Regional Referral Hospital In Uganda Research Articles

Late Stage at Diagnosis of Cervical Cancer and Its Correlates at a Large Regional Referral Hospital in Uganda: A Cross-Sectional Study.

Background The stage of disease at diagnosis is one of the major determinants of survival in women with cervical cancer. Most women with cervical cancer in low- and middle-income countries (LMICs) present to hospitals with advanced stages, thus reducing their survivorship following the diagnosis. Factors correlated with late-stage disease at diagnosis are not completely explored. This study aimed to describe the association between sociodemographic, clinical, and metabolic characteristics with late-stage disease at diagnosis in women with cervical cancer attending the Mbarara Regional Referral Hospital in Southwestern Uganda. Methodology We conducted a cross-sectional study of women with histological diagnoses of invasive cervical cancer between November 2022 and August 2023. Women who presented to the hospital with the International Federation of Gynecology and Obstetrics stage IIb and above were considered to have late-stage cervical cancer while those with stage IIa and below were considered to have early-stage disease. We used modified Poisson regression to determine the factors independently associated with the outcome. Results We enrolled 157 women. The average age of the participants was 52.4 years. The majority of the participants (83.4%) had late-stage disease at diagnosis. Women with adenocarcinoma (adjusted prevalence ratio (aPR) = 1.18, 95% confidence interval (CI) = 1.10-1.38) and those with lymphovascular space involvement on histology (aPR = 1.30, 95% CI = 1.05-1.60) were more likely to have late-stage disease at diagnosis while women living with human immunodeficiency virus (aPR = 0.83, 95% CI = 0.71-0.97) were less likely to present with late-stage disease at diagnosis. None of the sociodemographic and metabolic characteristics were associated with late-stage disease at diagnosis. Conclusions The number of women presenting with late-stage cervical cancer is high. Efforts to increase the availability and uptake of cervical cancer screening services in LMICs should be reinforced. Cervical cancer treatment services should be decentralized to increase accessibility.

Incidence and Determinants of Adverse Neonatal Outcomes among HIV-Positive Pregnant Women: A Prospective Cohort Study at Regional Referral Hospitals in Uganda

HIV infection remains a significant global health challenge, affecting over 37.9 million people worldwide. Despite widespread access to antiretroviral therapy (ART), adverse neonatal outcomes are prevalent among pregnant women living with HIV. This prospective cohort study aimed to determine the incidence and factors associated with early adverse neonatal outcomes among HIV-positive mothers at Mubende and Fort Portal Regional Referral Hospitals (MRRH and FRRH), compared to HIV-negative mothers. The study excluded mothers with known risks for adverse neonatal outcomes. Neonates were monitored from birth to discharge within 7 days for adverse outcomes. Among 203 participants, 135 were HIV-negative and 68 were HIV-positive. Adverse neonatal outcomes were more frequent in the HIV-positive group (39.7% vs. 28.1%), although the difference was not statistically significant (P=0.096). Prematurity (20.6% vs. 8.1%, P=0.031) and low birth weight (25.0% vs. 12.6%, P=0.047) were significantly higher among HIV-positive mothers. Multivariate analysis identified detectable viral load as a significant risk factor for early neonatal adverse outcomes (aRR=4.036, CI=1.428-11.406, P=0.008). These findings underscore the importance of close monitoring and viral load suppression in HIV-positive mothers. Further research is needed to understand the causes of detectable viral loads in mothers on ART and to capture neonatal adverse outcomes beyond 7 days post-delivery. Keywords: HIV, Adverse neonatal outcomes, Antiretroviral therapy (ART), Viral load, Prematurity, Low birth weight, public health and Maternal health

Factors associated with early inhospital adverse outcome following surgery for acute appendicitis in Uganda: a multicenter cohort

IntroductionSurgery for acute appendicitis has been associated with significant morbidity. This study aimed to determine the factors associated with early inhospital adverse outcomes following surgery for acute appendicitis in Uganda.MethodsThis was a multicentre, prospective cohort in which early inhospital outcome following surgery for acute appendicitis was assessed at 4 regional referral hospitals in Uganda. The occurrence of complications during the admission period was documented as well as the length of hospital stay. Factors associated with adverse outcomes were determined using Poisson regression.ResultsOf the 102 patients who underwent surgery for acute appendicitis, the majority were males 79(77.5%) with a mean age of 23.8(SD = 12.5) years. The perforated appendix was seen in 26 (25.5%) patients. Post-operative complications occurred in 21(20.6%) with the commonest being surgical site infection in 19(18.6%) patients. The median length of hospital stay was 3(IQR = 3–4) days with 43(42.2%) staying in hospital for more than 3 days. The presence of anemia (Hb < 8) (aRR = 1.376, CI = 1.159–1.634, P = < 0.001) and having a perforated appendix (aRR = 1.263, CI = 1.026–1.555, P = 0.027) were independently associated with occurrence of complications while being HIV positive (aRR = 1.379, CI = 1.105–1.721, P = 0.005) and having a perforated appendix (aRR = 1.258, CI = 1.019–1.554, P = 0.033) were independently associated with prolonged hospital stay.ConclusionCommunity education about early presentation is still required in order to reduce the number of patients that present late which should, in turn, reduce the risk of complications and length of hospital stay.

