Mbarara Regional Referral Hospital Research Articles

Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda

BackgroundThere is a paucity of recent prospective data on the incidence of postpartum infections and associated risk factors in sub-Saharan Africa. Retrospective studies estimate that puerperal sepsis causes approximately 10% of maternal deaths in Africa.MethodsWe enrolled 4231 women presenting to a Ugandan regional referral hospital for delivery or postpartum care into a prospective cohort and measured vital signs postpartum. Women developing fever (> 38.0 °C) or hypothermia (< 36.0 °C) underwent symptom questionnaire, structured physical exam, malaria testing, blood, and urine cultures. Demographic, treatment, and post-discharge outcomes data were collected from febrile/hypothermic women and a random sample of 1708 normothermic women. The primary outcome was in-hospital postpartum infection. Multivariable logistic regression was used to determine factors independently associated with postpartum fever/hypothermia and with confirmed infection.ResultsOverall, 4176/4231 (99%) had ≥1 temperature measured and 205/4231 (5%) were febrile or hypothermic. An additional 1708 normothermic women were randomly selected for additional data collection, for a total sample size of 1913 participants, 1730 (90%) of whom had complete data. The mean age was 25 years, 214 (12%) were HIV-infected, 874 (51%) delivered by cesarean and 662 (38%) were primigravidae. Among febrile/hypothermic participants, 174/205 (85%) underwent full clinical and microbiological evaluation for infection, and an additional 24 (12%) had a partial evaluation. Overall, 84/4231 (2%) of participants met criteria for one or more in-hospital postpartum infections. Endometritis was the most common, identified in 76/193 (39%) of women evaluated clinically. Twenty-five of 175 (14%) participants with urinalysis and urine culture results met criteria for urinary tract infection. Bloodstream infection was diagnosed in 5/185 (3%) participants with blood culture results. Another 5/186 (3%) tested positive for malaria. Cesarean delivery was independently associated with incident, in-hospital postpartum infection (aOR 3.9, 95% CI 1.5–10.3, P = 0.006), while antenatal clinic attendance was associated with reduced odds (aOR 0.4, 95% CI 0.2–0.9, P = 0.02). There was no difference in in-hospital maternal deaths between the febrile/hypothermic (1, 0.5%) and normothermic groups (0, P = 0.11).ConclusionsAmong rural Ugandan women, postpartum infection incidence was low overall, and cesarean delivery was independently associated with postpartum infection while antenatal clinic attendance was protective.

The burden of chronic rhinosinusitis and its effect on quality of life among patients re-attending an otolaryngology clinic in south western Uganda

BackgroundWorldwide, the burden of chronic rhinosinusitis (CRS) is variable, but not known in Uganda. CRS has significant negative impact on quality of life (QOL) and as such QOL scores should guide adjustments in treatment strategies. However, most of these studies have been done in the west. Our hypothesis was that QOL scores of the majority of CRS patients in low- to- middle income countries are poorer than those among patients without CRS. The aim of this study was to determine the burden of CRS among patients re-attending the Otolaryngology clinic and whether CRS is related to poor QOL.MethodsA cross sectional study was conducted at Mbarara Regional Referral Hospital Otolaryngology clinic. One hundred and twenty-six adult re-attendees were consecutively recruited. Data was collected using a structured questionnaire and the Sinonasal Outcome Test 22 (SNOT 22) questionnaire measured QOL.ResultsThe proportion of re-attendees with CRS was 39.0% (95% CI 30–48%). Majority of CRS patients had poor quality of life scores compared to non-CRS (88% versus 20% p < 01). The poor quality of life scores on the SNOT 22 were almost solely as a result of the functional, physical and psychological aspects unique to CRS.ConclusionsCRS is highly prevalent among re-attendees of an Otolaryngology clinic at a hospital in resource limited settings and has a significant negative impact on the QOL of these patients.

Hematological abnormalities in HIV-antiretroviral therapy naïve clients as seen at an immune suppression syndrome clinic at Mbarara Regional Referral Hospital, southwestern Uganda.

