Hospital In Uganda Research Articles

Success of Local Fistula Mentorship; Review of Routine Repairs At Referral Hospital in Uganda

Aims: To assess surgical capacity building training during fistula camps using FIGO competency manualand skills tracker.
 Methods: Between January 2016 to September 2018, six fistula camps were conducted in which the trainee worked with three expert surgeons. The trainee observed, assisted and operated fistula cases with supervision and mentorship from the FIGO accredited expert surgeons. The trainee competence was progressively monitored. Continuous mentorship and coaching was done over two years and the trainee was encouraged to do routine repairs after their skill level improved from standard to advanced level. The routine fistula repairs were done using FIGO competency manual and skills tracker by the trainee.
 Results: During the period, 632 patients sought care for treatment of fistula, 31% (199) were diagnosed with fistula, 92 %( 183) treated, 23%(34) through routine while 77 % (149) through camps.Out of the routine repairs, 74% (25) were simple fistulae and 26% (9) were complex 97%. Of the routine repair (33 cases) were continent at discharge with a negative dye test, while 3 %(1) had a failed repair.
 Conclusion: The local onsite fistula-training program is a cheaper yet successful way of capacity building for surgeons as individuals and for institutions for routine fistula repairs.

Utilization of \u201cprevention of mother-to-child transmission\u201d of HIV services by adolescent and young mothers in Mulago Hospital, Uganda

BackgroundPrevention of mother to child transmission (PMTCT) has lowered the incidence of paediatric HIV globally. The risk of mother-to-child transmission of HIV (MTCT) remains high in Africa, where there is a high prevalence of pregnancy and poor health-seeking behaviour among young girls and women.MethodsIn this cross-sectional, mixed-methods study, we evaluated the utilization of PMTCT services and associated factors among adolescent and young postpartum mothers aged 15 to 24 years at a public urban referral hospital in Uganda. Both HIV-positive and HIV-negative participants were recruited. Utilization of PMTCT services was defined as use of the PMTCT cascade of services including ever testing for HIV, receiving HIV test results; If tested negative, subsequent retesting up to 14 weeks; If tested positive, Antiretroviral drugs (ARVs) for the mother, ARVs and septrin prophylaxis for infant, safe delivery, safer infant feeding, early infant diagnosis within 6 weeks, and linkage to treatment and care. Optimal utilization of PMTCT was defined as being up to date with utilization of PMTCT services for reported HIV status at the time of being interviewed. The overall proportion of participants who optimally utilized PMTCT services was determined using descriptive statistics. Qualitative data was analyzed manually using the content thematic approach.ResultsOf the 418 participants, 65 (15.5%) were HIV positive. Overall, only 126 of 418 participants (30.1%) had optimally utilized PMTCT services. However, utilization of PMTCT services was better among HIV positive mothers, with 83% (54/65) having utilized the services optimally, compared to only 20% (72/353) of the HIV negative mothers (OR 18.2 (95% CI; 9.0–36.7)). The benefits of knowing ones HIV status, health of the unborn child, and counseling and support from health workers and peers, were the major factors motivating adolescent and young mothers to utilize PMTCT services, while stigma, financial constraints, non-disclosure, and lack of partner and family support were key demotivating factors.ConclusionUtilization of PMTCT services by these adolescent and young mothers was suboptimal. Special consideration should be given to adolescents and young women in the design of elimination of mother to child transmission (EMTCT) programs, to improve the utilization of PMTCT services.