Poor long-term outcomes despite improved hospital survival for patients with cryptococcal meningitis in rural, Northern Uganda.

Cryptococcal meningitis (CM) remains a major cause of death among people living with HIV in rural sub-Saharan Africa. We previously reported that a CM diagnosis and treatment program (CM-DTP) improved hospital survival for CM patients in rural, northern Uganda. This study aimed to evaluate the impact on long-term survival. We conducted a retrospective study at Lira Regional Referral Hospital in Uganda evaluating long-term survival (≥1 year) of CM patients diagnosed after CM-DTP initiation (February 2017-September 2021). We compared with a baseline historical group of CM patients before CM-DTP implementation (January 2015-February 2017). Using Cox proportional hazards models, we assessed time-to-death in these groups, adjusting for confounders. We identified 318 CM patients, 105 in the Historical Group, and 213 in the CM-DTP Group. The Historical Group had a higher 30-day mortality of 78.5% compared to 42.2% in the CM-DTP Group. The overall survival rate for the CM-DTP group at three years was 25.6%. Attendance at follow-up visits (HR:0.13, 95% CI: [0.03-0.53], p <0.001), ART adherence (HR:0.27, 95% CI: [0.10-0.71], p = 0.008), and fluconazole adherence: (HR:0.03, 95% CI: [0.01-0.13], p <0.001), weight >50kg (HR:0.54, 95% CI: [0.35-0.84], p = 0.006), and performance of therapeutic lumbar punctures (HR:0.42, 95% CI: [0.24-0.71], p = 0.001), were associated with lower risk of death. Altered mentation was associated with increased death risk (HR: 1.63, 95% CI: 1.10-2.42, p = 0.016). Long-term survival of CM patients improved after the initiation of the CM-DTP. Despite this improved survival, long-term outcomes remained sub-optimal, suggesting that further work is needed to enhance long-term survival.

Corneal endothelial cell density and associated factors among adults at a regional referral hospital in Uganda: a cross-sectional study.

To assess the prevalence of low corneal endothelial cell density and correlates of corneal endothelial cell density among adults attending Mbarara University and Referral Hospital Eye Centre in Uganda. In this hospital-based cross-sectional study, participants 18 years and older, were enrolled. We obtained informed consent, and basic demographic data. We also conducted visual acuity, a detailed slit lamp examination, intra-ocular pressure, corneal diameter, tear-film break-up time, keratometry, A-scan, and pachymetry on all participants. A confocal microscope Heidelberg HRT3 was used to examine the central cornea and to obtain the mean cell density (cells/mm2). To calculate the proportion of low endothelial cell density, descriptive statistics were used, whereas correlates of endothelial cell density were assessed, using linear regression analyses. We evaluated a total of 798 eyes of 404 participants aged between 18 and 90 years (males = 187, females = 217). The average endothelial cell density was 2763.6 cells/mm2, and there was a decrease in endothelial cell density with increasing age, irrespective of gender. There was no significant difference in endothelial cell density between males and females. Increasing age (adjusted coefficient - 10.1, p < 0.001), history of smoking (adjusted coefficient - 439.6, p = 0.004), history of ocular surgery (adjusted coefficient - 168.0, p = 0.023), having dry eye (adjusted coefficient - 136.0, p = 0.051), and having arcus senilis (adjusted coefficient - 132.0, p = 0.08), were correlated with lower endothelial cell density. However, increasing corneal diameter (adjusted coefficient 134.0, p = 0.006), increasing central corneal thickness (adjusted coefficient 1.2, p = 0.058), and increasing axial length (adjusted coefficient 65.8, p = 0.026), were correlated with higher endothelial cell density. We found five eyes (0.63%) from different participants with a low endothelial cell density (< 1000cells/mm2). Our study established baseline normal ranges of ECD in a predominantly black African population, and found that low ECD is rare in our population. The elderly, smokers, and those with past ocular surgery are the most vulnerable. The low prevalence could be due to a lack of reference values for the black African population.

