Journal of Kenya Assocation of Physicians

Describing medical consultations and finding common ground in Tororo Hospital, Eastern Uganda

L.N. Mukisa — 2024-11-08

Background: Patient-centeredness is essential to healthcare provision worldwide. Finding common ground between healthcare providers and their patients is an important component of patient-centered care, increasing patient satisfaction and adherence, leading to better patient outcomes. In Uganda, low levels of information provision and patient satisfaction with healthcare provision have been reported in Tororo District Hospital (TDH) compared with other public health facilities in the country.
Objective: The aim of this study was to assess the healthcare provider - patient interaction in the medical consultations, with the aim of establishing factors associated with finding common ground.
Methods: A descriptive cross-sectional study design was done, using quantitative methods. Data from adults attending the outpatient clinics was collected using an interviewer-administered structured questionnaire and analyzed using bivariate and multivariate logistic regression.
Results: Of the patients that attended TDH, a primary care facility, 59% attended as a first visit for their complaint and 82.5% did not know the name of their healthcare provider. The providers were mainly males (65.9%) and used the language that the patient understood (97.8%). The factors associated with finding common ground were: patient’s age between 25–54 years (p=0.002), patients with formal employment (p=0.005), married (p = 0.043), taking less than one hour to reach the health facility regardless of the means
of transport used (p=0.048), knowing the name of their healthcare provider (p=0.000) as well as the healthcare provider being male (p=0.000).
Conclusion: The level of finding common ground between healthcare providers and their patients in medical consultations in TDH was at 41.3%. Six patients or healthcare provider attributes were associated with finding common ground.

Antimicrobial resistance patterns among patients admitted with sepsis at a tertiary hospital in Uganda

E.N. Rugaatwa — 2024-11-08

Background: Antimicrobial Resistance (AMR) poses a significant global health challenge, associated with an estimated 4.95 million deaths and 1.27 million deaths directly attributable to it annually. There is a lack of routine surveillance of AMR in sepsis patients in many healthcare settings, especially in Low- and Middle-Income Countries (LMICs).
Objective: This study aimed to determine patient characteristics, and AMR profiles of bacterial isolates in sepsis at St. Francis Hospital Nsambya (SFH) in Uganda.
Methods: Between 1st August 2022 and 31st July 2023, we consecutively enrolled 157 adult participants with suspected or confirmed infection who fulfilled the q-SOFA criteria for sepsis. Collected demographic and clinical information and biological specimens (blood, urine, pus, throat secretions, CSF) for culture and susceptibility testing. The overall SOFA score was also calculated after getting all laboratory results. Descriptive statistics (median, interquartile range, frequencies, and percentages) and tabular antibiograms and
heat maps were used to describe the study findings.
Results: About 59.2% were female, with a median age of 64 (IQR=50-74). The median SOFA score was 4 (IQR = 2-6). 49.7% had diabetes, 79% had community-onset sepsis, and the most prevalent infection sites were the genito-urinary tract (33%), respiratory tract (30%), and skin and soft tissue (15%). Pre-hospital antibiotic exposure was present in 61.7% of the participants. Microbial growth was observed in 61.1%, majorly bacterial 89 (92.6%) and fungal 7 (7.4%). The growth rates were highest in throat swabs 14 (92.9%), urine 74
(68.9%), and pus 28 (71.4%). The most common isolated bacterial species (N=90) were E. coli (28.9%), K. pneumoniae (14.4%), and P. aeruginosa (10%). High resistance (>75-80%) to penicillins, ephalosporins, quinolones, tetracyclines, cotrimoxazole) was noted. “There was zero resistance to colistin, polymixin B, tigecycline, teicoplanin, and bacitracin. Average resistance to carbapenems stood at 24%, and 27% for both meropenem and imipenem. Vancomycin-resistant enterococcus was 50%.
Conclusions: In this study population, bacterial sepsis was the most predominant affecting majorly the middle aged and elderly with comorbidities. E. coli, K. pneumonia, P. aeruginosa, S. aureus, and E. faecalis were major causative bacterial species. There was high resistance to commonly used first line antibiotics and rising resistance to carbapenems and vancomycin. Routine AMR surveillance and ensuring antibiotics are used judiciously, guided by culture and susceptibility tests must be prioritized. Future research should investigate antimicrobial stewardship programs to reduce AMR. Funding for development of vaccine against E. coli should be looked into.

Cognitive decline in chronic disease

F. Ssali — 2024-11-08

Background: Cognitive decline in adult individuals on treatment for diabetes or hypertension or HIV can have significant impact on the functional status and quality of life of an individual in chronic care for non-communicable diseases like diabetes, systemic hypertension and even for communicable diseases like chronic HIV and the HBA1c. Blood pressure measurement and HIV-viral load assays are used as quality indicators in the management and prevention of complications from these diseases respectively and the cause of cognitive decline can be difficult to ascertain when these conditions coexist.
Case 1: A 71 year old woman developed unexpected cognitive decline on treatment for hypertensive heart disease controlled on telmisartan 80mg OD, bisoprolol 5mg OD, rosuvastatin 10mg OD, aspirin 75mg OD, Lasix 20mg once daily and on Antiretroviral Therapy (ART) with viral suppression <50 copies/mL. Her ART history had AZT/3TC/NVP, changed to ABC/3TC/NVP due to severe anaemia in 2004. She suffered from osteopenia and arm fractures from minor trauma. And after ART switch to ABC/3TC/DTG in 2020, she developed diabetes and ART was switched to RLT/ATVr. The brain CT imaging was non-diagnostic but MRI revealed focal gray mater lesions considered lacunar infarcts. The routine CSF analysis was normal, however had a CSF viral load of .415,092 copies/mL.
Case 2: A 55 year old man, on treatment for systemic hypertension, Type-2DM and chronic HIV, with excellent control for all the three conditions, developed unexpected cognitive loss with focal seizures and visual hallucinations. His treatment included gliclazide 80mg OD, empagliflozin 25mg OD, pioglitazone 30mg OD for DM, telmisartan/H (80/12.5) mg OD and S-Amlodipine 5mg OD for hypertension. His ART history included TDF/3TC/EFV as initial therapy, that was changed to ABC/3TC/DTG in September of 2021 due to raised creatinine but due to onset of diabetes in September 2023, the ART was switched to atazanavir/ritonavir plus raltegravir and he maintained viral suppression <50 copies/mL but in May 2024, he developed focal seizures, visual hallucinations and memory loss. The CSF examination was normal, except for a CSF Viral load of 27,849 copies/mL.
Discussion: Both of these patients had white mater MRI lesions, consistent with lacunar infarcts, with normal CSF chemistry and microscopy, however despite the excellent HIV-VL suppression in the peripheral blood, they had high CSF viral loads, with HIV drug resistance. They both attained complete cognitive recovery after a drug-resistance guided ART switch.
Conclusion: CNS-sequestration of HIV infection is a potentially reversible cause of cognitive loss among patients on ART with HIV viral suppression and it should be included in the clinical evaluation.