Aim/objectiveTo assess the common hematological abnormalities among HIV-antiretroviral therapy (ART) naïve clients attending an immune suppression syndrome (ISS) clinic at Mbarara Regional Referral Hospital (MRRH), southwestern Uganda.Patients and methodsThis was a cross-sectional study carried out during the months of March to August 2016 at the ISS clinic of MRRH. We collected approximately 4.0 mL of EDTA anticoagulated blood samples, which were assayed for complete blood count, CD4+ cell count and thin film examination. Correlation of the hematological abnormalities with CD4+ cell counts was done using correlation coefficient (r) and analysis of variance (F), and the p-value was set at ≤0.05.ResultsA total of 141 clients were enrolled. Of these, 67.38% (95/141) were anemic, 26.24% (40/141) had thrombocytopenia while 26.95% (38/141) had leucopenia. Of the 95 participants with anemia, 89.47% (85/95) presented with normocytic-normochromic anemia, 8.42% (8/95) with microcytic-hypochromic anemia and 2.11% (2/95) with macrocytic-hypochromic anemia. Anemia was not different across the several World Health Organization (WHO) stages of HIV infection disease progression (p>0.05). Statistically significant differences were present among participants with leucopenia (p<0.05). Also, leucopenia was more prevalent (11/38) among participants in WHO stage 4 of HIV infection. CD4+ cell counts correlated with thrombocytopenia (r=0.24, p<0.05) and leucopenia (r=0.15, p<0.05).ConclusionPeople living with HIV/AIDS (PLWHIV/AIDS) ought to be routinely monitored and treated for the occurrence of hematological abnormalities. Early initiation of ART can help to prevent some hematological abnormalities.

P-001 - Factors influencing late presentation for health care among men with cancer esophagus attending Hospice Africa Uganda (HAU)

Introduction: Late presentation for health care among patients with Cancer Esophagus is a major problem in Uganda. Cancer of Esophagus is one of the curable cancers if caught in its early stages. World Health Organization (2010) reports that esophageal cancer is the second most common cancer among men and was responsible for over 25000 deaths in 2010, approximately 80% occurred in developing countries. It was projected that it will increase by 25% over the next 10 years if nothing is done like putting prevention measures of adequate screening and treatment into place. Methods: A recording tape was used to store all the discussions for flexibility. The recorded material was first transcribed from local language then translated into English. Different themes were identified and then coding was done to come up with clear relations to the topic. Results: The results were also presented to Hospice Africa Uganda and Mbarara regional referral hospital management for proper planning. The 60% of the patient had no transport neither finicial support to access or report at the health facilities. The 40% of these patient had financial support but did not have time to visit the health workers. Conclusion: In conclusion, the themes realized which contributed to the late presentation for health care, could be grouped under three main factors: Socio-economic factors, Health system factors and Patient and community factors. These factors are interdependent. These need to be addressed by the responsible personnel in order to realize a change for the better in the health seeking mannerisms of patients.

Enhanced recovery after surgery: Effect on outcome of patients undergoing laparotomy at Mbarara regional referral hospital

Objectives: Compare the length of post-operative hospital stay and the incidence of postoperative complications between patients in the ERAS group and in the conventional care group. Methods: 33 participants above 18 years of age, undergoing laparotomy, were randomly assigned to an intervention (ERAS) arm or to a control (standard surgical care) arm at Mbarara Regional Referral Hospital in Uganda. The ERAS and the control arm had 16 and 17 patients respectively, followed-up 14 days after surgery. Results: patients in the ERAS arm had 2.4 days (SD 0.7) of post-operative hospital stay shorter than those in the control arm, p=0.0025 (4.1±0.2 vs 6.5±0.6). 18.8% of patients in the control arm developed post-operative complications compared to 5.9% in the ERAS arm (Statistical insignificance, p=0.335). ERAS patients passed flatus eight hours earlier than patients in the control arm, and mobilisation out of bed happened 12 hours earlier in the ERAS group. Conclusion: ERAS is feasible at Mbarara Regional Referral Hospital, and it leads to reduced hospital stay duration and post-operative complications in laparotomy cases. Disclosure of Interest: None declared.