Infection control and treatment guidelines and neonatal mortality in a rural hospital in Uganda

ABSTRACTBackground: The neonatal mortality rate in Uganda has been 24–27/1000 live births for the last 14 years.Aim: To determine the impact on neonatal mortality of the introduction of infection prevention and treatment guidelines in a resource-poor setting.Methods: A prospective study was undertaken in Kagando Hospital, a rural hospital in Western Uganda of infants live-born in hospital and those admitted from the community or other hospitals between 2013 and 2017. Guidelines were developed from a literature review and informed by local doctors and nurses and a visiting paediatrician. The guidelines highlighted that unwell infants should be admitted to the neonatal unit which was a section of the paediatric ward, emphasised hand hygiene, the separation of infants with and without sepsis and that unwell infants should be treated with evidence-based antibiotic regimens and enteral feeds withheld from unwell infants. Mortality within 28 days of birth was audited for 3 months before and after the intervention; the audit was repeated 3 and 5 years later.Results: Pre-intervention, there were 137 neonatal admissions and 79 neonatal deaths in 3 months (0.58 deaths per admission). Post-intervention there were 187 admissions and the death rate was lower (0.26 deaths per admission, p < 0.001). Three years after the intervention, there were 60 deaths among 233 admissions (0.26 deaths per admission, p < 0.001) and, at 5 years, 53 deaths among 315 admissions (0.17 deaths per admission, p < 0.001).Conclusion: These data suggest that the introduction of infection, prevention and treatment guidelines can reduce neonatal mortality in a resource-poor setting.

WaSH as a maternal health issue: three perspectives from rural Uganda

ABSTRACTInadequate water, sanitation, and hygiene (WaSH) knowledge and practices affect maternal and newborn morbidity and mortality. This article describes postpartum knowledge, resources, and practices in three rural Ugandan hospitals. A lack of WaSH resources was problematic for both staff and newly-birthed mothers who demonstrated a lack of knowledge about the appropriate use of WaSH resources and the links between WaSH and health protection. These results suggest that in addition to increasing the availability of medical interventions, basic preventative public health practices should be reflected in policy and practice integrated across the spaces inhabited by pregnant women to achieve improved maternal and newborn outcomes.

Health and sustainable development; strengthening peri-operative care in low income countries to improve maternal and neonatal outcomes

BackgroundUganda is far from meeting the sustainable development goals on maternal and neonatal mortality with a maternal mortality ratio of 383/100,000 live births, and 33% of the women gave birth by 18 years. The neonatal mortality ratio was 29/1000 live births and 96 stillbirths occur every day due to placental abruption, and/or eclampsia – preeclampsia and other unkown causes. These deaths could be reduced with access to timely safe surgery and safe anaesthesia if the Comprehensive Emergency Obstetric and Newborn Care services (CEmONC), and appropriate intensive care post operatively were implemented. A 2013 multi-national survey by Epiu et al. showed that, the Safe Surgical Checklist was not available for use at main referral hospitals in East Africa. We, therefore, set out to further assess 64 government and private hospitals in Uganda for the availability and usage of the WHO Checklists, and investigate the post-operative care of paturients; to advocate for CEmONC implementation in similarly burdened low income countries.MethodsThe cross-sectional survey was conducted at 64 government and private hospitals in Uganda using preset questionnaires.ResultsWe surveyed 41% of all hospitals in Uganda: 100% of the government regional referral hospitals, 16% of government district hospitals and 33% of all private hospitals. Only 22/64 (34.38%: 95% CI = 23.56–47.09) used the WHO Safe Surgical Checklist. Additionally, only 6% of the government hospitals and 14% not-for profit hospitals had access to Intensive Care Unit (ICU) services for postoperative care compared to 57% of the private hospitals.ConclusionsThere is urgent need to make WHO checklists available and operationalized. Strengthening peri-operative care in obstetrics would decrease maternal and neonatal morbidity and move closer to the goal of safe motherhood working towards Universal Health Care.

Trends in neurosurgical care in Western Uganda: an interrupted time series analysis.