Dementia subtypes, cognitive decline and survival among older adults attending a memory clinic in Cape Town, South Africa: a retrospective study

M. Ssonko — 2024-11-08

Background: There are no published longitudinal studies from Africa of people with dementia seen in memory clinics.
Objective: The aim of this study was to determine the proportions of the different dementia subtypes, rates of cognitive decline, and predictors of survival in patients diagnosed with dementia and seen in a memory clinic.
Methods: Data were collected retrospectively from clinic records of patients aged ≥ 60 seen in the memory clinic at Groote Schuur Hospital, Cape Town, South Africa over a 10-year period. Diagnostic and Statistical Manual of Mental Disorders (DSM–5) criteria were used to identify patients with major neurocognitive disorders (dementia). Additional diagnostic criteria were used to determine the
specific subtypes of dementia. Linear regression analysis was used to determine crude rates of cognitive decline, expressed as Mini-Mental State Examination (MMSE) points lost per year. Changes in MMSE scores were derived using mixed effects modelling to curvilinear models of cognitive change, with time as the dependent variable. Multivariable cox survival analysis was used to determine factors at baseline that predicted mortality.
Results: Of the 165 patients who met inclusion criteria, 117 (70.9%) had major neurocognitive disorder due to Alzheimer’s Disease (AD), 24 (14.6%) Vascular Neurocognitive Disorder (VND), 6 (3.6%) Dementia with Lewy Bodies (DLB), 5 (3%) Parkinson Disease-associated Dementia (PDD), 3 (1.8%) fronto-temporal dementia, 4 (2.4%) mixed dementia and 6 (3.6%) other types of dementia. The average annual decline in MMSE points was 2.2 (DLB/PDD), 2.1 (AD) and 1.3 (VND). Cognitive scores at baseline were significantly lower in patients with 8 compared to 13 yea ars of educationnd in those with VND compared with AD. Factors associated with shorter survival included age at onset greater than 65 (HR = 1.82, 95% C.I. 1.11, 2.99, p = 0.017), lower baseline MMSE (HR = 1.05, 95% C.I. 1.01, 1.10, p = 0.029), Charlson’s comorbidity scores of 3 to 4 (HR = 1.88, 95% C.I. 1.14, 3.10, p = 0.014), scores of 5 or more (HR = 1.97, 95% C.I. 1.16, 3.34, p = 0.012) and DLB/PDD (HR = 3.07, 95% C.I. 1.50, 6.29, p = 0.002). Being female (HR = 0.59, 95% C.I.0.36, 0.95, p = 0.029) was associated with longer survival.
Conclusions: Knowledge of dementia subtypes, the rate and factors affecting cognitive decline and survival outcomes will help inform decisions about patient selection for potential future therapies and for planning dementia services in resource-poor settings.

Differential manifestation of Type 2 Diabetes in Black Africans and White Europeans with new-onset Type 2 Diabetes: advocating for African- specific diabetes treatment guidelines

D Kibirige — 2024-11-08

Background: Type 2 Diabetes (T2D) is characterised by marked heterogeneity in clinical presentation, progression, and therapeutic response to glucose-lowering therapies. Data comparing the phenotypic characteristics and atypical diabetes subtypes in native Black Africans and White populations with new-onset diabetes is limited.
Objective: This systematic review aimed to compare the phenotypic characteristics of native Black Africans and White Europeans with recently diagnosed T2D to inform African-specific diabetes management guidelines.
Methods: We searched Medline, EMBASE, CINAHL, Google Scholar, African Index Medicus, and Global Health for studies reporting information on phenotypic characteristics in Black Africans and White Europeans with recently diagnosed T2D. We also described three atypical diabetes subtypes largely described in patients of African ancestry.
Results: A total of 28 studies were included in the systematic review (14 studies conducted on 2,586 Black Africans in eight countries and 14 conducted on 279,621 White Europeans in nine countries). Compared with White Europeans, Black Africans had a lower pooled mean age (49.4±4.4 years vs. 61.3±2.7 years), Body Mass Index [BMI] (26.1±2.6 kg/m² vs. 31.4±1.1 kg/m²), and a higher pooled median glycated haemoglobin (9.0 [8.0-10.3] % vs. 7.1 [6.7-7.7] %). Ugandan and Tanzanian participants had lower markers of beta-cell function and insulin resistance when compared with four White European populations. We also report three atypical diabetes subtypes, i.e., lean T2D, ketosis-prone diabetes, and fibro calculous pancreatic diabetes, described widely in patients of African ancestry. These three subtypes exhibit distinct phenotypic features such as low markers of adiposity, metabolic syndrome, and pancreatic beta-cell secretory function.
Conclusion: These findings provide evidence of the ethnic differences in the manifestation of T2D (early onset of T2D at lower BMI levels with severe hyperglycaemia and predominance of beta-cell dysfunction in some African populations). This underscores the need to formulate African-specific approaches for managing and preventing T2D.

Drug-pathogen concordance and its association to mortality in hospitalized patients with Enterobacteriaceae bloodstream infections