Incidence and predictors of 6 months mortality after an acute heart failure event in rural Uganda: The Mbarara Heart Failure Registry (MAHFER)

ObjectiveWe sought to estimate the incidence and predictors of all-cause mortality 6 months after heart failure hospitalization in Uganda. MethodsMbarara Heart Failure Registry is a cohort of patients hospitalized with a clinical diagnosis of heart failure at Mbarara Regional Referral Hospital, Uganda. We measured serum electrolytes, cardiac markers, and echocardiograms. All participants were followed until death or end of 6 months. We used Fine and Gray models to estimate the incidence and predictors all-cause mortality. ResultsA total of 215 participants were enrolled, 141 (66%) were women, and mean age 53 (standard deviation 22) years. Nineteen (9%) had diabetes, 40 (19%) had HIV, and 119 (55%) had hypertension. The overall incidence of all-cause mortality was 3.58 (95% CI 2.92, 4.38) per 1000 person-days. Men had higher incidence of death compared to women (4.02 vs 3.37 per 1000 person-days). The incidence of all-cause mortality during hospitalization was almost twice that of in the community (27.5 vs 14.77 per 1000 person-days). In adjusted analysis, increasing age, NYHA class IV, decreasing renal function, smoking, each unit increase in serum levels of Potassium, BNP, and Creatine kinase-MB predicted increased incidence of 6 months all-cause death whereas taking beta-blockers and having an index admission on a weekend compared to a week day predicted survival. Conclusions and interpretationThere is a high incidence of all-cause mortality occurring in-hospital among patients hospitalized with heart failure in rural Uganda. Heart failure directed therapies should be instituted to curb heart failure-related mortality.

Development of a Comprehensive Trauma Training Curriculum for the Resource-Limited Environment

The goal of this project was to create a multitiered trauma training curriculum that was designed specifically for the low-resource setting. We developed 2 courses designed to teach principles and skills necessary for trauma care. The first course, "Emergency Ward Management of Trauma (EWMT)," is designed to teach interns the initial assessment and stabilization of trauma patients in the emergency ward. The second course for mid-level surgical residents, "Surgical Techniques and Repairs in Trauma for the Low-resource Environment" (STaRTLE), is a cadaver-based operative trauma course designed to teach surgical exposures and techniques. The courses were rolled out at Mbarara Regional Referral Hospital in the low-income country of Uganda. Precourse and postcourse tests and surveys were administered. This study took place at Mbarara Regional Referral Hospital (MRRH). This is a hospital in southwest Uganda with a subspecialty care, a medical school, nursing school, and multiple residency programs. Students in the EWMT course were interns at MRRH. After 1 year of training, most of these interns will become medical officers as the only provider at a district hospital in Uganda. The students in the STARTLE course were second-year residents in the general surgery program at MRRH. Scores on knowledge based tests improved significantly with both courses. Survey results from the EWMT course suggest that participants feel better prepared to care for the injured patient (median Likert [IQR]: 5.0 [5.0-5.0]) and that their practice improved (5.0 [5.0-5.0]). Similarly, following the STaRTLE course we found participants felt significantly more comfortable with performing 20 of the 22 operative procedures taught. These courses represent a feasible, cost-effective, and resource appropriate trauma education curriculum that if standardized and implemented may improve trauma care and outcomes in the resource-limited setting.

Mechanism of Pediatric Traumatic Brain Injury in Southwestern Uganda: AProspective Cohort of 100 Patients.

