is generally discouraged after completion of surgery. However, little is known about the pattern of peri-operative antibiotic use in resource-limited settings. We aimed to describe its use at a typical government hospital in Uganda. Methods: A study was originally conducted in a rural Ugandan regional referral and teaching hospital in 2014 and 2015 to improve hand hygiene practice and measure its impact on health-care-associated infections including SSI (WardGel study). This is a secondary analysis of the data from the WardGel study to assess the frequency of peri-operative antibiotic use among surgical patients. Results: Of 3,627 patients enrolled into the original study, 960 (26.5%) underwent surgery at the hospital and 907 patients (94.5%) received antibiotic agents during hospitalization. Of these, 880 patients (97.0%, of 907 patients) received antibiotic agents on the day of surgery. A combination of ceftriaxone and metronidazole was the most common regimen (609/907 patients, 67.1%). Thirty-six of 907 patients (4.0%) started and completed their antibiotic agents on the day of surgery. The mean length of antibiotic use during hospitalization was 3.5 days (standard deviation, 3.3). After adjusting for covariates, linear regression analysis showed an extra 1.9 days of antibiotic use post-operatively (95% confidence interval = 1.7-2.3). During the total 4,960 inpatient-days for those having surgery, there were 6,503 days of therapy (DOTs) of antibiotic agents and 1,649 antibiotic-free days (AFDs). Conclusions: Most patients received prolonged antibiotic therapy after surgery. Antimicrobial stewardship for SAP can play a major role in combating antimicrobial resistance in resource-limited settings.

Prevalence and Predictors of Cancellation of Elective Surgical Procedures at a Tertiary Hospital in Uganda: A Cross-Sectional Study.

Introduction. The cancellation of elective procedures has been shown to waste resources and to have the potential to increase morbidity and mortality among patients. This study aimed to determine the prevalence of the cancellation of elective surgical procedures and to identify the factors associated with these cancellations at Mulago Hospital, a large public hospital in Kampala, Uganda. Methods A cross-sectional study was conducted from January 10, 2018, to February 20, 2018. We recruited patients of all ages who were admitted to surgical wards and scheduled for elective surgery. Data on patients' demographic characteristics and diagnosis, as well as the specialty of the surgery, the planned procedure, the specific operating theatre, cancellation, and the reasons for cancellation were extracted and analyzed using logistic regression. Results Of a total of 400 cases, 115 procedures were canceled—a cancellation prevalence of 28.8%. Orthopedic surgery had the highest cancellation rate, at 40.9% (n = 47). Facility-related factors were responsible for 67.8% of all cancellations. The most common reason for cancellation was insufficient time in the theatre to complete the procedure on the scheduled day. No procedures were canceled because of a lack of intensive care unit beds. There was a significant association between surgical specialty and cancellation (P < 0.05) at multivariate analysis. Conclusion The prevalence of cancellation of elective surgical procedures at Mulago Hospital was 28.8%, with orthopedic surgery having the highest cancellation rate. Two-thirds of the factors causing cancellations were facility-related, and more than 50% of all cancellations were potentially preventable. Quality-improvement strategies are necessary in the specialties that are susceptible to procedure cancellation because of facility factors.

Prevalence, factors associated and treatment outcome of hyperbilirubinaemia in neonates admitted to St Francis hospital, Nsambya, Uganda: a descriptive study.

With targeted management of neonatal hyperbilirubinaemia in high-income countries, there has been a drastic drop in both the prevalence and mortality. On the contrary, over two-thirds of the global burden of neonatal hyperbilirubinaemia is in Sub-saharan Africa and South East Asia with a high mortality risk of 16-35%. Neonatal hyperbilirubinaemia is not a leading global cause of neonatal mortality, however leads to irreversible neurological damage and death when managed poorly. Three-quarters of the babies admitted to the national referral hospital in Uganda had significant hyperbilirubinaremia; 16.6% of these babies died. We aimed at determining the prevalence, treatment outcome and describing factors associated with hyperbilirubinaemia in neonates admitted to St Francis hospital, Nsambya. A cross sectional study was carried out. A total of 242 files of babies with a preliminary diagnosis of hyperbilirubinaemia were retrieved retrospectively. Relevant data was extracted from the files and analysed using STATA version 14.0. The prevalence of significant hyperbillirubinaemia was 22.7% (55/242). Seventy-seven percent of the babies admitted did not require treatment for hyperbilirubinaemia. No factors were found to be significantly associated with significant hyperbilirubinaemia. The case fatality for severe hyperbilirubinaemia was 20% (6/30); half of these babies had haemolytic disease of the newborn. Establishment of local guidelines will prevent unnecessary admissions and ensure timely treatment is administered. Longitudinal studies are required to discover factors associated with neonatal hyperbilirubinaemia in this region.

Delayed initiation of enteral feeds is associated with postnatal growth failure among preterm infants managed at a rural hospital in Uganda

BackgroundPrematurity is the leading cause of mortality in children under 5 years of age globally and is also frequently associated with postnatal growth failure (PGF). Although most preterm births occur in low resource settings, little is known about their postnatal growth outcomes especially in rural areas. We evaluated the incidence and factors associated with PGF among preterm infants managed at a rural hospital in Uganda.MethodsRetrospective cohort study of preterm infants discharged from Kiwoko Hospital neonatal intensive care unit (NICU) from July 2017 to June 2018. Inclusion criteria included gestational age 26 up to but not including 37 weeks, admission within 24 h of birth and at least 7 days hospital stay. Exclusion criteria included major congenital anomalies and missing gestational age or birth weight. Birth and discharge weights from clinical notes were plotted on Fenton 2013 growth charts. Gestation age was determined by last normal menstruation period (LNMP), extracted from the mother’s antenatal card or early obstetric ultrasound scan reports. Postnatal growth failure was diagnosed if discharge weight was less than the 10th percentile for estimated gestational age. Other data from the clinical notes included demographic characteristics, neonatal morbidities as assigned by the attending physician and infant feeding practices. Multivariable logistic regression was used to explore factors associated with PGF.ResultsA total of 349 preterm infants with a mean gestational age of 31 (range 26 to 36) weeks were included. The incidence proportion of PGF was 254/349 (73%). Factors significantly associated with postnatal growth failure included: delayed initiation of enteral feeds [AOR = 3.70, 95% (CI 1.64 to 8.33)], sepsis [AOR = 6.76, 95% (CI 2.15 to 21.2)], multiple gestation [AOR = 1.81, 95% (CI 1.01 to 3.24)] and male gender [AOR = 1.71 95% (CI 1.01 to 2.91)].ConclusionNearly three quarters of preterm infants managed at a rural hospital in Uganda had postnatal growth failure. Delayed initiation of enteral feeds and sepsis were highly associated with postnatal growth failure. Enteral feeds should be initiated as soon as possible in these infants to reduce early protein deficits and hence postnatal growth failure.

Anaemia in HIV-Infected Children in A National Referral Hospital in Uganda: Prevalence and Associated Factors

Anaemia in HIV-Infected Children in A National Referral Hospital in Uganda: Prevalence and Associated Factors