S Fwoloshi — 2024-11-08

Background: Antibiotics are the mainstay of treatment in patients with bacteraemia. Drugpathogen concordance and its impact on mortality in Africa has not been extensively studied.
Objective: We sought to describe the concept of drug-pathogen concordance and determine if there was an association with mortality in patients with Enterobacteriaceae bacteraemia in the African context.
Methods: We analyzed data from MBIRA - a prospective cohort study conducted between 2020 and 2022 in hospitalized patients with Enterobacteriaceae bacteraemia in eight African countries. Antibiotic concordance was defined as administration of a drug with in vitro susceptibility, at the correct dose and route. Exposure of interest was empiric antibiotic concordance, 30-day mortality was the outcome. We used logistic regression for crude and adjusted effects and tested the final model for interaction by country income status. We used McNemar’s test to determine the difference in concordance between the empiric and definitive window.
Results: There was a total of 878 patients of all ages with Enterobacteriaceae bactraemia, of these, 787 (90%) received antibiotics in the empiric window. Antibiotic concordance in the empiric window was 44.3% (349/787), with less concordance in the empiric than the definitive window (difference -0.12 (95%CI: -1.15, -0.088: p<0.0001)). Before adjustment, there was suggestion of benefit among those that received concordant antibiotics (OR:0.80 (95%CI:0.59,1.08, p=0.14)). After adjustment, there was still no evidence of a difference in mortality between the two groups (aOR:1.05(95%CI:0.71,1.56; p=0.907). Strikingly, there was effect modification by country income (aOR:0.18 95% (0.05,0.66: p=0.009)) at the hospital in the upper-middle income setting, 1.20 (95%CI: 0.74,1.95: p=0.461 and (aOR:1.44;95% CI(0.67,3.07:p=0.348)) in the lower-middle/low income settings respectively.
Conclusion: Further studies considering confounders unique to the African context are needed to further unpack the relationship between empiric antibiotic concordance and mortality. Health leaders must consider factors beyond antibiotic use, in approaches to minimizing mortality associated with bacteraemia in African hospitals.
Public implication: As Anti-Microbial Stewardship programs (AMS) scale-up in resource-limited settings in sub Saharan Africa (SSA), they should consider the broader context of the role of antibiotics in reducing mortality for patients with bacteraemia. It may be worthwhile for researchers and policymakers to emphasize a holistic patient care approach in addition to AMR and antibiotics for patients with bacteraemia in these settings.

Enhancing cancer care through quality initiatives: The Uganda Cancer Institute experience with the quality oncology practice initiative

N. Bogere — 2024-11-08

Cancer care in Low- and Middle-Income Countries (LMICs) faces numerous challenges, such as limited resources, infrastructure constraints, and a shortage of specialized training. To address these challenges, innovative Quality Improvement (QI) approaches are required. The Quality Oncology Practice Initiative (QOPI) by the ASCO provides a framework for improving care quality through evidence-based standards. This article explores how QOPI has been adapted to the local context of the Uganda Cancer Institute (UCI) and highlights the importance of aligning international best practices with local health care realities to bridge disparities in care standards. The adaptation of the QOPI program at UCI commenced with a collaborative meeting with the ASCO-QOPI team in 2020. A tailored implementation plan was developed focusing on incorporating ASCO’s QOPI measures and additional metrics relevant to the Ugandan context, engaging multidisciplinary teams, and optimizing resource use by leveraging existing resources for data collection and analysis. The execution of the plan relied heavily on staff training, participatory data collection, and continuous quality improvement processes that utilized data-driven methodologies. A retrospective analysis of QOPI data of UCI from 2020 to 2023 shows significant improvements in oncology care quality, highlighted by an upward trend in QOPI assessment scores across various metrics. These reflect the journey of UCI toward aligning its oncology care practices with international standards despite facing significant challenges. UCI’s experience demonstrated the feasibility and impact of implementing international QI programs in LMICs. The success demonstrates that significant improvements in cancer care quality can be achieved in resource-constrained settings through adaptability, stakeholder engagement, and strategic resource optimization. UCI’s journey is a model for other LMICs seeking to raise their cancer care standards, demonstrating that QI is necessary and attainable worldwide.

Evidence based medical care of hospitalised older people – how this might be implemented in Sub-Saharan Africa

V. Naganathan — 2024-11-08

The health needs of frail older people are often complex. Models of hospital care that are designed to manage a single problem often fare poorly when faced with patients with multiple problems and functional limitations. The way that hospitals are structured and care is organised can result in significant improvements in the care of older people, with regards to managing illness, improving disability and maximizing independence at discharge. Hospitalisation can have particular risks for older patients and well-organised systems of care can help to mitigate these risks. (see Australian and New Zealand Society of Geriatric Medicine Position Statement on Geriatric Medicine services in and around General Hospitals at https://anzsgm. org/policy-advocacy/position-statements/).
There is high level evidence that Comprehensive Geriatric Assessment and Management (CGA) by multidisciplinary teams leads to better outcomes for hospitalised older people. In this presentation, Professor Vasi Naganathan will provide a summary of this evidence and then talk about how this evidence is applied in the day-to-day clinical care of older hospitalised patients in countries such as Australia and the UK. He will talk about some of the key features of CGA and show how it leads to better outcomes for older patients and has more wider benefits for the hospital system. Some of the features of the various inpatients models of care that have been developed to care for older people will be discussed. He will talk about how CGA models of care have been extended to not only patients under medical teams but also to older patients admitted under surgical teams. Specifically, he will discuss geriatrician liaison services to patients under the care of orthopaedic surgeons and a new model of care established at the hospital he works at where physician input has led to a decrease in hospital acquired complications in older patients under the care of vascular surgeons. Dr Michael Ssonko (Geriatrician based in Uganda) will then talk about how CGA could be implemented and operationalised in the local environment. It is possible for CGA to be delivered by a physician with expertise in Geriatric Medicine and a nurse with expertise in acute care of older people and Geriatric Medicine Syndromes such as delirium, polypharmacy, falls and multimorbidity. The role of the nurse would include linking patients appropriately with other health professionals from other disciplines such as physiotherapy, occupational therapy and social work to achieve more integrated care. He will also discuss potential inpatient integrated models of care to deliver CGA in the local setting.

Immuno-diagnosis of active tuberculosis

H Mayanja-Kizza — 2024-11-08

Background: Tuberculosis disease, caused by Mycobacterium tuberculosis (MTB) remains a major global health concern, causing millions of deaths annually.
Objective: The aim of this presentation is to discuss the potential of immuno-diagnosis for active tuberculosis (ATB) as a promising approach to address challenges associated with TB diagnosis.
Methods: Current TB diagnostic methods have limitations, and a point-of-care immuno-diagnostic test that can distinguish ATB from Latent Tuberculosis Infection (LTBI) and estimate the MTB body load could guide ATB management and prioritize LTB treatment at the community level. Immune-based POC tests offer advantages such as low invasiveness, simplicity, and cost-effectiveness. Potential approaches for MTB immune-diagnosis include serological diagnosis, investigation of cellmediated responses, immune metabolic markers, blood transcriptomic signatures, and immune profiling. Various body samples like blood, saliva, sputum, exudative fluids, and urine can be used to identify novel immune markers for ATB diagnosis.
Conclusions: Immuno-diagnosis holds promise for improving TB diagnosis, and ongoing research aims to develop user-friendly, sensitive, and specific tests for ATB and LTB management. This presentation will give an overview of the current progress in Mycobacterial tuberculosis immunodiagnosis.