Road traffic incidents (RTIs), falls, and violence contribute to more than two thirds of pediatric traumatic brain injuries in sub-Saharan Africa. In this study, we sought to assess mechanisms of pediatric traumatic brain injury in an effort to propose interventions for more effective pediatric head injury prevention. A cohort of 100 patients who were <18 years treated at Mbarara Regional Referral Hospital between November 2016 and June 2017 were enrolled in the study. Information on etiology of injury was obtained via a questionnaire administered to patient caretakers at the time of admission. The mean age was found to be 7.5 years (standard deviation 5.2) and 38% were female. In our sample, 61% had computed tomography imaging done, of whom 88.5% had a positive finding. A majority of patients presented with a mild head injury (55%). RTIs were the predominant mechanism of injury across age groups (75%). Across all age groups, falls were responsible for a greater proportion of injuries in children aged 10-14 years (13.3%), whereas the greatest proportion of intentional injuries was reported in age group 10-14 and 15-17 years, 20% and 31.3%, respectively. Patients involved in pedestrian RTIs were significantly younger compared with those injured in nonpedestrian RTIs. Most parents (87.9%) were not with their children at the time of a pedestrian RTI. In Southwestern Uganda, the majority of pediatric neurotrauma patients are injured pedestrians, with no adult supervision at the time of the injury. Conducting a public awareness and education campaign on the necessity of child supervision is critical to decreasing pediatric head injuries in Uganda.

Bridging the data gap in global health: an electronic surgical outcomes database at Mbarara Regional Referral Hospital, Uganda

Abstract Background Annually, an estimated 17 million lives are lost from conditions requiring surgical care and at least 77·2 million disability-adjusted life-years could be averted through provision of basic surgical services. Despite the staggering burden of surgical disease, there are scarce data available to track current capacity, volume, epidemiology, outcomes, and quality of surgical care delivery in low-income and middle-income countries. We aimed to organise the hospital record system into a high-quality and high-fidelity searchable database that can be used to measure and guide expansion and provision of quality care at Mbarara Regional Referral Hospital (MRRH) in western Uganda. Methods Initiated in 2013, the Surgical Services QUality Assessment Database (SQUAD) arose from a shared commitment to improving surgical quality and capacity through a collaboration between MRRH and Massachusetts General Hospital. SQUAD systematically enrols and collects data on all surgical patients admitted to MRRH. Data are extracted from patient charts and admission, discharge, and operation logbooks by trained clerks—a process overseen by a data manager/statistician. Data variables are grouped into patient demographics, disease characteristics, cadre of clinicians, interventions, outcomes, and time. Data access and use is supervised by a committee of representatives. Findings To date, SQUAD contains more than 49 000 patient records in a searchable electronic database. Quality assurance reports have been produced for internal use at MRRH, and in-hospital initiatives have been made in response to findings. SQUAD was prospectively validated in 2016, and retrospective validation studies are currently underway. Interpretation Ongoing challenges include transitioning data capture methods from chart and log book review to a point-of-care electronic medical register and record system, while maintaining data entry. A future objective is the dissemination of clinical outcome reports through peer reviewed publications by authors from the collaborating institutions. Funding GE Foundation, Milton Foundation, Kletjian Foundation, and MGH Department of Anesthesia, Critical Care and Pain Medicine.

Quantifying delays and self-identified barriers to timely access to pediatric surgery at Mbarara Regional Referral Hospital, Uganda

PurposeFavorable surgical outcomes depend on timely access to care. This study quantifies these delays and explores caregiver barriers to access in a Ugandan facility. MethodsAn interviewer-facilitated survey was administered over 8months to consecutive pediatric surgical families at Mbarara Regional Referral Hospital (MRRH). Delays were classified using the Three Delays Model: care-seeking, arrival at health facility, and from surgical consultation to surgery. Barriers at each stage were explored with caregivers. ResultsThe survey included 174 patients. Family members were first to recognize disease in 90%, but only 14% sought medical attention immediately. Delays in seeking care predominated (median 30days), mostly attributed to home treatments (51%) and other responsibilities (28%). After referral decision, 80% of caregivers brought their child to MRRH immediately (median time to arrival <24h). Upon MRRH arrival, 57% of patients were assessed the same day, and time to surgery was relatively short (median 4days). Despite free under-5 care, out-of-pocket payments (between $1–42 USD) were reported by 64%. ConclusionsCare-seeking delays dominate access to pediatric surgical care in Uganda, and cost remains a significant barrier. Primary provider education and advocacy for increased resources would be useful interventions to improve timeliness of pediatric surgical care. Level of EvidenceLevel II.

