Regional Referral Hospital In Uganda Research Articles

Burden of Heart Diseases in Children Attending Cardiology Clinic in a Regional Referral Hospital in Uganda

nbsp nbsp Introduction Patterns and prevalence of heart diseases are different between the high income countries and low income countries Acquired heart diseases like RHD cardiomyopathies pericarditis are still a public health burden while congenital heart diseases still carry a poor outcome among children The aim of this study was to report the burden and pattern of heart diseases in a semi urban referral hospital in Uganda nbsp nbsp Methods This was a prospective study in the pediatrics rsquo department at a regional referral hospital in Uganda over a period of months All children from birth up to years who were referred or presented at pediatric department from different areas in the region for an index cardiac evaluation and had their Transthoraxic echo done were included in the study These children were enrolled and followed up in the cardiology clinic for chronic care Those who did not turn up for their expected reviews were followed up with phone calls to find out their outcome nbsp nbsp Results Two hundred and forty children were screened during period and had abnormal echocardiological findings More females than males were had abnormal Echos at VSD were the commonest acyanotic heart disease followed by PDA at and respectively TOF was highest at followed by Truncus arteriosus at Mean age at diagnosis of congenital heart disease was months SD RHD was the commonest at of the acquired heart diseases Sixty three percent of children needed and were referred to the national cardiac centre Only managed to go to the cardiac centre only got surgical intervention of the children died while were lost to follow up nbsp nbsp Conclusion There is a high burden of heart diseases in our setting with limited access to interventional services nbsp

MP86-15 EFFECTS OF GROUP REHABILITATION UPON WOMEN UNDERGOING SURGERY FOR OBSTETRIC FISTULA

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Quality of Life and Shared Decision Making V1 Apr 2017MP86-15 EFFECTS OF GROUP REHABILITATION UPON WOMEN UNDERGOING SURGERY FOR OBSTETRIC FISTULA Pooja Parameshwar, Musa Kayondo, A. Lenore Ackerman, Jennifer Anger, and Christopher Tarnay Pooja ParameshwarPooja Parameshwar More articles by this author , Musa KayondoMusa Kayondo More articles by this author , A. Lenore AckermanA. Lenore Ackerman More articles by this author , Jennifer AngerJennifer Anger More articles by this author , and Christopher TarnayChristopher Tarnay More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2698AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Obstetric fistula due to prolonged obstructed labor is a significant public health concern in the developing world. Fistula patients experience chronically elevated levels of social isolation, stigmatization, and depression. In this qualitative study, we aimed to evaluate the experience of group rehabilitation during postoperative recovery in the setting of a “fistula camp” upon women seeking surgical care for fistula and related birth injuries. As this population is marginalized and ostracized, we predicted that group rehabilitation might be particularly germane. METHODS Study participants were women who received surgical care for obstetric fistula and high-grade perineal lacerations at the Mbarara Regional Referral Hospital in Uganda during 2 fistula camps in 2015 and 2016. Using semi-structured interviews, we sought to characterize the lived experiences of these women and their feelings surrounding their medical and surgical care in the setting of a group-based rehabilitative fistula camp. Interviews were conducted via translators who spoke the native dialects. Data was transcribed and analyzed using grounded theory methods, as described by Charmaz. We also directly observed women during their stay and recorded the frequency and types of interpersonal behaviors and interactions. RESULTS Twenty-six women participated in the interviews. Themes of social isolation, depression, shame, and stress were present in women's testimonials of their experiences prior to fistula camp arrival (see Table). When discussing experiences during and after fistula camp stay, themes of social support and hopefulness emerged. Behaviors and interactions indicating social integration with bond formation and social support within the fistula ward were observed. CONCLUSIONS Exposure to other women who had obstetric fistula was of therapeutic benefit to women with these same conditions. We found that the impact of shared experience amongst the women played a critical role in their understanding, perception, and outlook towards their condition and their hope for recovery. A group-based model of postoperative care that integrates physical and psychosocial healing may be highly effective for this population. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1162 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Pooja Parameshwar More articles by this author Musa Kayondo More articles by this author A. Lenore Ackerman More articles by this author Jennifer Anger More articles by this author Christopher Tarnay More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Neonatal resuscitation training for midwives in Uganda: Strengthening skill and knowledge retention