Incidence of acute kidney injury and associated mortality among individuals with drug-susceptible tuberculosis in Uganda

G. Kansiime — 2024-11-08

Background: Although tuberculosis (TB) is associated with significant mortality and morbidity, its impact on kidney function is not well understood and is often attributed to anti-TB drugs.
Objectives: The study aimed to assess the incidence of Acute Kidney Injury (AKI) in the immediate post-TB diagnosis period in Uganda, a TB/HIV-endemic country in sub-Saharan Africa.
Methods: We included patients enrolled in an observational cohort study of adults diagnosed with drug-susceptible TB followed longitudinally. Adults (>18 years) without known kidney disease were enrolled between August 2022 and July 2023 at three regional hospitals serving 12.5% of the Ugandan population. Our primary outcome was the incidence of KDIGO-defined AKI within two weeks of TB diagnosis. Other outcomes included predictors of AKI and its association with 30-day survival.
Results: A total of 156 adults were included. The median (IQR) age was 39 (28-53) years, most were male (68.6%) and 49.4% had HIV. HIV-positive participants had a shorter time to TB diagnosis from symptom onset (21[7-30] days) compared to HIV-negative participants (60[23-90] days), p<0.001. The overall incidence of AKI was 33.3% (52/156), and not different between HIV and non-HIV
participants. Proteinuria or hematuria at enrollment was associated with higher odds of AKI (OR—2.68, 95%CI 1.09-6.70, p~0.033). AKI was associated with a significant risk of mortality (aHR—5.82, 95%CI 1.54-21.95, p=0.009) regardless of HIV status.
Conclusion: The incidence of AKI in the immediate post-TB diagnosis period is high regardless of HIV status and is associated with increased mortality risk. According to our study findings, monitoring kidney function should be routine among patients with TB, even before treatment initiation.

Optimizing detection and early management of acute kidney injury using trained caregivers on the infectious disease wards of Kiruddu National Referral Hospital

E Mulema — 2024-11-08

Background: Acute Kidney Injury (AKI) is a prevalent condition among hospitalized patients and a known cause of morbidity and mortality. AKI can be resolved in up to two-thirds of the patients with proper timely management. Current clinical practice rarely Urine Output (UO) monitoring since it is tedious. Due to limited human resources in Low and Middle-Income Countries (LMICs), informal active involvement of patient caregivers has proved beneficial. In this study, we used a Quality Improvement (QI) approach by training caregivers in UO monitoring to optimize the detection and early management of AKI through a task-shift model.
Methods: A cross-sectional study with a six-month retrospective data review of randomly sampled 121 patient files was done for AKI diagnosis and related outcomes among patients who were admitted on the Infectious Disease (ID) wards of Kiruddu National Referral Hospital (KNRH) to generate pre-intervention data. The same data was prospectively collected in a review of 119 patient files on the same wards for eight weeks during the implementation of the QI interventions. The QI interventions were implemented in two stages: (i) clinical staff education on AKI detection and early management, and (ii) training caregivers on UO monitoring respectively to generate trends in AKI diagnosis. We used Pearson’s chi-square test and Fisher’s exact test to determine trends in UO monitoring and the prevalence of diagnosed AKI during the pre-intervention phase and the two stages of QI intervention. Multilevel models using mixed effects logistic regression were used at a 5% significant level to estimate Odds Ratios [ORs] for hypothesized correlates of QI interventions.
Results: In the pre-intervention phase, 72 (60%) were females and their median age was 37 years (IQR; 28-47) while during the QI interventions, only 43 (36%) were females and their median age was 38 years (IQR: 29-48). In the pre-intervention phase, there was no record of UO monitoring and AKI was diagnosed in 12% of the records. In stage one of the QI intervention, UO monitoring increased to 12% and AKI was diagnosed in 25% of patients while in stage two UO monitoring increased to 62% and AKI diagnosed in 31%. Overall during the QI interventions, UO monitoring increased to 40% and AKI was detected in among 29% of the patients while mortality reduced from 40% at baseline to 13% (P value <0.001).
Conclusions: Involving trained patient caregivers in UO monitoring through a multicomponent quality improvement approach optimizes the detection and early management of AKI among patients on the ID wards of KNRH. This study detected a causal impact of the QI interventions on mortality and it is likely that the interventions played a role in the observed decrease in mortality.

Predicting viral load at six months after initiation of antiretroviral therapy in Lusaka district; A multilevel regression analysis

F Mupeta — 2024-11-08

Background: Zambia has made tremendous progress towards HIV epidemic control. In 2020, it become one of the first countries to attain the 90-90-90 UNAIDS targets. Expansion of ART services, a switch to dolutegravir-based 1st line and expanding VL testing platforms has been responsible for this success. To attain epidemic control, the ART programme needs to investigate the system-level factors affecting viral load suppression in Zambia.
Objective: This study aimed to investigate those factors.
Methods: This was a retrospective cross-section analytic study of PLHIV 6 months who enrolled on ART in Lusaka district between 2016 and 2020. Data was extracted from the SmartCare and analysed using Stata version 17. Data was analysed using mixed effects regression analysis.
Results: A total of 38 ART facilities with a total patient population of 22,329 were analysed. VLS was significantly different at primary level (91%) compared to (80%) at tertiary level. There was a high VLS rate among persons older than 50 years (92%) compared to children below 15 years (79%). Both late clinical stage and advanced HIV disease were associated with lower VLS rates at 61% and 70% respectively. Being on dolutegravir-based ART was associated with high VLS rates at 90% compared to LPV/ATV at 46%. The mixed
effects analysis showed that 0.24% of variation in VL was associated with variation at facility level. Facility size was associated with reduction in VL at 6 months even when adjusted for facility level (pseudo R2=0.637) or age centred at the mean (pseudo R2=0.15). Receiving ART from higher level of care and increasing age by 1 year from the mean was associated statistically significant increase VL
adjusting for facility size and facility mean age. The between-facility differences in VL were not affected by individual factors such as increase in mean age (LR=23.88, df =2, p<0.001).
Conclusion: The study shows that the variation in VL was associated to facility differences. The ART programme will need to develop programmes that considers these facility-specific differences in order for the country to each epidemic control.