False-positive HIV diagnoses: lessons from Ugandan and Russian research cohorts

Background: Research studies rely on accurate assessment of entry criteria in order to maintain study integrity and participant safety, however, challenges can exist with HIV studies in international settings.Objective: Examine the unexpectedly high proportion of study participants with an undetectable HIV viral load found in Ugandan and Russian research cohorts meeting antiretroviral therapy (ART)-naïve entry criteria.Methods: Russian participants with documented HIV and ART-naïve status were recruited between 2012 and 2015 from clinical and non-clinical sites in St. Petersburg. Participants in Uganda were recruited from Mbarara Regional Referral Hospital from 2011 to 2014 with documented HIV infection via rapid diagnostic testing and recorded ART-naïve in the clinic database. HIV viral load testing of baseline samples was performed; the lower limit of detection was 500 copies/mL in Russia and 40 in Uganda. Due to an unexpectedly high proportion of participants with undetectable viremia, additional tests were performed: enzyme-linked immunosorbent assay HIV testing and testing for ART.Results: In Russia, 16% (58/360) had undetectable viremia; 3% (9/360) re-tested HIV-seronegative and 4% (13/360) tested positive for ART. In Uganda 11% (55/482) had undetectable viremia; 5% (26/482) re-tested HIV-seronegative, while <1% (4/482) tested positive for ART.Conclusions: In both Russia & Uganda, undetectable viremia was much higher than would be expected for an HIV-infected ART-naïve cohort. Misclassification of study participants was due to misdiagnosis of HIV with rapid diagnostic testing and inaccurate accounting of ART use. Confirmatory HIV testing could improve accuracy of participants meeting entry criteria for HIV infection as might increased scrutiny of medication use in an ART-naïve cohort.

Prevalence and Factors Associated with Hydatidiform Mole among Patients Undergoing Uterine Evacuation at Mbarara Regional Referral Hospital.

Objective We sought to determine the prevalence of and factors associated with hydatidiform molar gestations amongst patients undergoing uterine evacuation at Mbarara Regional Referral Hospital (MRRH), Mbarara, Uganda. Methods This was a cross-sectional study carried out from November 2016 to February 2017. All patients admitted for uterine evacuation for nonviable pregnancy were included. The study registered 181 patients. Data were collected on sociodemographics, medical conditions, obstetrics, and gynecological factors. The evacuated tissue received a full gross and histopathologic examination. Cases of pathologically suspected complete hydatidiform mole were confirmed by p57 immunohistochemistry. Data were analyzed using STATA 13. Results The prevalence of hydatidiform mole was 6.1% (11/181). All detected moles were complete hydatidiform moles, and there were no diagnosed partial hydatidiform moles. Clinical diagnosis of molar pregnancy was suspected in 13 patients, but only 69.2% (9/13) were confirmed as molar pregnancies histologically. Two cases were clinically unsuspected. Factors that had a significant relationship with complete hydatidiform mole included maternal age of 35 years and above (aOR 13.5; CI: 1.46–125.31; p=0.00), gestational age beyond the first trimester at the time of uterine evacuation (aOR 6.2; CI: 1.07–36.14; p=0.04), and history of previous abortion (aOR 4.3; CI: 1.00–18.57; p=0.05). Conclusion The prevalence of complete hydatidiform mole was high at 6.1%. Associated risk factors included advanced maternal age (35 years and above), history of previous abortions, and gestational age beyond the first trimester at the time of evacuations. Recommendations We recommend putting in place capacity to do routine histopathological examination of all products of conception especially those at high risk for a molar gestation either by clinical suspicion or by risk factors including advanced maternal age, advanced gestational age, and history of previous abortion because of high prevalence of complete mole.