The objective of this project was to improve birth outcomes for babies in a regional referral hospital in Uganda by strengthening factors that influence the retention and application of neonatal resuscitation skills. Initial training in neonatal resuscitation is not enough on its own. In order to better understand the gap between training and effective practice, an evaluation of a neonatal resuscitation program was carried out. This included practical skill testing of local midwives using a neonatal resuscitation doll pre- and post-training, as well as follow up testing at 1 month and 12 months, followed by focus groups and interviews. Test scores revealed that participants’ knowledge grew significantly immediately following the workshop, and remained high after 1 month, but fell by 12 months post-training. Interviews with hospital staff revealed a number of facilitators and barriers to practice, namely knowledge retention and skill application. The most important barrier identified is the lack of refresher training post-workshop. Importantly, the findings demonstrated a need not for refresher training alone, but for improved organizational and administrative support for the newly assigned trainers.

Epidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital.

The unmet surgical need, specifically neurosurgical need, in Uganda is significant, yet only 2 public hospitals currently perform neurosurgery in the country. This study examines the epidemiology and outcomes of neurosurgical conditions presenting to 1 of 12 regional referral hospitals in Uganda, in an effort to understand the neurosurgical needs of this population. The study was conducted at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. Demographics, clinical characteristics, and outcomes were retrospectively collected for all patients who presented to MRRH with a neurosurgical condition between January 2012 and September2015. During the study period, 1854 patients presented to MRRH with a neurosurgical condition. More than half of the patients were between 19 and 40 years old, and the majority were males (76.1%). The overall median length of stay was 5 days (interquartile range: 2.5-10). The majority of admissions were due to trauma (87%), with almost 60% due to road traffic incidents. The overall mortality rate was 12.8%. A multivariable Cox proportional hazards model revealed that age, closed head injury, and admission Glasgow Coma Scale have a strong positive correlation with mortality while getting a diagnostic image and neurosurgical procedure were negatively correlated with mortality. Traumatic brain injury represented the majority of neurosurgical admissions at MRRH, disproportionately affecting young males. Age, closed head injury, admission Glasgow Coma Scale, getting a diagnostic image, and neurosurgical procedure were all independent predictors of mortality. Resource appropriate interventions throughout the health system are needed to meet the demand and improve outcomes.

Patterns and Short Term Outcomes of Chest Injuries at Mbarara Regional Referral Hospital in Uganda

Background: This study was conducted to establish the causes, injury patterns and short-term outcomes of chest injuries at Mbarara Regional Referral Hospital. Methods: This was a prospective study involving chest injury patients admitted to Mbarara Regional Referral Hospital (MRRH) for a period of one year from April 2014 to 31st March 2015. Results: A total of 71 chest injury patients were studied. Males (91.6%) were the majority and the ages ranged from 8 to 76 years (mean 32.9 years (+/- 14.0). Majority of the patients (57.7%) sustained blunt injury. RTA was the most common cause of injury, affecting 49.3%.The commonest injury patterns were chest wall injuries and lung and pleural injuries accounting for 69.0% and 64.8 respectively. Rib fractures were the commonest chest wall injury (71.4%) while hemopneumothorax was the commonest (34.9%) finding among those with lung and pleural injury. Associated injuries were found in 64.2% and out of these, abdominal injuries were the commonest extra thoracic injury (39.1%) followed by head injury(37.0%),cuts and lacerations(37%) andfractures (28.3%).The commonest abdominal organs injured were spleen(44.4%), liver (27.8%) and stomach (16.7%). Majority of the patients had thoracostomy (47.9%) while 33.8% had non surgical treatment. Laparotomy and thoracotomy were done in 11(15.5%) and 3 (4.2%) of the patients respectively. Complications occurred in 20(28.2%) and the commonest complication was pneumonia 6 (30%).The mean length of stay was 7.14 days, SD=±6.1) and the mortality was 16.9%.The significant determinants of mortality were associated injuries (X2=4.57, F.E=0.046), complications (X2=36.82, F.E=0.000) and severe head injury (X2=13.85, F.E=0.001). Conclusion: The causes, patterns and short-term outcomes of this study are similar to those observed in other developing countries. Chest injury in our setting causes high mortality and measures to reduce road traffic accidents are urgently required.Key words: Chest injury, pattern, outcomes

Prevalence and correlates of MRSA and MSSA nasal carriage at a Ugandan regional referral hospital.