Predictors of hospital survival among patients initiated on haemodialysis at a tertiary hospital

K. Nakabugo — 2024-11-08

Background: Haemodialysis (HD) is a life-saving treatment for kidney disease patients, but hospital survival rates are poor in low-income countries due to limited resources. Despite this, there is a lack of knowledge on factors affecting hospital survival among HD patients in these countries.
Objective: This study aimed to identify the hospital survival rates and predictors of hospital survival among HD patients in low-income countries.
Methods: We retrospectively analyzed medical records of adult patients who started haemodialysis (HD) at St. Francis Hospital, Nsambya between 2015 and 2022. We included patients aged 18+ years having their first time haemodialysis sessions at St. Francis Hospital, Nsambya and excluded those with renal transplants, missing records, or early referrals. We collected demographic, clinical, and laboratory data. Survival analysis and Cox regression were used to estimate hospital survival and hazard ratios among variables respectively.
Results: We retrieved 172 admission charts of patients initiated on HD, with a 59.3% hospital survival (n=102). Positive predictors of hospital survival included: being male (HR 0.61, p=0.046), prior nephrologist care (HR 0.53, p=0.046), age <60 (HR 0.51, p=0.006), ward admission (HR 0.21, p<0.001), and blood transfusion (HR 0.34, p<0.001). Negative predictors included: reduced level of consciousness (HR 17.74, p<0.001), mechanical ventilation (HR 2.46, p<0.001), and vasopressor use (HR 2.56, p<0.001)
Conclusion: There is a low in-hospital survival rate among patients initiated on HD in our setting. Critically ill patients (on ventilation, vasopressors, or with altered consciousness) and those without prior nephrologist care are less likely to survive. Thus, early identification of high risk patients and early referral of kidney patients to nephrologists can improve hospital survival among haemodialysis patients in low-income countries.

Pre-hospital delay and patient knowledge in acute cerebrovascular accidents at Kenyatta National Hospital

W, Kinyanjui — 2024-11-08

Background: Stroke is a leading cause of death and disability worldwide. In Kenya, stroke is the third leading cause of death, and the burden of the disease is increasing due to the aging population and the increasing prevalence of risk factors such as hypertension, diabetes, and smoking. Pre-hospital delay is a major contributor to poor outcomes in stroke patients. Knowledge about stroke and its symptoms is essential in reducing pre-hospital delay and improving outcomes in stroke patients.
Objectives: The main objective of this study was to investigate the factors influencing pre-hospital delay of acute stroke patients at Kenyatta National Hospital by the end of 2022 using a cross section survey of 50 patients, to identify the main influencers of presentation time including patient and community factors, healthcare system factors and stroke related factors.
Methods: This was a cross-sectional study involving 50 acute stroke patients who presented to neurology ward (7B) and Intensive Care Units (ICU) at Kenyatta National Hospital after random sampling. Data was collected using a structured questionnaire. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 24. Univariate analysis was conducted using student t-test or the Wilcoxon –Mann-Whiney test for continuous variables and using Chi-square or Fisher’s exact test for categorical variables for the subgroup analyses such as comparison between patient arrival at first hospital within 4.5 hours and after 4.5 hours. The results were presented in the form of tables.
Results: The study involved predominantly female patients (62%), married (62%) and had NHIF hospital cost coverage. The majority of patients were nonsmokers, had no history of stroke, patients’ families had no history of stroke. The median time interval was approximately 4.25 hours. The majority of the patients (66%) had poor knowledge on stroke risk factors and stroke warning signs and symptoms (62%). Certain social demographic factors, such as age, education, and marital status, were associated with the timing of patient presentations to the hospital. The study found that patients with better knowledge of warning symptoms were more likely to present to the hospital on time, while there was no significant association between knowledge of stroke risk factors and timely presentation.
Conclusion: Most of the patients managed to arrive at the hospital on time. The study highlights a concerning gap in knowledge regarding stroke risk factors and warning signs. Certain social demographic factors (age, education, and marital status) exhibited statistically significant associations with timely hospital presentation. Knowledge concerning warning symptoms had significant associations with the timing of hospital presentations. The study did not establish a significant link between knowledge of stroke risk
factors and the timing of patient presentations.

Prevalence and correlates of electrocardiographic indication for cardiac catheterization among heart failure patients with reduced ejection fraction in Western Kenya

C.A. Gathigia — 2024-11-08

Background: Heart failure is a life-threatening syndrome that affects 26 million individuals with the phenotype Heart Failure with reduced Ejection Fraction (HFrEF) contributing to 60% of all cases. Despite the use of Guideline Directed Medical Therapy, a significant number of HFrEF patients remain symptomatic with the risk of death. Electrocardiographic abnormalities are more prevalent in HFrEF and associated with poorer outcomes. However, improved outcomes have been demonstrated in patients with pathological “Q” wave, clinically significant arrhythmias and prolonged QRS through cardiac catheterization procedures.
Objectives: To determine the prevalence and clinical correlates of pathological “Q” waves, prolonged QRS and clinically significant arrhythmias in patients with HFrEF at Moi Teaching and Referral Hospital (MTRH), Western Kenya.
Methods: This was a cross-sectional study with consecutive sampling technique. A current echocardiogram (≤6 months) was used to identify HFrEF (LVEF ≤40%) subjects at MTRH medical wards, cardiac care unit and cardiology clinic. Eligible subjects above 18 years were consented and underwent a 12-lead electrocardiogram (ECG). Those with the prespecified ECG abnormalities were identified and correlates namely older age, obesity, documented hypertension, renal dysfunction and diabetes mellitus analyzed.
Results: Between July and November 2023, 243 participants were recruited. Females were the majority 137 (56.4%), and mean age was 60 years. One hundred and thirty two (54%) had abnormal ECG with prolonged QRS being the commonest 62 (25.5%). Clinically significant arrhythmias were 48 (19.8%) and pathological Q waves 33 (13.6%). Hypertension was the commonest comorbidity 132 (54.3%). On bivariate analysis, older age and being overweight were associated with abnormal ECGs.
Conclusion: Over half of our participants with HFrEF in Western Kenya had at least one ECG indication for cardiac catheterization procedures. Being elderly and overweight were significantly associated with the indications.