Assessment of nurses knowledge and skills following cardiopulmonary resuscitation training at Mbarara Regional Referral Hospital, Uganda.

IntroductionCardiopulmonary resuscitation (CPR) is considered a core emergency skill in which all health care professionals must be proficient. CPR remains a new procedure in developing compared to develop countries. The objective of this study was to assess Nurses Knowledge and Skills following Cardiopulmonary Resuscitation Training at Mbarara Regional Referral Hospital.MethodsA prospective pre/post intervention design was adopted. CPR knowledge and skills of 32 nurses from MRRH were assed using two tools. Tool I consisted of 17 item of multiple choice questions that assessed CPR knowledge. Tool II involved an observation checklist of 15-point skills questions. A penalty score of 5 or 10 or 20 was set for each question, based on the guideline.ResultsThe average score prior to instruction was 53.8 for knowledge and posttest 82.5, and for skills was 46 pre-instruction and 81.5 post instruction. There was a statistically significant (p < 0.001) improvement in the CPR knowledge and (p = 0.02) for CPR skills. The percentage change in respondent's knowledge and skills ranged from 16.8% to137.2% with a mean of 59.9% for knowledge and from 19.18% to 2115.6% with a mean of 159.8% for the skills assessment.ConclusionRespondents had inadequate CPR knowledge and skills at pretest. The study revealed statistically significant improvement in both knowledge and skills of CPR for all nurses post training. There was a significant change in nurses' skills than in knowledge post training.

Association between Prior Chlamydia trachomatis Infection and Ectopic Pregnancy at a Tertiary Care Hospital in South Western Uganda.

Background Increase in the number of ectopic pregnancy is attributed to increase in the incidence of pelvic infections. Chlamydia trachomatis is responsible for most of the sexually transmitted bacterial infections. If undetected and untreated, the infection can ascend to the upper genital tract and cause pelvic inflammatory disease (PID) and related sequelae (ectopic pregnancy and tubal factor infertility). Objective To determine the association between prior Chlamydia trachomatis infection and ectopic pregnancy at Mbarara Regional Referral Hospital (MRRH). Methods This was an unmatched case-control study carried out at MRRH involving 25 cases and 76 controls. Serological evidence of prior chlamydial infection was determined by testing for the presence of Chlamydia immunoglobulin G antibodies in their blood. Logistic regression was used to determine the association between prior Chlamydia trachomatis infection and also the factors associated with ectopic pregnancy. The significant level of <0.05 was used. Results. Chlamydia antibodies were found in 60% of patients with ectopic pregnancy and 26.3% of the controls (p=0.002). The presence of Chlamydia antibodies was associated with a fourfold risk of ectopic pregnancy. Conclusion There was a strong association between prior Chlamydia trachomatis infection and ectopic pregnancy.

Pediatric traumatic brain injury at Mbarara Regional Referral Hospital, Uganda

BackgroundIn Uganda, TBI constitute the majority of neurosurgical admissions and deaths specially in the pediatric population. This study aims to determine the factors associated with poor outcome among pediatric TBI cases at a major referral hospital in western Uganda. MethodsThis study was conducted at Mbarara Regional Referral Hospital (MRRH) in western Uganda. All pediatric neurosurgical cases between 2012 and 2015 were reviewed. In-hospital mortality and discharge GCS were the main outcomes of interest. Multivariable logistic regression with backward elimination was used to determine the factors significantly associated with outcome. ResultsA total of 381 pediatric TBI patients were admitted to MRRH between 2012 and 2015. The mean age was 8.6 (SD 5.6) with a male predominance (62.0%). The most common mechanism of injury overall was RTI, which was responsible for 71% of all TBI cases. In the multivariable logistic regression model, admission GCS < 13 was a strong predictor of poor outcome and in-hospital mortality compared to admission GCS ≥ 13, with patients demonstrating an odds ratio of 30 (95%CI: 7-132) and OR of 18 (95%CI: 4-79), respectively. ConclusionGiven the lack of published literature on pediatric TBI in LMICs, this study was the first to describe and evaluate risk factors associated with TBI severity among pediatric patients at a major referral hospital in western Uganda. Injury severity on admission was the only variable found to be significantly associated with discharge outcome. This study ultimately highlights the need for more effective preventative measures to decrease admission severity.