Delivery of a post-natal neonatal jaundice education intervention improves knowledge among mothers at Jinja Regional Referral Hospital in Uganda.

Neonatal jaundice (NNJ) is a major contributor to childhood morbidity and mortality. As many infants are discharged by 24 hours of age, mothers are key in detecting severe forms of jaundice. Mothers with limited knowledge of NNJ have a hard time identifying these infants who could go on to have the worst outcomes. This study aimed to determine the effect of a jaundice education package delivered to mothers prior to hospital discharge on maternal knowledge after discharge. This was a before and after interventional study involving an education package delivered through a video message and informational voucher. At 10-14 days after discharge, participants were followed up via telephone to assess their post-intervention knowledge. A paired t-test was used to determine the effectiveness of the intervention on knowledge improvement. Linear regression was used to determine predictors of baseline knowledge and of change in knowledge score. Of the 250 mothers recruited, 188 were fit for analysis. The mean knowledge score was 10.02 before and 14.61 after the intervention, a significant difference (p<0.001). Factors determining higher baseline knowledge included attendance of 4 or more antenatal visits (p < 0.001), having heard about NNJ previously (p < 0.001), having experienced an antepartum illness (p = 0.019) and higher maternal age (p = 0.015). Participants with poor baseline knowledge (β = 7.523) and moderate baseline knowledge (β = 3.114) had much more to gain from the intervention relative to those with high baseline knowledge (p < 0.001). Maternal knowledge of jaundice can be increased using a simple educational intervention, especially in settings where the burden of detection often falls on the mother. Further study is needed to determine the impact of this intervention on care seeking and infant outcomes.

Predictors and Risks of Vaginal Birth after Cesarean Section: Insights from a Regional Referral Hospital in Uganda

Vaginal birth after cesarean section (VBAC) remains a topic of significant interest due to its potential benefits and associated risks. This retrospective cohort study aimed to identify predictors and risks associated with VBAC compared to elective repeat cesarean section (ERCD) among women delivering at Jinja Regional Referral Hospital in Uganda. We analyzed data from 384 women who had a previous cesareansection and delivered at the hospital between 2022 and 2023. Socio-demographic, obstetric, and medical characteristics were assessed for their association with successful VBAC using logistic regression. Risks of maternal morbidities between VBAC and ERCD groups were compared using Chi-square tests. The study found that BMI &lt;35 kg/m², birth weight &lt;3500g, spontaneous onset of labor, previous safe vaginal birth, and absence of diabetes mellitus were significant predictors of successful VBAC. Women undergoing TOLAC had a higher incidence of uterine rupture (p = 0.030), thromboembolism (p &lt; 0.001), and blood transfusion requirement (p &lt; 0.001) compared to ERCD. However, hysterectomy, hemorrhage, viscus injury, and pelvic floor trauma did not significantly differ between the two groups. Our findings highlight important predictors and risks associated with VBAC compared to ERCD in a regional referral hospital setting. Understanding these factors can aid clinicians in counseling women on their delivery options and managing potential risks associated with VBAC. Further research is warranted to explore strategies for optimizing VBAC outcomes while minimizing associated morbidities. Keywords: Maternal, Morbidity, Labor, Cesarean Section, Elective Repeat Cesarean Delivery, Jinja, Hospital

273 A Direct Domparative Analysis of Pediatric Traumatic Brain Injury Presentation and Outcomes in the United States and Uganda

INTRODUCTION: Pediatric traumatic brain injury (pTBI) is the leading cause of death and disability among children globally. However, few studies have explored pTBI in low- and middle-income countries (LMICs) compared to high-income countries (HICs). METHODS: Patient records were extracted from the Duke University Hospital subset of the National Trauma Data Bank (NTDB, n = 866) and a dataset at the Mbarara Regional Referral Hospital in Uganda (MRRH, n = 571). Descriptive statistics were performed to compare across settings. Logistic regression was used to quantify the odds of mortality in each setting given ICU utilization, admission GCS, and other factors. RESULTS: In-hospital mortality was higher in the LMIC versus the HIC (9.4% vs 2.9%, p &lt; 0.001), while ICU utilization was lower in the LMIC (9.0% vs 33.4%, p &lt; 0.001). Rates of surgical management did not differ significantly (15.8% vs 17.0%). More patients presented with moderate (27.8% vs 4.3%) and severe TBI (16.5% vs 11.8%) in the LMIC (p &lt; 0.001). No deaths were reported among patients presenting with moderate or mild TBI in the HIC setting, whereas LMIC pTBI patients died in every TBI severity category. Over 50% of LMIC ICU patients died, versus 8.1% of HIC ICU patients. In a multivariate regression model of mortality, ICU placement was associated with mortality (OR: 6.7, 95% CI: 2.1-20.9), an association not seen in the HIC setting. CONCLUSIONS: Pediatric TBI mortality is greater in the LMIC vs the HIC setting. The LMIC setting also had a high prevalence of moderate/severe TBI and low ICU availability and effectiveness. Future work should involve the implementation and evaluation of interventions to assess these gaps in the LMIC setting.