Despite increasing antimicrobial resistance globally, data are lacking on prevalence and factors associated with Staphylococcus aureus (SA) and MRSA carriage in resource-limited settings. To determine the prevalence of SA and MRSA nasal carriage and factors associated with carriage among Ugandan regional referral hospital patients. We enrolled a cross-section of 500 adults, sampling anterior nares for SA and MRSA carriage using Cepheid Xpert SA Nasal Complete. Mean age was 37 years; 321 (64%) were female and 166 (33%) were HIV infected. Overall, 316 (63%) reported risk factors for invasive SA infection; 368 (74%) reported current antibiotic use. SA was detected in 29% and MRSA in 2.8%. MRSA and MSSA carriers were less likely than SA non-carriers to be female (50% and 56% versus 68%, P = 0.03) or to have recently used β-lactam antibiotics (43% and 65% versus 73%, P = 0.01). MRSA carriers were more likely to have open wounds than MSSA carriers and SA non-carriers (71% versus 27% and 40%, P = 0.001) and contact with pigs (21% versus 2% and 6%, P = 0.008). MRSA carriage ranged from 0% of HIV clinic participants to 8% of inpatient surgical ward participants ( P = 0.01). In multivariable logistic regression analysis, male sex was independently associated with SA carriage (OR 1.68, 95% CI 1.12-2.53, P = 0.01) and recent β-lactam antibiotic use was associated with reduced odds of SA carriage (OR 0.61, 95% CI 0.38-0.97, P = 0.04). MRSA nasal carriage prevalence was low and associated with pig contact, open wounds and surgical ward admission, but not with HIV infection.

Methemoglobin and nitric oxide therapy in Ugandan children hospitalized for febrile illness: results from a prospective cohort study and randomized double-blind placebo-controlled trial.

BackgroundExposure of red blood cells to oxidants increases production of methemoglobin (MHb) resulting in impaired oxygen delivery to tissues. There are no reliable estimates of methemoglobinemia in low resource clinical settings. Our objectives were to: i) evaluate risk factors for methemoglobinemia in Ugandan children hospitalized with fever (study 1); and ii) investigate MHb responses in critically ill Ugandan children with severe malaria treated with inhaled nitric oxide (iNO), an oxidant that induces MHb in a dose-dependent manner (study 2).MethodsTwo prospective studies were conducted at Jinja Regional Referral Hospital in Uganda between 2011 and 2013. Study 1, a prospective cohort study of children admitted to hospital with fever (fever cohort, n = 2089 children 2 months to 5 years). Study 2, a randomized double-blind placebo-controlled parallel arm trial of room air placebo vs. 80 ppm iNO as an adjunctive therapy for children with severe malaria (RCT, n = 180 children 1–10 years receiving intravenous artesunate and 72 h of study gas). The primary outcomes were: i) masimo pulse co-oximetry elevated MHb levels at admission (>2 %, fever cohort); ii) four hourly MHb levels in the RCT.ResultsIn the fever cohort, 34 % of children admitted with fever had elevated MHb at admission. Children with a history of vomiting, delayed capillary refill, elevated lactate, severe anemia, malaria, or hemoglobinopathies had increased odds of methemoglobinemia (p < 0.05 in a multivariate model). MHb levels at admission were higher in children who died (n = 89) compared to those who survived (n = 1964), p = 0.008. Among children enrolled in the iNO RCT, MHb levels typically plateaued within 12–24 h of starting study gas. MHb levels were higher in children receiving iNO compared to placebo, and MHb > 10 % occurred in 5.7 % of children receiving iNO. There were no differences in rates of study gas discontinuation between trial arms.ConclusionsHospitalized children with evidence of impaired oxygen delivery, metabolic acidosis, anemia, or malaria were at risk of methemoglobinemia. However, we demonstrated high-dose iNO could be safely administered to critically ill children with severe malaria with appropriate MHb monitoring.Trial registrationClinicalTrials.gov Identifier: NCT01255215 (Date registered: December 5, 2010).

164 Evaluation of Trauma Patient Presentations and Outcomes at a Ugandan Regional Referral Hospital

164 Evaluation of Trauma Patient Presentations and Outcomes at a Ugandan Regional Referral Hospital

The Quality and Utility of Surgical and Anesthetic Data at a Ugandan Regional Referral Hospital