Prevalence and factors associated with liver fibrosis among adults with chronic hepatitis B infection at the Mbarara Regional Referral Hospital

P. Ucama — 2024-11-08

Background: The prevalence of chronic hepatitis B is high in low- and middle-income countries, with rates exceeding 8% in sub- Saharan Africa. Liver fibrosis is a crucial stage in the progression of hepatitis B-related liver disease, leading to severe complications like cirrhosis and hepatocellular carcinoma. Transient elastography, a non-invasive test for detecting liver scarring, has improved liver fibrosis assessment, providing a practical alternative to liver biopsy. However, there is limited local data on the prevalence and determinants of liver fibrosis among adults with chronic hepatitis B infection using transient elastography.
Objectives: The aim of this study was to determine the prevalence and factors associated with liver fibrosis among patients with chronic hepatitis B infection at Mbarara Regional Referral Hospital (MRRH).
Methods: We conducted a cross-sectional study from November 2023 to March 2024 at the MRRH hepatitis clinic. We consecutively consented and enrolled patients aged ≥18 years who had persistent positive HepBsAg test for more than 6 months. Data on socio-demographic, comorbidities, laboratory parameters were collected and transient elastography was performed. Liver fibrosis was considered in patients who had liver stiffness measurement above 7 kPa. The prevalence of liver fibrosis was expressed as a percentage. We used logistic regression analysis to determine the factors associated with liver fibrosis.
Results: A total of 96 participants were consecutively enrolled. The median age was 33.5 (IQR 26-42.5) years, and 58 (69.4%) were males. The median liver stiffness measurement was 6 (IQR 4.8-8.0) kPa. The prevalence of liver fibrosis was 35.5% (95% C.I, 26.4-45.5). Having hepatitis B viral load ≥ 20,000 IU/ml (aOR, 10.9; 95% C.I, 3.2 - 37.2; p < 0.001), elevated ALT ≥ 42 IU (aOR, 9.5; 95% C.I, 2.2 – 39.4; p<0.002), and duration of hepatitis B infection for 2 years or more (aOR, 5.0; 95% C.I, 1.6-15.2; p<0.004) are the factors that were independently associated with liver fibrosis.
Conclusion: At MRRH, the prevalence of liver fibrosis among patients with CHB is 35.5% by transient elastography. Hepatitis B viral load ≥ 20,000 IU/ml, elevated ALT ≥ 42 IU, and duration of hepatitis B infection for 2 years or more was associated with liver fibrosis. We recommend screening and close follow-up for liver fibrosis among patients with chronic hepatitis B with a viral load ≥20,000 IU/ml and a duration of disease of 2 years and above.

Probiotic use reduces incidence of antibiotic associated diarrhoea among adult patients; a systematic review and meta-analysis

H Wanyama — 2024-11-08

Background: Among efforts used to combat Antibiotic Associated Diarrhoea (AAD), particularly clostridiodes difficile infection, is prescription of probiotics. These live microorganisms are deemed to offer beneficial effects in a dysbiotic gut, limiting the incidence and severity of diarrhoea.
Objective: To evaluate available evidence for use of probiotics in controlling and preventing antibiotic associated diarrhoea.
Methods: We designed a systematic review and meta-analysis protocol, with intention to search literature published between 2010 and 2023 in the following electronic databases: PubMed, EMBASE, Scopus, Google Scholar. Only articles published in English were considered. Randomised controlled trials were reviewed if they met a prior inclusion criteria. Eligible studies were analysed for risk of bias using Rob2 tool, followed by data extraction using pre-constructed forms. We used a random effects model for all meta-analysis. Subgroups analysis were performed to evaluate sample size, age and number of probiotic strains influence on pooled outcome.
Results: Fifteen trials with total participants (7,427) were included in this review. Overall quality of studies evaluated was rated as moderate. The pooled analysis favoured administration of probiotics by reducing incidence of AAD by 40% (risk ratio= 0.60, 95% (0.43, 0.82). In subgroup analyses, studies with sample sizes below 180 per group or with participants with mean age above 65 years also demonstrated beneficial effect (RR: 0.75, 0.47, respectively). Multi strain probiotics showed more protective effect compared to dual or single strain probiotics (RR: 0.40 versus 0.9 or 0.6, respectively). However, there existed significant heterogeneity across studies.
Conclusion: This review suggests a protective effect of administering probiotics to reduce incidence of AAD. Multi strain combinations are considered to be more beneficial. The results are obscured by heterogeneity of studies, calling for properly designed large scale RCTs to better characterise these benefits.

Refeeding syndrome in severe malnutrition: a case study and clinical overview

C.E. Limbani — 2024-11-08

Background: Refeeding Syndrome (RFS) is a potentially fatal condition characterized by severe fluid and electrolyte shifts that occur during aggressive nutritional rehabilitation of malnourished patients.
Objectives: This abstract presents a comprehensive overview of RFS, including epidemiology, a case study, pathophysiology, clinical manifestations, and management strategies.
Epidemiology: Studies reveal the widespread occurrence of RFS across various patient populations. It has been reported in 48% of severely malnourished patients, 34% of ICU patients, 33% of anorexia nervosa patients, 25% of cancer inpatients, and 9.5% of patients with malnutrition due to gastrointestinal fistulae. A French paediatric study involving 1,261 children found an overall RFS incidence of 7.4%, with a striking 46.7% incidence among at-risk children. These figures underscore the importance of recognizing and addressing RFS in clinical practice.
Case report: We present a case of a 46-year-old Malawian man presenting with severe malnutrition and pellagra, characterized by weakness, dermatitis, diarrhea, and depression. Initial treatment for malnutrition and electrolyte imbalances showed some improvement. However, on day 8 of hospitalization, the patient developed refeeding syndrome, manifesting with confusion, hypoglycemia, and severe electrolyte disturbances including hyponatremia, hypokalemia, hypophosphatemia, and hypocalcemia. This case highlights the complex interplay between chronic malnutrition and the acute metabolic derangements of RFS.
Clinical overview: The pathophysiology of RFS centers on the rapid shift from a catabolic to an anabolic state upon refeeding. This transition triggers insulin release, promoting cellular uptake of glucose, phosphate, potassium, and magnesium. The resulting electrolyte imbalances, particularly hypophosphatemia, can lead to widespread organ dysfunction. Clinical manifestations affect multiple organ systems, including cardiovascular, neurological, respiratory, and hematological complications. Management requires prevention through careful nutritional rehabilitation and close electrolyte monitoring. Treatment focuses on correcting electrolyte imbalances, with severe cases requiring intensive care.
Conclusion: This case study and literature review emphasize the critical importance of recognizing RFS in at-risk patients. Early identification, preventive strategies, and appropriate management are crucial in mitigating the potentially life-threatening complications of this syndrome. Further research is needed to establish standardized protocols for RFS prevention and treatment across diverse patient populations.