Factors Influencing Folic Acid and Iron Supplement Use Among Pregnant Women at Hoima Regional Referral Hospital in Uganda

The study sought to assess adherence levels to Folic Acid and Iron supplementation among expectant women attending antenatal care at Hoima Regional Referral Hospital. Findings revealed a 58.8% adherence rate among pregnant mothers. Among adherents, the majority were younger than 30, Christians, rural residents, cohabiting, had primary education, and were homemakers. Notably, only a minority were experiencing their first pregnancy. Regarding awareness and advice, a significant percentage knew about the preventive benefits of Iron-folic acid supplements against anemia, had received advice on supplementation benefits and the necessity of not missing doses. However, awareness about the specific benefits, dosage, and sources of folic acid and iron was limited. While most attended early ANC visits, only a fraction knew about folic acid benefits and sources, the correct dosage, or foods containing folic acid. Additionally, just over half met the recommended ANC visit frequency. Factors influencing adherence were largely tied to demographics such as age, religion, residence, partnership status, education, and employment, alongside knowledge gaps about supplementation benefits and dosages. Conversely, behaviors like alcohol intake, late or infrequent ANC attendance, and negative experiences during ANC acted as barriers to adherence. Keywords: Pregnancy, Anaemia, Antenatal Care, Folic acid, Iron supplementation.

Pharmacokinetic-Guided Hydroxyurea to Reduce Transfusion Requirements in Ugandan Children with Sickle Cell Anemia: Baseline Data from the Alternative Dosing and Prevention of Transfusions (ADAPT) Trial

Background: Children are the primary recipients of blood transfusions in sub-Saharan Africa where the demand for safe blood far exceeds the supply. Without disease-modifying therapy, sickle cell anemia (SCA) causes excess morbidity, mortality, and healthcare resource utilization, specifically requiring a high reliance on blood transfusions. Hydroxyurea is a safe and effective medication for the treatment of SCA that decreases blood transfusion use in this population, which may offset the costs of improving hydroxyurea access. The widespread use of hydroxyurea in Africa is limited in part by challenges determining an individual's optimal dose; pharmacokinetic (PK) dosing of hydroxyurea may streamline the dosing process, maximizing the clinical benefits and minimizing toxicities. We designed the Alternative Dosing And Prevention of Transfusions (ADAPT) trial to analyze the reduction in transfusion use with hydroxyurea and as a pilot evaluation of the feasibility of PK-guided hydroxyurea dosing in Uganda. Methods: ADAPT (NCT05662098) is a prospective, single-center, open-label cohort study at Jinja Regional Referral Hospital in Uganda. Children 1-10 years old with HbSS were eligible to enroll; those already receiving hydroxyurea or scheduled blood transfusions, or with malignancy, HIV, tuberculosis, or other chronic illnesses were excluded, and those who received a transfusion within 30 days were temporarily excluded. All participants completed a 3-month screening period during which they underwent baseline evaluations and hydroxyurea PK testing. For PK testing, a 500 mg hydroxyurea test dose was administered, and serum was collected 30, 60, and 180 minutes after the dose. Hydroxyurea concentrations were determined via chemical derivatization and high-performance liquid chromatography in Uganda. Area-under-time-concentration-curves (AUC) and Bayesian estimation were then used to calculate the optimal hydroxyurea dose based on target medication exposure. Those for whom hydroxyurea PK evaluation was completed successfully with a dose recommendation between 15-35 mg/kg/day started on their PK-guided hydroxyurea dose; otherwise, participants started on the default dose of 20 mg/kg/day. All participants will be treated on hydroxyurea for a minimum of 12 months during which time both treatment groups will follow the same laboratory monitoring and dose adjustment protocol to achieve the maximum tolerated dose. The primary study endpoint is the incidence rate ratio of blood transfusion use during screening versus treatment. Secondary endpoints include characterization of blood transfusions (indications, risk factors, adverse reactions), feasibility of PK testing, and laboratory and clinical adverse events comparing children started on PK-guided versus default dosing. Results: From June 2022 to January 2023, 106 participants were enrolled, exceeding the projected enrollment pace and goal. The average age (mean ± SD) at enrollment was 4.6 ± 2.3 years, and 50% were female. Per family-reported history, most participants had previously received a blood transfusion (78%) with 15% reporting at least 6 lifetime transfusions. Five percent had a prior stroke. A majority also had a history of pain events (86%), malaria (79%), and dactylitis (74%). Only 2% had previously used hydroxyurea. At enrollment, the median weight-for-height z-score was -0.19 (interquartile range -1.03-0.32), and baseline exam demonstrated a palpable spleen in 20%. Abdominal ultrasonography was completed on all participants, and the spleen was identified in 75% of participants with a mean volume of 132 ± 99 mL. Transcranial Doppler exams were completed on 105 participants (99%) during screening with 13% conditional and 6% abnormal results. Baseline labs (mean ± SD) documented hemoglobin = 7.7 ± 1.3 g/dL and HbF = 10.3 ± 7.1 %. Of 106 children enrolled, 1 died from acute chest syndrome in screening and 2 were withdrawn after moving away from the clinic; 103 successfully initiated hydroxyurea treatment. Conclusion: ADAPT has fully completed enrollment and will prospectively evaluate the effectiveness of hydroxyurea treatment on reducing transfusion use in Ugandan children with SCA, a finding with both individual and public health implications. ADAPT will also provide pilot data regarding the feasibility of PK-guided dosing of hydroxyurea to facilitate safe, effective hydroxyurea use in Africa.