There are little primary data available on the delivery or quality of surgical treatment in rural sub-Saharan African hospitals. To initiate a quality improvement system, we characterized the existing data capture at a Ugandan Regional Referral Hospital. We examined the surgical ward admission (January 2008-December/2011) and operating theater logbooks (January 2010-July 2011) at Mbarara Regional Referral Hospital. There were 6346 admissions recorded over three years. The mean patient age was 31.4±22.3years; 29.8% (n=1888) of admissions were children. Leading causes of admission were general surgical problems (n=3050, 48.1%), trauma (n=2041, 32.2%), oncology (n=718, 11.3%) and congenital condition (n=193, 3.0%). Laparotomy (n=468, 35.3%), incision and drainage (n=188, 14.2%) and hernia repair (n=90, 6.8%) were the most common surgical procedures. Of 1325 operative patients, 994 (75%) had an ASA I-II score. Of patients undergoing 810 procedures booked as non-elective, 583 (72%) had an ASA "E" rating. Records of 41.3% (n-403/975) of patients age 5 years or older undergoing non-obstetric operations were missing from the ward logbook. Missing patients were younger (25 [13,40] versus 30 [18,46] years, p=0.002) and had higher ASA scores (ASA III-V 29.0% versus 18.9%, p<0.001) than patients recorded in the logbbook; there was no diffence in gender (male 62.8% versus 67.0%, p=0.20). The hospital records system measures surgical care, but improved data capture is needed to determine outcomes with sufficient accuracy to guide and record expansion of surgical capacity.

Retrospective Descriptive Study of an Intensive Care Unit at a Ugandan Regional Referral Hospital.

We describe delivery and outcomes of critical care at Mbarara Regional Referral Hospital, a Ugandan secondary referral hospital serving a large, widely dispersed rural population. Retrospective observational study of ICU admissions was performed from January 2008 to December 2011. Of 431 admissions, 239 (55.4%) were female, and 142 (33.2%) were children (<18years). The median length of stay was 2 (IQR 1-4) days, with 365 patients (85%) staying less than 8days. Indications for admission were surgical 49.3% (n=213), medical/pediatric 27.4% (n=118), or obstetrical/gynecological 22.3% (n=96). The overall mortality rate was 37.6% (162/431) [adults 39.3% (n=113/287), children 33.5% (n=48/143), unspecified age 100% (n=1/1)]. Of the 162 deaths, 76 (46.9%) occurred on the first, 20 (12.3%) on the second, 23 (14.2%) on the third, and 43 (26.5%) on a subsequent day of admission. Mortality rates for common diagnoses were surgical abdomen 31.9% (n=29/91), trauma 45.5% (n=30/66), head trauma 59.6% (n=28/47), and poisoning 28.6% (n=10/35). The rate of mechanical ventilation was 49.7% (n=214/431). The mortality rate of ventilated patients was 73.5% (n=119/224). The multivariate odd ratio estimates of mortality were significant for ventilation [aOR 6.15 (95% CI 3.83-9.87), p<0.0001] and for length of stay beyond seven days [aOR 0.37 (95% CI 0.19-0.70), p=0.0021], but not significant for decade of age [aOR 1.06 (95% CI 0.94-1.20), p=0.33], gender [aOR 0.61(95% CI 0.38-0.99), p=0.07], or diagnosis type [medical vs. surgical aOR 1.08 (95% CI 0. 63-1.84), medical vs. obstetric/gynecology aOR 0.73 (95% CI 0.37-1.43), p=0.49]. The ICU predominantly functions as an acute care unit for critically ill young patients, with most deaths occurring within the first 48h of admission. Expansion of critical care capacity in low-income countries should be accompanied by measurement of the nature and impact of this intervention.

Barriers and facilitators of surgical care in rural Uganda: a mixed methods study

BackgroundSurgical care delivery is poorly understood in resource-limited settings. To effectively move toward universal health coverage, there is a critical need to understand surgical care delivery in developing countries. This study aims to identify the barriers and facilitators of surgical care delivery at Soroti Regional Referral Hospital in Uganda. MethodsIn this mixed methods study, we (1) applied the Surgeons OverSeas’ Personnel, Infrastructure, Procedures, Equipment, and Supplies tool to assess surgical capacity; (2) retrospectively reviewed inpatient records; (3) conducted four semistructured focus group discussions with 18 purposively sampled providers involved in perioperative care; and (4) observed the perioperative process of care using a time and motion approach. Descriptive statistics were generated from quantitative data. Qualitative data were thematically analyzed. ResultsThe Personnel, Infrastructure, Procedures, Equipment, and Supplies survey revealed severe deficiencies in workforce (P-score = 14) and infrastructure (I-score = 5). Equipment, supplies, and procedures were generally available. Male and female wards were overbooked 83% and 60% of the time, respectively. Providers identified lack of space, patient overload, and superfluous patients' attendants as barriers to surgical care. Workforce challenges were tackled using teamwork and task sharing. Inadequate equipment and processes were addressed using improvisations. All observed subjects (n = 31) received interventions. The median decision-to-intervention time was 2.5 h (Interquartile Range [IQR], 0.4, 21.4). However, 48% of subjects experienced delays. Median decision-to-intervention delay was 14.8 h (IQR, 0.9, 26.6). ConclusionsDespite severe workforce and physical infrastructural deficiencies at Soroti Regional Referral Hospital, providers are adjusting and innovating to deliver surgical care.