Therapeutic effects of glucagon-like peptide -1 receptor agonist in adult overweight and obese women with polycystic ovary syndrome: a narrative review

F. Keli — 2024-11-08

Background: Abnormal glucose metabolism, adiposity, and hyperandrogenism occur in polycystic Ovary Syndrome (PCOS) phenotypes.
Objectives: Lifestyle modification and metformin are mainstays in managing Insulin Resistance (IR) in PCOS. This narrative review evaluated the effects of glucagon-like-1 receptor agonists (GLP-1 RA) on IR, glucose metabolism, anthropometrics, lipids and androgens in women with excess weight and PCOS.
Methods: A logic criteria constructed based on the study question was used to assemble medical subheadings and synonyms for retrieval of articles published between 2013 and May 2023 in PubMed, EMBASE, EBSCO, Cochrane Library and MEDLINE. These filters; human studies, time and publications in English language were applied to select 56 out of 1012 articles retrieved. Data was extracted from 12 Randomized Control Trials (RCTs) identified from the 56 articles using a google questionnaire, RCTs were included if participants;
• Were aged ≥ 18 years.
• Had PCOS and excess weight.
• A GLP1-RAs was administered.
The quality of RCTs was assessed using the Critical Appraisal Skills Program assessment tool. Eliminated articles were; 4 duplicate RCTs, 12 RCTs not meeting inclusion criteria, 26 literature reviews, 2 systematic reviews and 2 metanalysis.
Results: Liraglutide, exenatide, semaglutide and dulaglutide improved ir and 2hour oral glucose tolerance. Liraglutide and exenatide caused ≥ 5%, semaglutide and dulaglutide, 7%, weight loss from the baseline weight. These agents reduced basal metabolic index and waist circumference. Liraglutide reduced triglycerides only while total-, low density-, triglyceride and high density-cholesterols improved with exenatide, dulaglutide and semaglutide. All the GLP-1 ras increased sex hormone binding globulins, reduced total testosterone, free androgen index and dehydroepiandrosterone sulphate.
Conclusions: Glucagon Like Peptide -1 Receptor agonists are potential add on therapy in managing IR, hyperglycemia, excess weight, hyperandrogenemia and dyslipidemia in women with PCOS. Importantly, these RCTs were conducted in women of non-African descent and outcomes may differ locally. Additionally, GLP-1 RAs cause increased gastrointestinal disturbance and are not cheap.

Updating scientific articles via the Deckermed Platform: a comprehensive approach to learning and revision for ECSACOP trainees

W.Y. Kamanga — 2024-11-08

Background: The East Central and Southern Africa College of Physicians (ECSACOP) offers a comprehensive internal medicine residency program that encompasses didactic lectures, hands on clinical mentorship as well as a weekly curriculum readership on the DeckerMed Africa platform. Exposure to scientific advances as well as research methodology remains limited during the training program, which is primarily hosted in resource-limited countries. This is further compounded by limited locally generated clinical evidence, with most literature predominantly citing western data.
Objectives: To improve Between February 2023 and January 2024, Dr. Wezzie Y. Kamanga, a third-year ECSACOP resident, updated DeckerMed review articles on HIV prevention, macrovascular and microvascular complications of diabetes mellitus, and obstructive sleep apnea.
Methods: The review process involved initially reading the article for a general overview, followed by a detailed reading to summarize and update the text and references. A critical appraisal of meta-analyses, systematic reviews, clinical trials, and relevant guidelines was done with the aid of Critical Appraisal Skills Program (CASP) checklists. References were color-coded, and practice questions for junior and senior trainees were formulated. The updated articles were then submitted to the original authors or senior ECSACOP faculty for feedback, which was incorporated before publishing the final review.
Results: Lessons learnt
- The resident gained a deeper understanding and greater exposure to recent literature on the updated topics.
- DeckerMed provided a platform for collaboration between residents and established authors, resulting in high-quality publications.
- DeckerMed offered appropriate monetary compensation, which is particularly beneficial during residency.
Conclusion: The DeckerMed authorship program is a valuable and scalable initiative for third-year internal medicine residents to enhance their literature review and academic writing skills.

What drives willingness to receive a new vaccine that prevents an emerging infectious disease? A discrete choice experiment among university students in Uganda

H Ssekyanzi — 2024-11-08

Background: There is a critical need to identify the drivers of willingness to receive new vaccines against emerging and epidemic diseases. A discrete choice experiment is the ideal approach to evaluating how individuals weigh multiple attributes simultaneously.
Objectives: We assessed the degree to which six attributes were associated with willingness to be vaccinated among university students in Uganda.
Methods: We conducted a single-profile discrete choice experiment at Makerere University in 2019. Participants were asked whether or not they would be vaccinated in eight unique scenarios where attributes varied by disease risk, disease severity, advice for or against vaccination from trusted individuals, recommendations from
influential figures, whether the vaccine induced indirect protection, and side effects. We calculated predicted probabilities of vaccination willingness using mixed logistic regression models, comparing health professional students with all other disciplines.
Results: Of the 1576 participants, 783 (49.8%) were health professional students and 685 (43.5%) were female. Vaccination willingness was high (78%), and higher among health students than other students. We observed the highest vaccination willingness for the most severe disease outcomes and the greatest exposure risks, along with the Minister of Health’s recommendation or a vaccine
that extended secondary protection to others. Mild side effects and recommendations against vaccination diminished vaccination willingness.
Conclusions: Our results can be used to develop evidence-based messaging to encourage uptake for new vaccines. Future vaccination campaigns, such as for COVID-19 vaccines in development, should consider acknowledging individual risk of exposure and disease severity and incorporate recommendations from key health leaders.