In addition to the rising burden of surgical disease globally, infrastructure and human resources for health remain a great challenge for low- and middle-income countries, especially in Uganda. In this study, the authors aim to explore the trends of neurosurgical care at a regional referral hospital in Uganda and assess the long-term impact of the institutional collaboration between Mulago National Referral Hospital and Duke University. An interrupted time series is a quasi-experimental design used to evaluate the effects of an intervention on longitudinal data. The authors applied this design to evaluate the trends in monthly mortality rates for neurosurgery patients at Mbarara Regional Referral Hospital (MRRH) from March 2013 to October 2015. They used segmented regression and autoregressive integrated moving average models for the analysis. Over the study timeframe, MRRH experienced significant increases in referrals received (from 117 in 2013 to 211 in 2015), neurosurgery patients treated (from 337 in 2013 to 625 in 2015), and operations performed (from 61 in 2013 to 173 in 2015). Despite increasing patient volumes, the hospital achieved a significant reduction in hospital mortality during 2015 compared to prior years (p value = 0.0039). This interrupted time series analysis study showed improving trends of neurosurgical care in Western Uganda. There is a steady increase in volume accompanied by a sharp decrease in mortality through the years. Multiple factors are implicated in the significant increase in volume and decrease in mortality, including the addition of a part-time neurosurgeon, improvement in infrastructure, and increased experience. Further in-depth prospective studies exploring seasonality and long-term outcomes are warranted.

Subspecialty pediatric neurosurgery training: a skill-based training model for neurosurgeons in low-resourced health systems.

There is inadequate pediatric neurosurgical training to meet the growing burden of disease in low- and middle-income countries (LMIC). Subspecialty expertise in the management of hydrocephalus and spina bifida-two of the most common pediatric neurosurgical conditions-offers a high-yield opportunity to mitigate morbidity and avoid unnecessary death. The CURE Hydrocephalus and Spina Bifida (CHSB) fellowship offers an intensive subspecialty training program designed to equip surgeons from LMIC with the state-of-the-art surgical skills and equipment to most effectively manage common neurosurgical conditions of childhood. Prospective fellows and their home institution undergo a comprehensive evaluation before being accepted for the 8-week training period held at CURE Children's Hospital of Uganda (CCHU) in Mbale, Uganda. The fellowship combines anatomy review, treatment paradigms, a flexible endoscopic simulation lab, daily ward and ICU rounds, radiology rounds, and clinic exposure. The cornerstone of the fellowship is the unique operative experience that includes a high volume of endoscopic third ventriculostomy with choroid plexus cauterization, myelomeningocele closure, and ventriculoperitoneal shunting, among many other procedures performed at CCHU. Upon completion, fellows return to their home institution to establish or rejuvenate a robust pediatric practice as part of a worldwide network of CHSB trainees committed to the care of underserved children. To date, the fellowship has graduated 33 surgeons from 20 different LMIC who are independently performing thousands of hydrocephalus and spina bifida operations each year.

Estimating the cost and cost-effectiveness for obstetric fistula repair in hospitals in Uganda: a low income country.

In Africa, about 33000 cases of obstetric fistula occur each year. Women with fistula experience debilitating incontinence of urine and/or faeces and are often socially ostracized. Worldwide, Uganda ranks third among countries with the highest burden of obstetric fistula. Obstetric fistula repair competes for scarce resources with other healthcare interventions in resource-limited settings, even though it is surgically efficacious. There is limited documentation of its cost-effectiveness in the most affected settings. We therefore sought to assess the cost-effectiveness of surgical intervention for obstetric fistula in Uganda so as to provide appropriate data for policy-makers to prioritize fistula repair and reduce women's suffering in similarly burdened countries. We built a decision-analytic model from the perspective of Uganda's National Health System to estimate the cost-effectiveness of vesico-vaginal and recto-vaginal fistula surgery vs a competing strategy of no surgery for Ugandan women with fistula. Long-term disability outcomes were assessed based on a lifetime Markov state-transition cohort and effectiveness of surgery. Surgical costs were estimated by micro-costing local Ugandan health resources. Disability weights associated with vesico-vaginal, recto-vaginal fistula and mortality rates among the general population in Uganda were based on published sources. The cost of providing fistula repair surgery in Uganda was estimated at $378 per procedure. For a hypothetical 20-year-old woman, surgery was estimated to decrease the lifetime disability burden from 8.53 DALYs to 1.51 DALYs, yielding a cost per DALY averted of $54. The results were robust to variations in model inputs in one-way and probabilistic sensitivity analyses. Surgery for obstetric fistula appears highly cost-effective in Uganda. In similar low-income countries, governments and non-governmental organizations need to prioritize training and strengthening surgical capacity to increase access to fistula surgical care, which would be an important step towards achieving universal health coverage.