Host Biomarkers Are Associated With Response to Therapy and Long-Term Mortality in Pediatric Severe Malaria.

Background. Host responses to infection are critical determinants of disease severity and clinical outcome. The development of tools to risk stratify children with malaria is needed to identify children most likely to benefit from targeted interventions.Methods. This study investigated the kinetics of candidate biomarkers of mortality associated with endothelial activation and dysfunction (angiopoietin-2 [Ang-2], soluble FMS-like tyrosine kinase-1 [sFlt-1], and soluble intercellular adhesion molecule-1 [sICAM-1]) and inflammation (10 kDa interferon γ-induced protein [CXCL10/IP-10] and soluble triggering receptor expressed on myeloid cells-1 [sTREM-1]) in the context of a randomized, double-blind, placebo-controlled, parallel-arm trial evaluating inhaled nitric oxide versus placebo as adjunctive therapy to parenteral artesunate for severe malaria. One hundred eighty children aged 1–10 years were enrolled at Jinja Regional Referral Hospital in Uganda and followed for up to 6 months.Results. There were no differences between the 2 study arms in the rate of biomarker recovery. Median levels of Ang-2, CXCL10, and sFlt-1 were higher at admission in children who died in-hospital (n = 15 of 180; P < .001, P = .027, and P = .004, respectively). Elevated levels of Ang-2, sTREM-1, CXCL10, and sICAM-1 were associated with prolonged clinical recovery times in survivors. The Ang-2 levels were also associated with postdischarge mortality (P < .0001). No biomarkers were associated with neurodisability.Conclusions. Persistent endothelial activation and dysfunction predict survival in children admitted with severe malaria.

Outcomes of patients with severe sepsis after the first 6 hours of resuscitation at a regional referral hospital in Uganda

IntroductionThe optimal resuscitation strategy for patients with severe sepsis in resource-limited settings is unknown. Therefore, we determined the association between intravenous fluids, changes in vital signs and lactate after the first 6 hours of resuscitation from severe sepsis, and in-hospital mortality at a hospital in Uganda. Materials and methodsWe enrolled patients admitted with severe sepsis to Mbarara Regional Referral Hospital and obtained vital signs and point-of-care blood lactate concentration at admission and after 6 hours of resuscitation. We used logistic regression to determine predictors of in-hospital mortality. ResultsWe enrolled 218 patients and had 6 hour postresuscitation data for 202 patients. The median (interquartile range) age was 35 (26-50) years, 49% of patients were female, and 57% were HIV infected. The in-hospital mortality was 32% and was associated with admission Glasgow Coma Score (adjusted odds ratio [aOR], 0.749; 95% confidence interval [CI], 0.642-0.875; P < .001), mid-upper arm circumference (aOR, 0.876; 95% CI, 0.797-0.964; P = .007), and 6-hour systolic blood pressure (aOR, 0.979; 95% CI, 0.963-0.995; P = .009) but not lactate clearance of 10% or greater (aOR, 1.2; 95% CI, 0.46-3.10; P = .73). ConclusionsIn patients with severe sepsis in Uganda, obtundation and wasting were more closely associated with in-hospital mortality than lactate clearance of 10% or greater.

Implementation of the WHO Surgical Safety Checklist and surgical swab and instrument counts at a regional referral hospital in Uganda - a quality improvement project.

The World Health Organization (WHO) Surgical Safety Checklist is a cost-effective tool that has been shown to improve patient safety. We explored the applicability and effectiveness of quality improvement methodology to implement the WHO checklist and surgical counts at Mbarara Regional Referral Hospital in Uganda between October 2012 and September 2013. Compliance rates were evaluated prospectively and monthly structured feedback sessions were held. Checklist and surgical count compliance rates increased from a baseline median (IQR [range]) of 29.5% (0-63.5 [0-67.0]) to 85.0% (82.8-87.5 [79.0-93.0]) and from 25.5% (0-52.5 [0-60.0]) to 83.0% (80.8-85.5 [69.0-89.0]), respectively. The mean all-or-none completion rate of the checklist was 69.3% (SD 7.7, 95% CI [64.8-73.9]). Use of the checklist was associated with performance of surgical counts (p value < 0.001; r(2) = 0.91). Pareto analysis showed that understaffing, malfunctioning and lack of equipment were the main challenges. A carefully designed quality improvement project, including stepwise incremental change and standardisation of practice, can be an effective way of improving clinical practice in low-income settings.