Diagnostic accuracy of Xpert MTB/RIF Ultra for tuberculous meningitis in HIV-infected adults: a prospective cohort study

SummaryBackgroundWHO recommends Xpert MTB/RIF as initial diagnostic testing for tuberculous meningitis. However, diagnosis remains difficult, with Xpert sensitivity of about 50–70% and culture sensitivity of about 60%. We evaluated the diagnostic performance of the new Xpert MTB/RIF Ultra (Xpert Ultra) for tuberculous meningitis.MethodsWe prospectively obtained diagnostic cerebrospinal fluid (CSF) specimens during screening for a trial on the treatment of HIV-associated cryptococcal meningitis in Mbarara, Uganda. HIV-infected adults with suspected meningitis (eg, headache, nuchal rigidity, altered mental status) were screened consecutively at Mbarara Regional Referral Hospital. We centrifuged CSF, resuspended the pellet in 2 mL of CSF, and tested 0·5 mL with mycobacteria growth indicator tube culture, 1 mL with Xpert, and cryopreserved 0·5 mL, later tested with Xpert Ultra. We assessed diagnostic performance against uniform clinical case definition or a composite reference standard of any positive CSF tuberculous test.FindingsFrom Feb 27, 2015, to Nov 7, 2016, we prospectively evaluated 129 HIV-infected adults with suspected meningitis for tuberculosis. 23 participants were classified as probable or definite tuberculous meningitis by uniform case definition, excluding Xpert Ultra results. Xpert Ultra sensitivity was 70% (95% CI 47–87; 16 of 23 cases) for probable or definite tuberculous meningitis compared with 43% (23–66; 10/23) for Xpert and 43% (23–66; 10/23) for culture. With composite standard, we detected tuberculous meningitis in 22 (17%) of 129 participants. Xpert Ultra had 95% sensitivity (95% CI 77–99; 21 of 22 cases) for tuberculous meningitis, which was higher than either Xpert (45% [24–68]; 10/22; p=0·0010) or culture (45% [24–68]; 10/22; p=0·0034). Of 21 participants positive by Xpert Ultra, 13 were positive by culture, Xpert, or both, and eight were only positive by Xpert Ultra. Of those eight, three were categorised as probable tuberculous meningitis, three as possible tuberculous meningitis, and two as not tuberculous meningitis. Testing 6 mL or more of CSF was associated with more frequent detection of tuberculosis than with less than 6 mL (26% vs 7%; p=0·014).InterpretationXpert Ultra detected significantly more tuberculous meningitis than did either Xpert or culture. WHO now recommends the use of Xpert Ultra as the initial diagnostic test for suspected tuberculous meningitis.FundingNational Institute of Neurologic Diseases and Stroke, Fogarty International Center, National Institute of Allergy and Infectious Disease, UK Medical Research Council/DfID/Wellcome Trust Global Health Trials, Doris Duke Charitable Foundation.

Brief surgical procedure code lists for outcomes measurement and quality improvement in resource-limited settings