Availability of post-hospital services supporting community reintegration for children with identified surgical need in Uganda

BackgroundCommunity services and supports are essential for children transitioning home to recover from the hospital after surgery. This study assessed the availability and geographic capacity of rehabilitation, assistive devices, familial support, and school reintegration programs for school-aged children in Uganda with identified surgical need.MethodsThis study assessed the geographic epidemiology and spatial analysis of resource availability in communities in Uganda. Participants were children with identified surgical need using the Surgeons OverSeas Assessment of Surgical need (SOSAS). Community-based resources available to children and adolescents after surgery in Uganda were identified using publicly available data sources and searching for resources through consultation with in-country collaborators We sought resources available in all geographic regions for a variety of services.ResultsOf 1082 individuals surveyed aged 5 to 14 yearsr, 6.2% had identified surgical needs. Pediatric surgical conditions were most prevalent in the Northern and Central regions of Uganda. Of the 151 community-based services identified, availability was greatest in the Central region and least in the Northern region, regardless of type. Assuming 30% of children with surgical needs will need services, a maximum of 50.1% of these children would have access to the needed services in the extensive capacity estimates, while only 10.0% would have access in the minimal capacity estimates. The capacity varied dramatically by region with the Northern region having much lower capacity in all scenarios as compared to the Central, Eastern, or Western regions.ConclusionsOur study found that beyond the city of Kampala in the Central region, community-based services were severely lacking for school-aged children in Uganda. Increased pediatric surgical capacity to additional hospitals in Uganda will need to be met with increased availability and access to community-based services to support recovery and community re-integration.

Hypertension among newly diagnosed diabetic patients at Mulago National Referral Hospital in Uganda: a cross sectional study.

SummaryBackgroundThe prevalence of hypertension in patients with diabetes is approximately two-fold higher than in age-matched subjects without the disease and, conversely, individuals with hypertension are at increased risk of developing diabetes compared with normotensive persons. Up to 75% of cases of cardiovascular disease (CVD) in patients with diabetes are attributed to hypertension. Diabetics who have hypertension are more likely to develop complications and die, and appropriate blood pressure control in these individuals reduces the risk. This study sought to determine the prevalence and factors associated with hypertension among newly diagnosed adult diabetic patients in a national referral hospital in Uganda.MethodsIn this cross-sectional study, conducted between June 2014 and January 2015, we recruited 201 newly diagnosed adult diabetic patients. Information on patients’ socio-demographics was obtained using a pre-tested questionnaire, while biophysical profile, blood pressure measurement, biochemical testing and echocardiographic findings were obtained by the research team for all the participants. Bivariate and multivariate logistic regression analyses were used to investigate the association of several factors with hypertension. ResultsOf the 201 patients recruited, 102 were male (50.8%) and the mean age was 46 ± 15 years. The majority of patients (159) had type 2 diabetes mellitus (DM) (79.1%) with a mean HbA1c level of 13.9 ± 5.3%. The prevalence of hypertension was 61.9% (95% CI: 54.8–68.6%). Knowledge of hypertension status was at 56 (27.7%) patients, 24 (44.4%) hypertensives were on treatment, and 19 (33.9%) were using ACE inhibitors/ angiotensin receptor blockers. The independent factors associated with hypertension were being employed (OR 0.37, 95% CI: 0.16–0.90, p = 0.029) and being overweight or obese (OR 11.6, 95% CI: 4.29–31.2, p < 0.0001). ConclusionThe prevalence of hypertension was high in this population of newly diagnosed diabetics, few patients had knowledge of their hypertension status and few were on appropriate treatment. Both modifiable and non-modifiable risk factors were associated with hypertension in this group. Therefore routine assessment, treatment and control of hypertension among diabetics is necessary to prevent cardiovascular complications and death. There is also a need to address the modifiable risk factors.