EMF4 Characterization of Emergency Presentations at Regional Referral Hospital in a Low-Income Country

Emergency care remains largely underdeveloped and underfunded in low-income countries. There is little information about the epidemiology of emergency presentations in these countries, which leaves educators and policy makers with little guidance when developing educational programs and allocating resources toward emergency care. Furthermore, lack of pre-intervention outcome data complicates assessment of the impact that newly introduced emergency care programs have on important patient oriented outcomes. This study documents the epidemiology and outcome of patients with emergent illnesses and injuries at a Ugandan Regional Referral Hospital. This was a prospective cohort of acutely ill and injured patients presenting for care between November 1, 2014 and February 28, 2015 at Masaka Regional Referral Hospital in central Uganda. A database of emergent patient visits was created and data was collected on all patients presenting to the hospital emergency department and on all patients under twelve years of age who reported to the out-patient clinic. A standardized protocol that had previously been developed in Uganda was used to follow-up all patients three days after their index visit. Patients who remained in the hospital three days after presentation were followed up on the ward. Those who were discharged initially or were discharged from ward before the third day had follow-up attempted via phone call. A total of 8,549 patient presentations occurred during the study period, of which 4,554 were triaged to the emergency department (ED). Of patients triaged to the ED 18.5% were under 5 years, 14.3% were between 5-18, and 7.9% were over 65 years old. Fifty patients (0.6%) either expired in the ED or were dead on arrival. Providers tested 25.8% of ED patients for malaria (5.5% were positive). Less than 1% of all patients were tested for HIV. Trauma accounted for 22.9% of all ED visits and 63.6% of traumatic deaths (21 of 33) occurred in the ED. Three-day mortality for the ED cohort was 3.5% for all patients and 3.2% for trauma patients. Three-day mortality for children under five was 3.1%. Three-day follow-up rates improved from 53.8% to 72.8% over the first four months of the program. This regional referral hospital emergently manages a mixture of communicable and non-communicable diseases. There is a very high acuity as evidenced by in-ED mortality rate and three-day mortality rate, but overall mortality rate was lower than expected. Using a standardized protocol allowed for three-day follow-up in approximately 70% of patients over the study period.

Surgical Diagnosis and Procedure Codes for Outcomes Research in a Ugandan Regional Referral Hospital: The Mbarara Experience

Liu, Charles; Riesel, Johanna N. MD; Twesigye, Deus MB, ChB; Mugyenyi, Godfrey MB, ChB; Ngonzi, Joseph N.J. MB, ChB, MMED; Sanyu, Frank; Ttendo, Stephen MB, ChB; Musinguzi, Nicholas; Mushagara, Rhina; Firth, Paul G. MB, ChB Author Information

Sublingual misoprostol versus intramuscular oxytocin for prevention of post-partum haemorrhage in Uganda: a randomised, controlled, non-inferiority trial