The lack of a classification system for surgical procedures in resource-limited settings hinders outcomes measurement and reporting. Existing procedure coding systems are prohibitively large and expensive to implement. We describe the creation and prospective validation of 3 brief procedure code lists applicable in low-resource settings, based on analysis of surgical procedures performed at Mbarara Regional Referral Hospital, Uganda's second largest public hospital. We reviewed operating room logbooks to identify all surgical operations performed at Mbarara Regional Referral Hospital during 2014. Based on the documented indication for surgery and procedure(s) performed, we assigned each operation up to 4 procedure codes from the International Classification of Diseases, 9th Revision, Clinical Modification. Coding of procedures was performed by 2 investigators, and a random 20% of procedures were coded by both investigators. These codes were aggregated to generate procedure code lists. During 2014, 6,464 surgical procedures were performed at Mbarara Regional Referral Hospital, to which we assigned 435 unique procedure codes. Substantial inter-rater reliability was achieved (κ=0.7037). The 111 most common procedure codes accounted for 90% of all codes assigned, 180 accounted for 95%, and 278 accounted for 98%. We considered these sets of codes as 3 procedure code lists. In a prospective validation, we found that these lists described 83.2%, 89.2%, and 92.6% of surgical procedures performed at Mbarara Regional Referral Hospital during August to September of 2015, respectively. Empirically generated brief procedure code lists based on International Classification of Diseases, 9th Revision, Clinical Modification can be used to classify almost all surgical procedures performed at a Ugandan referral hospital. Such a standardized procedure coding system may enable better surgical data collection for administration, research, and quality improvement in resource-limited settings.

Validation of an Electronic Surgical Outcomes Database at Mbarara Regional Referral Hospital, Uganda.

Accurate, complete and sustainable methods of tracking patients and outcomes in low-resource settings are imperative as we launch efforts to improve surgical care globally. The Surgical services QUality Assessment Database (SQUAD) at the Mbarara Regional Referral Hospital in Uganda is one of very few electronic surgical databases in a low-resource setting. We evaluated the completeness and accuracy of SQUAD. Data were prospectively collected on 20 of the most clinically relevant variables captured by SQUAD for all general surgery patients admitted to MRRH over a two-week period. Patients were followed until discharge, death or hospital day 30; whichever occurred first. These data were compared to that in SQUAD for the same time period for completeness and accuracy. Of 186 unique patients seen over the two-week period, 172 (92.5%) were captured by SQUAD. The capture rate was greater than 86% for each of the 20 variables evaluated, except American Society of Anesthesiologists score, which had a 69% capture rate. Regarding accuracy, there was almost perfect agreement for 16/20 variables (all k>0.81), substantial agreement for 2/20 variables (k 0.63, 0.73) and moderate agreement for the remaining 2/20 variables (k 0.43, 0.48) between SQUAD and the prospectively collected data. SQUAD is an electronic surgical database that has been implemented and sustained in a low-resource setting. For the 20 variables evaluated, the data within SQUAD are highly complete and accurate. This database may serve as a model for the development of additional surgical databases in low-resource environments.

Stage of labor at admission among Ugandan women with a prior cesarean, and its impact on management and delivery outcomes.

To describe stage of labor at admission among women with a prior cesarean, and examine its impact on intrapartum management and delivery mode. In a prospective cohort study, women admitted to Mbarara Regional Referral Hospital, Uganda, for delivery were enrolled between March and June 2015. Rates of vaginal delivery (VBAC) and in-hospital trial of labor (TOL) were compared between early (<4cm dilation) and late (≥4cm) presenters. Women were interviewed after delivery about decision making and labor preferences. Overall, 188 women comprised the study sample; 98 (52.1%) and 65 (34.6%) women presented at ≥4cm and ≥6cm, respectively, and 18 (9.6%) were fully dilated. In-hospital TOL and VBAC rates were 25.5% (42/165) and 9.6% (18/188), respectively. Compared with early presenters, late presenters were significantly more likely to undergo TOL (28/88 [31.8%] vs 14/77 [18.2%]; odds ratio [OR] 2.3, 95% confidence interval [CI] 1.1-5.0), and achieve VBAC (16/98 [16.3%] vs 2/90 [2.2%]; OR 7.6, 95% CI 1.7-35.1). Most women arrived in active labor, but most had a repeat cesarean. Work is needed to understand the clinical decision making and provider management driving low TOL and VBAC rates.

Predictors and Patterns of HIV Status Disclosure among HIV Positive Pregnant Women at Mbarara Regional Referral Hospital, South-Western Uganda

Predictors and Patterns of HIV Status Disclosure among HIV Positive Pregnant Women at Mbarara Regional Referral Hospital, South-Western Uganda