Experience of perceived barriers and enablers of safe uninterrupted skin-to-skin contact during the first hour after birth in Uganda

ObjectiveTo identify barriers and enablers to conducting safe uninterrupted skin-to-skin contact (SSC) in the first hour after birth in a low-resource setting and to evaluate how health care professionals coped with the identified barriers after completion of an intervention package. Design and settingA qualitative method using focus-group and individual interviews with health professionals at a governmental hospital in Uganda. Participants81 health professionals. InterventionsA 6-step intervention package including, amongst other things, showing a DVD on safe uninterrupted SSC following birth and discussing with the professionals what barriers and possibilities there were to changing practice to allow SSC for one hour. Measurements and findingsThe thematic analysis of the intervention interviews yielded the following themes: Perceived barriers including medical events, psychosocial issues and standard midwifery practice; Pragmatic barriers including economic constraints in the hospital and community; Anticipated barriers by staff and families; Enabling events including staff involvement.Most of the barriers involving expenses were not solved. When the mother and infant had to move to the postnatal ward within one hour after birth, there were difficulties in keeping SSC during the transportation, but this obstacle was partly solved. A few mothers (i.e. depressed and/or adolescent) were considered to be unwilling to keep the infant skin-to-skin; this difficulty was not solved. Practising SSC led the participants to find advantages such as reduced work load and positive effects on pain during suturing. ConclusionsSSC following birth was shown to be applicable and accepted by the health professionals. The involvement of professionals had clinical implications, such as initiatives to broadcast the message of SSC by radio to the community and introduce SSC to women having a Caesarean section.

Assessment of attitudes and targeted educational needs for refugee care providers in a Ugandan hospital.

ObjectivesTo evaluate medical trainees’ attitudes toward refugee patients in a refugee host country, and to identify educational needs. MethodsA 54-question cross-sectional questionnaire was administered to a convenience sample of 81 post-graduate medical trainees at Mbarara Regional Referral Hospital, Uganda, in 2016. Descriptive statistics on medical trainees’ attitudes and educational needs regarding care for refugees were calculated. One-way ANOVA was used to assess relationships between an attitude scale and respondent characteristics. Reliability and validity of the survey items and attitude scale were assessed using Cronbach’s alpha, item-to-scale correlation, and factor analysis. ResultsThe mean score on the attitude scale of 2.8 (SD=1.7) indicated positive attitudes toward refugees. All respondents had contact with refugees, and 89% (n=72) reported a need for further training. Many specifically indicated the need for training in use of translators, support personnel, and behavioral health. Cronbach’s alpha values of greater than 0.7 indicated good internal consistency. Item-to-scale correlation and factor analysis validate the use of an attitude scale. ANOVA showed no significant difference between mean attitude scores in gender (F(1,77)=0.11, p=0.7367), country of origin (F(1.78) =0.53, p=0.8723), or year of study (F(4,74) =0.31, p=0.8273). ConclusionsMedical trainees in Uganda report positive attitudes toward refugees and a need for additional education in refugee care in multiple specific areas. This study piloted the use of an attitude scale for refugee healthcare providers with promising validity and reliability. Use of these questions could inform curriculum development in refugee host countries.

Renal Outcomes in Children with Operated Spina Bifida in Uganda.

Background To describe the extent of renal disease in Ugandan children surviving at least ten years after spina bifida repair and to investigate risk factors for renal deterioration in this cohort. Patients and Methods Children who had undergone spina bifida repair at CURE Children's Hospital of Uganda between 2000 and 2004 were invited to attend interview, physical examination, renal tract ultrasound, and a blood test (creatinine). Medical records were retrospectively reviewed. The following were considered evidence of renal damage: elevated creatinine, hypertension, and ultrasound findings of hydronephrosis, scarring, and discrepancy in renal size >1cm. Female sex, previous UTI, neurological level, mobility, detrusor leak point pressure, and adherence with clean intermittent catheterisation (CIC) were investigated for association with evidence of renal damage. Results 65 of 68 children aged 10–14 completed the assessment. The majority (83%) reported incontinence. 17 children (26%) were performing CIC. One child had elevated creatinine. 25 children (38%) were hypertensive. There was a high prevalence of ultrasound abnormalities: hydronephrosis in 10 children (15%), scarring in 42 (64%), and >1cm size discrepancy in 28 (43%). No children with lesions at S1 or below had hydronephrosis (p = 0.025), but this group had comparable prevalence of renal size discrepancy, scarring, and hypertension to those children with higher lesions. Conclusions Incontinence, ultrasound abnormalities, and hypertension are highly prevalent in a cohort of Ugandan children with spina bifida, including those with low neurological lesions. These findings support the early and universal initiation of CIC with anticholinergic therapy in a low-income setting.