36 Quality Improvement Integrated Kangaroo Mother Care (QIiKMC)-Development with Evidence-based Practice for Improving Quality (EPIQ) to Improve Learning and Implementation

Abstract Introduction/Background Kangaroo Mother Care (KMC) improves outcome for small newborns, but implementation has been slow. This lag may be associated with lack of short, effective learning programs for healthcare workers, and limited ability to overcome barriers to KMC program development. Objectives To develop a practical learning program for KMC with focus on facilitating healthcare workers assisting the learning of mothers and other family members in KMC care of small babies. To integrate KMC with quality improvement to assist healthcare workers overcome barriers to implementation and improve practice. Design/Methods Six neonatologists, with other global experts, developed as simulation-based, interactive, 12-contact-hour learning program with virtual pilot testing in Uganda, Tanzania, and Nepal, prior to implementation in Mbarara Regional Referral Hospital in Uganda. Revisions in QIiKMC course content and integration with quality improvement were accompanied by development of A KMC Readiness, Survey, Knowledge and Confidence Check, Parent Information, and Course Evaluation, with all components available at www.cnf-fnc.ca. Results Thirty-three nurses and physicians increased knowledge scores from 79% to 88% post-learning. 77% indicated the course was useful or very useful, appreciating “The link between EPIQ and KMC in identification and solving problems” and the “Usefulness of family involvement in caring for the newborn in the hospital and home”. Participants indicated preferences for face-to-face learning and more time for hands-on practice. KMC for small babies increased from 0% to 65% (by August-October 2022). Length of hospital stay decreased by 5 days. Government increased KMC beds from 4 to 8. Staff reported increased job satisfaction along with increased quality improvement activities. Family members in addition to mothers were involved (especially with multiple births or if the mother was ill). Families helped other families with learning. One father reported that “When my baby grows up, I will let him know that it was my warmth which kept him alive”. Conclusion Development of a short, practical KMC learning program was feasible. Integration with quality improvement was empowering and impactful. Acknowledgements Funding from the Royal College of Physicians and Surgeons of Canada and a Rotary Global Grant is appreciated. Potential competing interests Funding for learning program development was received from the Royal College of Physicians and Surgeons of Canada. Funding for KMC implementation in Uganda was supported by a Rotary Global Grant.