BackgroundPostpartum haemorrhage is a leading cause of maternal death in sub-Saharan Africa. Although WHO recommends use of oxytocin for prevention of postpartum haemorrhage, misoprostol is increasingly used owing to advantages in shelf life, ease of use, storage, and potential for sublingual administration. We assessed the comparative efficacy of oxytocin and sublingual misoprostol for prevention of postpartum haemorrhage during labour. MethodsWe did a double-dummy, non-inferiority, randomised, controlled trial from September 2012, to September 2013, at Mbarara Regional Referral Hospital in Uganda. We randomly assigned (1:1) women to receive misoprostol 600 μg sublingually or oxytocin 10 IU along with matching placebos. Patients and investigators giving treatment were both masked to treatment assignment. The primary outcome was postpartum haemorrhage (measured blood loss ≥500 mL within 24 h postpartum) with a non-inferiority margin of 6%. Secondary outcomes included measured blood loss of more than 1000 mL, mean blood loss at 1 h, 2 h, and 24 h postpartum, death, requirement of blood transfusion, haemoglobin change, and use of additional uterotonic drugs. We did the analyses in the intention-to-treat population. The trial was registered with ClinicalTrials.gov, number NCT01866241. FindingsWe included 1140 women: 570 (50%) assigned to misoprostol and 570 (50%) assigned to oxycotin. The primary outcome occurred in 163 (28·6%) participants in the misoprostol group versus 99 (17·4%) participants in the oxytocin group (relative risk [RR] 1·64, 95% CI 1·32–2·05, p<0·001. The lower 95% CI for the absolute difference was 6·44%, greater than our non-inferiority margin limit. Blood loss of more than 1000 mL occurred in 20 (3·6%) versus 15 (2·7%) participants (RR 1·33, 95% CI 0·69–2·58, p=0·391). 11 (1·9%) versus ten (1·8%) participants had severe postpartum haemorrhage at 1 h postpartum (RR 1·10, 95% CI 0·47–2·57, p=0·826). Mean measured blood loss was 341·5 mL (SD 206·2) versus 304·2 mL (SD 190·8; p=0·002) at 2 h postpartum and 484·7 mL (SD 213·3) versus 432·8 mL (SD 203·5; p<0·001) at 24 h. There were no significant differences between the groups for any other secondary outcomes. Participants in the misoprostol group more commonly had shivering (321 [56·4%] vs 168 [26·5%]; RR 1·91, 95% CI 1·65–2·21, p<0·001) and fever (53 [9·3%] vs 12 [2·1%]; RR 4·42, 95% CI 2·39–8·18, p<0·001). No maternal deaths or postpartum surgical interventions occurred in either group. InterpretationMisoprostol 600 μg is not non-inferior to oxytocin 10 IU for prevention of postpartum haemorrhage in active management of labour, supporting the preferential use of oxytocin when feasible. However—although our study was not powered to assess differences—similar rates of severe postpartum haemorrhage, haemoglobin change, and other clinically significant secondary outcomes seem to suggest that sublingual misoprostol might have a role for prevention of severe postpartum haemorrhage and other complications of postpartum haemorrhage in settings where oxytocin use is not feasible. Further research should focus on clarifying if and which subpopulations benefit most from use of oxytocin. FundingFather Bash Foundation and Divine Mercy Hospital.

Characteristics of acute heart failure hospitalizations in a general medical ward in Southwestern Uganda