Decomposition and Conceptualization to Support System Dynamics Behavior Modeling

With the increasing need for data-based decision making, social systems and the ecosystems; practitioners and decision makers need guidance in their decision making, as is offered by data-based models and a systematic generation of simulation tools. Overtly, relations between data and practice have been under-conceptualized. Data modelers and decision makers tend to lack a mutual understanding of each other’s knowledge systems which has led to huge knowledge gaps. Assimilation of modeling methods therefore is vital. Modeling methods use a specific way of thinking, rules and directions on how to model different aspects of systems. These rules and directions are what we refer to as constructs. Conceptualizing model relations and formulations requires significant domain knowledge and understanding of the constructs. In this article, we use the decomposition mechanism to better conceptualize and understand the System Dynamics (SD) model behavior, and show how using a natural language based domain modeling method (Object-Role Modeling, ORM) helps in dealing with complex SD models. Through applying the decomposition mechanism, we are able to better understand the underlying concepts of the stock and flow diagram and update behaviors of ORM objects. To achieve this, we use examples and an SD model derived from a case “Intrapartum process in Ugandan hospitals” to study the object behaviors. The main results of this article include: a theoretical founding of integrating ORM with SD; quantitative analysis at the level of ORM reasoning; and transformation rules from ORM into SD.

Manifestations of leprosy in an urban Ugandan hospital

Manifestations of leprosy in an urban Ugandan hospital

POST CESEREAN WOUND SEPSIS: Recognizable Risks and Causes at a Rural Ugandan Hospital

Post cesarean wound sepsis refers to a superficial surgical site infection that occurs within 30 days of the operative procedure and involves only the skin or subcutaneous tissue of the incision, and at least a purulent drainage from the incision or isolation of Organisms on culture or one of the cardinal signs of inflammation. Wound sepsis increases morbidity, mortality and length of hospital stay (Oliver, et al). In Uganda, rates of severe wound infection are as high as 25% [1]. Caesarean section rates at the Bwindi community Hospital are 30% of the total deliveries. Purpose: To determine the factors associated with post cesarean wound sepsis among mothers at Bwindi Community Hospital. Methods: This was a retrospective cross sectional study. Consecutive sampling was used to obtain 50 files of mothers who got post cesarean wound sepsis and a matching equal sample of controls at Bwindi Community Hospital from July 2015 to June 2017. Results: The rate of post caesarean sepsis was 3.5%.Multiple factors were associated with postoperative wound sepsis; Age between 26-30 years(OR 3.46, p0.008), Parity of greater than 5(OR 3.14, p0.010), Duration of labor of 5 -8hrs or greater (OR 10.67, p0.013), delayed time of ambulation greater than 24-72hrs (OR 0.14, p&lt;0.001), intra operative blood loss of 500- 1000mls or greater(OR 8.00, p0.023) and Post-operative administration of ampicillin and metronidazole (OR40.00,p&lt;0.001). Conclusion: Post-operative wound sepsis in caesarean section is a relatively common occurrence in low-resource settings and mitigation of the multiple identified modifiable associated factors will greatly reduce patient morbidity and improve their outcomes.