Cost-effectiveness analysis of Smart Triage, a data-driven pediatric sepsis triage platform in Eastern Uganda

BackgroundSepsis, characterized by organ dysfunction due to presumed or proven infection, has a case-fatality over 20% in severe cases in low-and-middle income countries. Early diagnosis and treatment have proven benefits, prompting our implementation of Smart Triage at Jinja Regional Referral Hospital in Uganda, a program that expedites treatment through a data-driven triage platform. We conducted a cost-effectiveness analysis of Smart Triage to explore its impact on patients and inform multicenter scale up.MethodsThe parent clinical trial for Smart Triage was pre-post in design, using the proportion of children receiving sepsis treatment within one hour as the primary outcome, a measure linked to mortality benefit in existing literature. We used a decision-analytic model with Monte Carlo simulation to calculate the cost per year-of-life-lost (YLL) averted of Smart Triage from societal, government, and patient perspectives. Healthcare utilization and lost work for seven days post-discharge were translated into costs and productivity losses via secondary linkage data.ResultsIn 2021 United States dollars, Smart Triage requires an annuitized program cost of only $0.05 per child, but results in $15.32 saved per YLL averted. At a willingness-to-pay threshold of only $3 per YLL averted, well below published cost-effectiveness threshold estimates for Uganda, Smart Triage approaches 100% probability of cost-effectiveness over the baseline manual triage system. This cost-effectiveness was observed from societal, government, and patient perspectives. The cost-effectiveness observed was driven by a reduction in admission that, while explainable by an improved triage mechanism, may also be partially attributable to changes in healthcare utilization influenced by the coronavirus pandemic. However, Smart Triage remains cost-effective in sensitivity analyses introducing a penalty factor of up to 50% in the reduction in admission.ConclusionSmart Triage’s ability to both save costs and avert YLLs indicates that patients benefit both economically and clinically, while its high probability of cost-effectiveness strongly supports multicenter scale up. Areas for further research include the incorporation of years lived with disability when sepsis disability weights in low-resource settings become available and analyzing budget impact during multicenter scale up.Trial registrationNCT04304235 (registered on 11/03/2020, clinicaltrials.gov).

Splenic Injury Following Blunt Abdominal Trauma: The Experience from a Regional Referral Hospital in Uganda

Splenic Injury Following Blunt Abdominal Trauma: The Experience from a Regional Referral Hospital in Uganda

Factors Associated with HIV Virological Non-Suppression Among Adults Receiving Anti-Retroviral Therapy at Lira Regional Referral Hospital, Northern Uganda

Background: By 2030, all Adults with HIV will have been diagnosed, will be receiving antiretroviral therapy (ART), and will have achieved viral load suppression. These goals form the global effort to stop new HIV infections, increase treatment coverage, and end AIDS-related deaths. This study investigated the variables that affect HIV RNA viral non-suppression among Adults living with HIV at Lira Regional Referral Hospital in Uganda. Methods: For this mixed-methods study, data was collected using a data extraction form, a semi-structured questionnaire, and a key informant interview guide. STATA 17 was used to analyze the quantitative data, and the thematic method was used to analyze the qualitative data. The results were presented in charts, tables, and themes for quantitative data and qualitative data, respectively. Results: Of the 425 respondents, 235 (55.3%) were female and 190 (44.7%) were male. The majority, 208 (48.9%), were between the ages of 31 and 40. Of those, 238 (56%) had at least a primary education, and 264 (62.1%) were married. The prevalence of HIV RNA viral non-suppression was at 8.5% among Adults living with HIV and 91.5% were HIV RNA virologically suppressed. Recent CD4 counts, Baseline viral load, and WHO clinical stage were significantly associated with HIV RNA virological suppression. In addition to that, adherence (aOR =1.00, 95%CI: 0.004-0.07, p=0.001) was associated with HIV RNA virological non-suppression. Qualitatively, results revealed that Status disclosure is always done by close relatives of the victims, stigma, and discrimination were not common in the community. There is a need for strategies on how to promote drug adherence among Adults living with HIV rather than just providing the treatment, as viral load suppression is related to baseline viral load, CD4, marital status, and drug adherence. In this study, monitoring the immunological response through scheduled CD4 and viral load tests is critical for maintaining patients' immunity and preventing disease progression. Intensive adherence support and counseling should conclusively be provided through the effective implementation of ART programs by providers to enhance viral suppression and ensure the quality of care and treatment.

Prevalence and factors associated with reported adverse-events among patients on multi-drug-resistant tuberculosis treatment in two referral hospitals in Uganda