Predictors of in-hospital mortality among acute heart failure (AHF) patients managed in general wards of sub-Saharan Africa are unknown, yet it poses enormous socioeconomic burden due to high prevalence and mortality, especially among young, economically productive individuals [1,2] and there are few specialized cardiology centers in the region [3]. Knowledge of the patients' course before the admission, during the in-hospital phase, and out of hospital follow-up, could aid in identifying patients at higher risk of mortality to whom focused intervention can be directed. We carried out a cohort study using medical records to describe the clinical characteristics and predictors of in-hospital mortality in adults hospitalized with acute heart failure in a general medical ward at Mbarara Regional Referral Hospital in Uganda, a publicly operated tertiary care hospital. Eligible patients were those hospitalized with acute de novo or decompensation of preexisting heart failure between February 1, 2013 and February 28, 2014.Mbarara University Institutional Review Board approved this study and waived the requirement for informed consent given that this was a retrospective study. A total of 516 black African patients were identified to have a diagnosis of heart failure at admission over the one year study period. Of these, 177 (34.3%) patient charts were not found for review and 65 patients were excluded because, after review, they were deemed not to have heart failure at admission. We analyzed data of the remaining 274 patients whose charts were available and who fulfilled a criterion for the diagnosis of acute heart failure at admission. The median age was 52 (IQR 35–67) years. Females constituted 69.7% (191) of the sample. The common chronic comorbidities were hypertension, human immunodeficiency virus (HIV), chronic kidney disease, and diabetes mellitus in 98 (35.8%), 31 (11.3%), 22 (8.0%), 20 (7.3%) patients respectively. One hundred fifty four (56.2%) patients had acute “de novo” heart failure while 120 (43.8%) patients had a prior diagnosis of heart failure. Among patients with a prior admission for heart failure, medication noncompliance, infections, and anemia were the precipitating factors for decompensation in 38 (31.7%), 32 (26.7%), and 22 (18.3%) respectively. In our study participants, the chronic medication prescriptions prior to admission were oral diuretics in 107 (39.1%), angiotensin converting enzyme inhibitors (ACEI) and/or angiotensin receptor blockers (ARB) in 70 (25.6%), and beta blockers in 57 (20.8%). During admission therapies prescribed included: intravenous furosemide and inotropic agents in 251 (91.6%) and 59 (21.5%) patients respectively. Of the oral drugs: digoxin, ACEI/ARBs, aspirin, and beta blocker were prescribed in 93 (33.9%), 93 (33.9%), 90 (32.9%), and 88 (32.1%) patients respectively. At discharge, the percentage prescription of all AHF drugs modestly improved when compared with the prescription levels at admission (Table 1). Table 1 Hospital course characteristics Our patients predominantly had reduced ejection fraction (LVEF ≤ 45%) and few with preserved ejection fraction (LVEF ≥ 45%), (mean LVEF 29.47% vs. 64.11%, p < 0.00001). At 12 months, the in-hospital mortality rate was 18.3% (50/274) whereas 206 (75.2%) patients were discharged after clinical improvement. A total of 14 (5.1%) patients were self-discharges, and 4 (1.5%) were referred to a higher level of care facility (Table 2). The overall median length of hospital stay for all patients was 5 (IQR, 3–9) days. The median length of hospitalization for those who died was 2 days (IQR, 0–6) compared to 6 days (IQR, 4–9) for those who survived to discharge (p = 0.0013). Concurrent infection (AOR, 2.48, 95% CI 1.106–5.596, p = 0.0027) was an independent predictor of longer hospital stay (>14 days). A total of 86 patients were readmitted within the 12 month study period and the 30 day readmission rate was 34.9% (30/86). The overall median days to re-hospitalization were 40 (IQR, 18–100) days. Table 2 In hospital outcomes. In the multivariate logistic regression analysis, being admitted with hypotension (AOR, 4.6, 95%CI 1.6–13.2, p = 0.005) and a reduced LVEF (AOR, 7.6, 95%CI 1.6–35.4, p = 0.010) were independent predictors of in-hospital mortality. After controlling for concurrent infection, hypotension remained a strong predictor of in-hospital mortality (AOR, 3.2, 95%CI 1.6–6.3, p = 0.0003). In this population, patients admitted to the general medical ward with acute heart failure commonly presented at a younger age, had a shorter length of hospital stay but a higher 12-month re-hospitalization rate and a higher in-hospital mortality rate than reported in US [4,5] and European [6–8] studies. The low rates of prescription/utilization of evidence based therapies could be the explanation for the observed high mortality and/or re-hospitalization rates. Further research to investigate factors that affect utilization/prescription of guideline based cardiovascular medication in this setting need urgent exploration.

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals, Uganda.

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases. To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes. A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010. The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73). Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.

Use of Colorimetric Culture Methods for Detection of Mycobacterium tuberculosis Complex Isolates from Sputum Samples in Resource-Limited Settings

Despite recent advances, tuberculosis (TB) diagnosis remains imperfect in resource-limited settings due to its complexity and costs, poor sensitivity of available tests, or long times to reporting. We present a report on the use of colorimetric methods, based on the detection of mycobacterial growth using colorimetric indicators, for the detection of Mycobacterium tuberculosis in sputum specimens. We evaluated the nitrate reductase assay (NRA), a modified NRA using para-nitrobenzoic acid (PNB) (NRAp), and the resazurin tube assay using PNB (RETAp) to differentiate tuberculous and nontuberculous mycobacteria. The performances were assessed at days 18 and 28 using mycobacterium growth indicator tube (MGIT) and Löwenstein-Jensen (LJ) medium culture methods as the reference standards. We enrolled 690 adults with suspected pulmonary tuberculosis from a regional referral hospital in Uganda between March 2010 and June 2011. At day 18, the sensitivities and specificities were 84.6% and 90.0% for the NRA, 84.1% and 92.6% for the NRAp, and 71.2% and 99.3% for the RETAp, respectively. At day 28, the sensitivity of the RETAp increased to 82.6%. Among smear-negative patients with suspected TB, sensitivities at day 28 were 64.7% for the NRA, 61.3% for the NRAp, and 50% for the RETAp. Contamination rates were found to be 5.4% for the NRA and 6.7% for the RETAp, compared with 22.1% for LJ medium culture and 20.4% for MGIT culture. The median times to positivity were 10, 7, and 25 days for colorimetric methods, MGIT culture, and LJ medium culture,respectively. Whereas the low specificity of the NRA/NRAp precludes it from being used for TB diagnosis, the RETAp might provide an alternative to LJ medium culture to decrease the time to culture results in resource-poor settings.