High dose oral and intravenous rifampicin for improved survival from adult tuberculous meningitis: a phase II open-label randomised controlled trial (the RifT study)

Background: Tuberculous meningitis (TBM) has 44% (95%CI 35-52%) in-hospital mortality with standard therapy in Uganda. Rifampicin, the cornerstone of TB therapy, has 70% oral bioavailability and ~10-20% cerebrospinal fluid (CSF) penetration. With current WHO-recommended TB treatment containing 8-12mg/kg rifampicin, CSF rifampicin exposures frequently fall below the minimal inhibitory concentration for M. tuberculosis. Two Indonesian phase II studies, the first investigating intravenous rifampicin 600mg and the second oral rifampicin ~30mg/kg, found the interventions were safe and resulted in significantly increased CSF rifampicin exposures and a reduction in 6-month mortality in the investigational arms. Whether such improvements can be replicated in an HIV-positive population remains to be determined. Protocol: We will perform a phase II, open-label randomised controlled trial, comparing higher-dose oral and intravenous rifampicin with current standard of care in a predominantly HIV-positive population. Participants will be allocated to one of three parallel arms (I:I:I): (i) intravenous rifampicin 20mg/kg for 2-weeks followed by oral rifampicin 35mg/kg for 6-weeks; (ii) oral rifampicin 35mg/kg for 8-weeks; (iii) standard of care, oral rifampicin 10mg/kg/day for 8-weeks. Primary endpoints will be: (i) pharmacokinetic parameters in plasma and CSF; (ii) safety. We will also examine the effect of higher-dose rifampicin on survival time, neurological outcomes and incidence of immune reconstitution inflammatory syndrome. We will enrol 60 adults with suspected TBM, from two hospitals in Uganda, with follow-up to 6 months post-enrolment. Discussion: HIV co-infection affects the bioavailability of rifampicin in the initial days of therapy, risk of drug toxicity and drug interactions, and ultimately mortality from TBM. Our study aims to demonstrate, in a predominantly HIV-positive population, the safety and pharmacokinetic superiority of one or both investigational arms compared to current standard of care. The most favourable dose may ultimately be taken forward into an adequately powered phase III trial. Trial registration: ISRCTN42218549 (24 th April 2018)

POST CESEREAN WOUND SEPSIS: Recognizable Risks and Causes at a Rural Ugandan Hospital

Post cesarean wound sepsis refers to a superficial surgical site infection that occurs within 30 days of the operative procedure and involves only the skin or subcutaneous tissue of the incision, and at least a purulent drainage from the incision or isolation of Organisms on culture or one of the cardinal signs of inflammation. Wound sepsis increases morbidity, mortality and length of hospital stay (Oliver, et al). In Uganda, rates of severe wound infection are as high as 25% [1]. Caesarean section rates at the Bwindi community Hospital are 30% of the total deliveries. Purpose: To determine the factors associated with post cesarean wound sepsis among mothers at Bwindi Community Hospital. Methods: This was a retrospective cross sectional study. Consecutive sampling was used to obtain 50 files of mothers who got post cesarean wound sepsis and a matching equal sample of controls at Bwindi Community Hospital from July 2015 to June 2017. Results: The rate of post caesarean sepsis was 3.5%.Multiple factors were associated with postoperative wound sepsis; Age between 26-30 years(OR 3.46, p0.008), Parity of greater than 5(OR 3.14, p0.010), Duration of labor of 5 -8hrs or greater (OR 10.67, p0.013), delayed time of ambulation greater than 24-72hrs (OR 0.14, p&lt;0.001), intra operative blood loss of 500- 1000mls or greater(OR 8.00, p0.023) and Post-operative administration of ampicillin and metronidazole (OR40.00,p&lt;0.001). Conclusion: Post-operative wound sepsis in caesarean section is a relatively common occurrence in low-resource settings and mitigation of the multiple identified modifiable associated factors will greatly reduce patient morbidity and improve their outcomes.