BackgroundMulti-drug-resistant tuberculosis (MDR-TB) treatment involves toxic drugs that cause adverse events (AEs), which are life-threatening and may lead to death if not well managed. In Uganda, the prevalence of MDR-TB is increasingly high, and about 95% of the patients are on treatment. However, little is known about the prevalence of AEs among patients on MDR-TB medicines. We therefore estimated the prevalence of reported adverse events (AEs) of MDR-TB drugs and factors associated with AEs in two health facilities in Uganda.MethodsA retrospective cohort study of MDR-TB was conducted among patients enrolled at Mulago National Referral and Mbarara Regional Referral hospitals in Uganda. Medical records of MDR-TB patients enrolled between January 2015 and December 2020 were reviewed. Data on AEs, which were defined as irritative reactions to MDR-TB drugs, were extracted and analyzed. To describe reported AEs, descriptive statistics were computed. A modified Poisson regression analysis was used to determine factors associated with reported AEs.ResultsOverall, 369 (43.1%) of 856 patients had AEs, and 145 (17%) of 856 had more than one. Joint pain (244/369, or 66%), hearing loss (75/369, or 20%), and vomiting (58/369, or 16%) were the most frequently reported effects. Patients started on the 24-month regimen (adj. PR = 1.4, 95%; 1.07, 1.76) and individualized regimens (adj. PR = 1.5, 95%; 1.11, 1.93) were more likely to suffer from AEs. Lack of transport for clinical monitoring (adj. PR = 1.9, 95%; 1.21, 3.11); alcohol consumption (adj. PR = 1.2, 95%; 1.05, 1.43); and receipt of directly observed therapy from peripheral health facilities (adj. PR = 1.6, 95%; 1.10, 2.41) were significantly associated with experiencing AEs. However, patients who received food supplies (adj. PR = 0.61, 95%; 0.51, 0.71) were less likely to suffer from AEs.ConclusionThe frequency of adverse events reported by MDR-TB patients is considerably high, with joint pain being the most common. Interventions such as the provision of food supplies, transportation, and consistent counseling on alcohol consumption to patients at initiation treatment facilities may contribute to a reduction in the rate of occurrence of AEs.

Adherence to severe malaria treatment guidelines in children at a Ugandan regional hospital: a baseline assessment for a malaria treatment quality improvement project

BackgroundMalaria is one of the most common causes of hospital admission and death in children under the age of five. The World Health Organization (WHO) has issued guidelines for the identification and treatment of severe malaria. Evidence has shown that adherence to standardized malaria treatment protocols improves outcomes. As a baseline assessment in preparation for a malaria treatment quality improvement project, this study aimed to determine adherence to the WHO severe malaria treatment guidelines in children at a Ugandan Regional Referral Hospital.MethodsA retrospective review was performed on a convenience sample of children discharged between June 2021 and March 2022 from the Mbale Regional Referral Hospital Paediatrics Ward with a diagnosis of severe malaria. Data were collected using a standardized case report form. Demographics, presenting symptoms, laboratory results, treatments, length of stay, and mortality were extracted. Comparison of treatments received to items recommended in the WHO guidelines was undertaken to determine adherence.Results147 patients were included. The median age was 5 years (IQR 2–7 years), and 55% were male. The most common features of severe malaria were haemoglobinuria (49%), haemoglobin < 5 mg/dL (34%), and altered mentation (24%). Median hospital length of stay was 3 days (IQR 2–4 days), and the mortality rate was 27% (n = 40). Overall adherence to all aspects of the WHO severe malaria guidelines was achieved in 3% (n = 4) of patients. The most common areas of deficiency were not testing to confirm malaria diagnosis (34%) and inadequate administration of artesunate (82%). Fewer than the three recommended doses of artesunate occurred in 22% of patients. Additionally, a delay in the administration of the second dose occurred in 67% (n = 78) and in the third dose in 77% (n = 71) of patients. While the recommended time between doses is 12 h, the median interval between dose one and dose two was 15 h (12–20) and the median interval from dose two to dose three was 17 h (14–25).ConclusionsCurrent adherence to severe malaria treatment guidelines in children at this Ugandan regional referral hospital is poor, but this study has identified target areas for improvement.

Cost-effectiveness analysis of the multi-strategy WHO emergency care toolkit in regional referral hospitals in Uganda.