High rate of inappropriate blood transfusions in the management of children with severe anemia in Ugandan hospitals

BackgroundSevere anaemia (SA) is a common reason for hospitalisation of children in sub-Saharan Africa but the extent to which blood transfusion is used appropriately in the management of severe anemia has hitherto remained unknown. We report on the use of blood transfusion in the management of anemic children in two hospitals in Uganda.MethodsInpatient records of children 0–5 years of age admitted to Lira and Jinja regional referral hospitals in Uganda were reviewed for children admitted on selected days between June 2016 and May 2017. Data was extracted on the results, if any, of pre-transfusion hemoglobin (Hb) level, whether or not a blood transfusion was given and inpatient outcome for all children with a diagnosis of ‘severe anemia’. Qualitative data was also collected from health workers to explain the reasons for the clinical practices at the two hospitals.ResultsOverall, 574/2275 (25.2%) of the children admitted in the two hospitals were assigned a diagnosis of SA. However 551 (95.9%) of children assigned a diagnosis of SA received a blood transfusion, accounting for 551/560 (98.4%) of the blood transfusions in the pediatric wards. Of the blood transfusions in SA children, only 245 (44.5%) was given appropriately per criteria (Pre-transfusion Hb ≤ 6 g/dL), while 306 (55.5%) was given inappropriately; (pre-transfusion Hb not done, n = 216, or when a transfusion is not indicated [Hb > 6.0 g/dl], n = 90). SA children transfused appropriately per Hb criteria had lower inpatient mortality compared to those transfused inappropriately, (7 (2.9%) vs. 22 (7.2%), [OR 0.4, 95% CI 0.16, 0.90]). Major issues identified by health workers as affecting use of blood transfusion included late presentation of SA children to hospital and unreliable availability of equipment for measurement of Hb.ConclusionMore than half the blood transfusions given in the management of anemic children admitted to Lira and Jinja hospitals was given inappropriately either without pre-transfusion Hb testing or when not indicated. Verification of Hb level by laboratory testing and training of health workers to adhere to transfusion guidelines could result in a substantial decrease in inappropriate blood transfusion in Ugandan hospitals.

High dose oral and intravenous rifampicin for improved survival from adult tuberculous meningitis: a phase II open-label randomised controlled trial (the RifT study).

Background: Tuberculous meningitis (TBM) has 44% (95%CI 35-52%) in-hospital mortality with standard therapy in Uganda. Rifampicin, the cornerstone of TB therapy, has 70% oral bioavailability and ~10-20% cerebrospinal fluid (CSF) penetration. With current WHO-recommended TB treatment containing 8-12mg/kg rifampicin, CSF rifampicin exposures frequently fall below the minimal inhibitory concentration for M. tuberculosis. Two Indonesian phase II studies, the first investigating intravenous rifampicin 600mg and the second oral rifampicin ~30mg/kg, found the interventions were safe and resulted in significantly increased CSF rifampicin exposures and a reduction in 6-month mortality in the investigational arms. Whether such improvements can be replicated in an HIV-positive population remains to be determined. Protocol: We will perform a phase II, open-label randomised controlled trial, comparing higher-dose oral and intravenous rifampicin with current standard of care in a predominantly HIV-positive population. Participants will be allocated to one of three parallel arms (I:I:I): (i) intravenous rifampicin 20mg/kg for 2-weeks followed by oral rifampicin 35mg/kg for 6-weeks; (ii) oral rifampicin 35mg/kg for 8-weeks; (iii) standard of care, oral rifampicin 10mg/kg/day for 8-weeks. Primary endpoints will be: (i) pharmacokinetic parameters in plasma and CSF; (ii) safety. We will also examine the effect of higher-dose rifampicin onsurvival time, neurological outcomes and incidence of immune reconstitution inflammatory syndrome. We will enrol 60 adults with suspected TBM, from two hospitals in Uganda, with follow-up to 6 months post-enrolment. Discussion: HIV co-infection affects the bioavailability of rifampicin in the initial days of therapy, risk of drug toxicity and drug interactions, and ultimately mortality from TBM. Our study aims to demonstrate, in a predominantly HIV-positive population, the safety and pharmacokinetic superiority of one or both investigational arms compared to current standard of care. The most favourable dose may ultimately be taken forward into an adequately powered phase III trial. Trial registration: ISRCTN42218549 (24 th April 2018).