Low- and middle-income countries bear a disproportionate amount of the global burden of disease from emergency conditions. To improve the provision of emergency care in low-resource settings, a multifaceted World Health Organization (WHO) intervention introduced a toolkit including Basic Emergency Care training, resuscitation area guidelines, a trauma registry, a trauma checklist, and triage tool in two public hospital sites in Uganda. While introduction of the toolkit revealed a large reduction in the case fatality rate of patients, little is known about the cost-effectiveness and affordability. We analysed the cost-effectiveness of the toolkit and conducted a budget analysis to estimate the impact of scale up to all regional referral hospitals for the national level. A decision tree model was constructed to assess pre- and post-intervention groups from a societal perspective. Data regarding mortality were drawn from WHO quality improvement reports captured at two public hospitals in Uganda from 2016-2017. Cost data were drawn from project budgets and included direct costs of the implementation of the intervention, and direct costs of clinical care for patients with disability. Development costs were not included. Parameter uncertainty was assessed using both deterministic and probabilistic sensitivity analyses. Our model estimated the incremental cost-effectiveness of implementing the WHO emergency care toolkit measuring all costs and outcomes as disability-adjusted life-years (DALYs) over a lifetime, discounting both costs and outcomes at 3.5%. Implementation of the WHO Toolkit averted 1,498 DALYs when compared to standard care over a one-year time horizon. The initial investment of $5,873 saved 34 lives (637 life years) and avoided $1,670,689 in downstream societal costs, resulted in a negative incremental cost-effectiveness ratio, dominating the comparator scenario of no intervention. This would increase to saving 884 lives and 25,236 DALYs annually with national scale up. If scaled to a national level the total intervention cost over period of five years would be $4,562,588 or a 0.09% increase of the total health budget for Uganda. The economic gains are estimated to be $29,880,949 USD, the equivalent of a 655% return on investment. The model was most sensitive to average annual cash income, discount rate and frequency survivor is a road-traffic incident survivor, but was robust for all other parameters. Improving emergency care using the WHO Toolkit produces a cost-savings in a low-resource setting such as Uganda. In alignment with the growing body of literature highlighting the value of systematizing emergency care, our findings suggest the toolkit could be an efficient approach to strengthening emergency care systems.

Evaluation of a tailored epilepsy training program for healthcare providers in Uganda

ObjectiveThis study evaluated an epilepsy training program for healthcare workers that was designed to improve their knowledge of epilepsy, its treatment, and its psychosocial effects. MethodsThis single group, before and after survey was conducted in three regional referral hospitals in Uganda. Healthcare workers participated in a 3-day epilepsy training program and were assessed immediately prior to and following the program using a 39-item epilepsy knowledge questionnaire. Pretest to posttest changes and acceptability ratings were analyzed. ResultsTwenty healthcare workers from each of our three study hospitals (N = 60) participated in the study. The average age of the participants was 39.9 years (SD = 9.6). Female participants constituted 45% of the study population. There was a significant improvement in the knowledge of healthcare workers about epilepsy following the training (t = 7.15, p < 0.001). Improvement was seen across the three sub-scores of general knowledge about epilepsy, assessment and diagnosis of epilepsy, and management of epilepsy. Subgroup analysis showed that both high and low baseline scorers showed significant training gains. ConclusionsThe study suggested that our training program was effective in improving the knowledge of health workers about epilepsy and that participants had favorable impressions of the program. Further work is needed to determine if the knowledge is retained over time and if the change in knowledge translates into a change in clinical practice.

Outcomes at Discharge of Pediatric Traumatic Brain Injury (pTBI) in Western Uganda: a Prospective Cohort Study

Background: The objective of this study was to describe pediatric TBI patients presenting to one regional referral hospital in Uganda and identify factors that contribute to unfavorable outcomes.&#x0D; Methods: This study was a prospective, observational cohort study conducted at Mbarara Regional Referral Hospital (MRRH). Favorable outcomes were defined as any patient who was either discharged from the hospital or had a Glasgow Outcome Score (GOS) greater or equal to four. Unfavorable outcomes were defined as any patient who died or had a GOS of three or less. Logistic regression was used to determine the factors significantly associated with unfavorable outcomes.&#x0D; Results: A total of 560 pediatric TBI patients were included in this study with males making up 65.5% (n=367) of all patients. The main etiology was Road Traffic Accidents (RTA) (n=372, 66.4%) with the majority being injured as pedestrians (n=271, 48.4%). Unfavorable outcomes were associated with bilaterally abnormal pupils (OR 22.39, 2.98-168.11 CI, p-value 0.003), incontinence (OR 19.01, 5.37-67.33 CI, p-value &lt;0.001), need for ICU care (OR 12.17, 5.47-27.08 CI, p-value &lt;0.001), and a severe Glascow Coma Scale (GCS) on admission (OR 11.25, 4.01-31.58 CI, p-value &lt;0.001).&#x0D; Conclusion: Demographic characteristics reflected trends seen around the world and highlighted that RTA, specifically involving pediatric patients as pedestrians, is a major driver of pTBI cases. TBI severity on presentation correlated with unfavorable outcomes reinforcing the need for rapid triage protocols and access to the necessary human and physical resources to appropriately manage pTBI.

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial.

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda. Randomized clinical trial. Regional referral hospital in Uganda. Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019. Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24). The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications. Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection. In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.