Adverse cardiovascular events morbidity and mortality, and HIV exposure in cardiovascular disease patients in Northern Uganda

M. Okwir — 2024-11-08

Background: Cardiovascular Disease (CVD) morbidity and mortality persist globally, even among patients living with Human Immunodeficiency Virus (HIV) infection in sub-Saharan Africa.
Objective: We aimed to determine the risk of all-cause mortality and morbidity of Major Adverse Cardiovascular Events (MACE) components (stroke, Acute Myocardial Infarction (AMI), and heart failure), comparing CVD patients with and without HIV infection hospitalized in two hospitals in northern Uganda.
Methods: We conducted a retrospective cohort study at Lira Regional Referral Hospital (LRRH) and Lira University Hospital (LUH) in northern Uganda. We compared outcomes between HIV and non-HIV CVD patients hospitalized from January 1st, 2015, to January 2022. Using logistic regression, Kaplan Meier, and Cox proportional hazards models, we conducted crude, adjusted, and stratified analyses for the association between components of MACE, and mortality by HIV status adjusting for confounders, and further stratified by HIV status.
Results: We identified 2,127 CVD patients, 292 (13.7%) were HIV positive, and 1,835 were non-HIV CVD patients. The majority were female (60.5%), and the HIV-positive group was younger (median age = 51 years) than the non-HIV group (median = 65 years). The risk of all-cause mortality during hospitalization was 26% and 15.8% among HIV-CVD and non-HIV CVD patients respectively. Cardiac patients with HIV had a higher proportion of heart failure (38.1% vs. 22.9%), AMI (60% vs. 36.5%), and stroke (41.8% vs. 27.8%) compared to non-HIV CVD patients. Despite the high risk of MACE among HIV-CVD patients, mortality risks remain comparable to non-HIV CVD patients. The risk of death among CVD patients with HIV-positive includes; heart failure (OR: 3.06, 95% CI: [1.56, 6.32], p-value = 0.002), stroke (OR: 2.50, 95% CI: [1.15, 5.42], p-value = 0.020), AMI (OR: 9.29, 95% CI: [4.64,19.34], p-value <0.001), and Any-MACE (OR: 3.04, 95% CI: [1.54, 6.27], p-value 0.033). The risk of death did not differ with HIV status [p-value for HIV- interaction term with heart failure, stroke, and AMI was p=0.465, p=0.613, and p=0.615 respectively].
Conclusion: Overall, all-cause mortality was higher among CVD patients with HIV compared to those without HIV infection. Despite the higher risk of MACE among HIV-positive CVD patients compared to non-HIV CVD patients, there was no evidence of increased risk of death due to any MACE component associated with the presence of HIV infection. Therefore, we suggest further studies to evaluate the association between HIV exposure and CVD in sub-Saharan Africa to improve outcomes and prevention.

Trends of HIV morbidity and mortality in Lesotho: A joinpoint regression analysis of trends over the last two decades

F. Mupeta — 2024-11-08

Background: Lesotho has one of the highest HIV disease burdens in the world. Recent estimates show a decreasing trend in morbidity and mortality. The decrease associated with various programmatic interventions were studied using Joinpoint regression analysis.
Methods: This was a retrospective cross-sectional study of the HIV programmatic between 2000 and 2021. Data was analysed using the Joinpoint regression analysis of trends based on the grid search method. Assuming constant homoscedacity. The Annual percentage Change (APC) and the Annual Average Percentage Change (AAPC) were estimated by parametric and permutation methods at 95% significance level.
Results: The incidence AAPC decreased by 5.9-6.3% in both sexes and between 5.6 - 8.6% for all age groups with the larger decreased being observed more in children than adults between 2000 and 2021. The antenatal clinic HIV incidence AAPC decreased by 17.5% (CI 95%: -22.00 to -12.7%, p<0.001) between 2015 and 2021 with all districts showing varying declines. The HIV prevalence APC increased by 15.6% (CI 95%: 11.5 to 19.8%, p<0.001) from 2003 to 2006, and rapidly declined by 9.8% (CI 95%: -12.9 to -6.5, p<0.001) from 2006 to 2009 a small but significant decline in the last decade (-1.48% , CI 95%: -1.1 to 1.9%, p<0.001). However, HIV prevalence APC increased by 3.4-6.1% among females aged 40-49 years while it decreased among males aged 20-34 years by 6.7-8.0% in the same period. The overall mortality decreased for both sexes in the last 20 years with a greater and significant decrease of 11.9-17.4% in the last 7 years. However, the AAPC statistically increased for the age group 15-19 years (5.1%, CI 95%: 3.8 to 6.4%, p<0.001) and for 10-14 years.
Conclusions: The study shows that the HIV incidence, prevalence, and mortality have been generally on the decline over the past 20 years in Lesotho. The decline was associated with the introduction of ART and the test and treat policy for prevention and treatment and option B+ in antenatal clinics. Despite this, HIV mortality among 10– 14 year-olds increased between 2004 and 2021 and among 0-4 years from 2017 to 2021. The increase in mortality among under-five year olds and 10-14-year-olds indicates the lack of paediatric-specific formulations of ART in the early response and delayed roll-out of dolutegravir in the last 5 years.

Cerebrospinal fluid cryptococcal antigen titers at 1-Year following successful antifungal treatment: a descriptive study

M.K. Rutakingirwa — 2024-11-08

Background: Cryptococcal Meningitis (CM) contributes up to 19% of AIDS-related mortality. Cerebrospinal Fluid Cryptococcal antigen (CSF CrAg) titers have been shown to positively correlate with the cryptococcal quantitative fungal culture and to predict 2-week mortality. However, the evolution of CSF CrAg titers after 1-year of successful treatment of CM is unknown.
Objective: We set out to describe changes in baseline CSF CrAg titers at one year post antifungal therapy.
Methods: Following diagnosis and treatment of HIV related meningitis, survivors of CM are enrolled in an open cohort. At the 1-year follow up visit, lumbar punctures were performed for consenting participants. CSF CrAg titers were then compared to their baseline titers. Participants’ variables were summarized as proportions, medians with interquartile ranges or means with standard deviations as appropriate. Wilcoxon matched-pairs signed rank test was used to determine a difference in the CrAg titers at baseline and 1-year post diagnosis.
Results: Of the 21 Ugandan survivors of CM, 13/21 (62%) were male. At baseline, median CD4 count was 29 cells/mL (IQR 14-49) and median CSF quantitative colon count was 800,000 CFU/ml (IQR 70,600-2,792,500). The median CSF CrAg titer at baseline was 1:2560 (IQR 960-1024) and 1:5.0 (IQR 0.0-25) at 1 year. Eight of the participants (38%) had a negative CSF CrAg test at 1 year. The mean ± SD decline of the CSF CrAg titer and dilutions at 1 year were 5886± 6810 and 7.5 ± 3.1 respectively which were statistically significant (Spearman’s r2 = 0.39; p<0.0001).
Conclusions: As expected, there was a significant decline in the CSF CrAg titers at 1-year following successful antifungal therapy. One third of patients had turned CrAg negative after one year. Titers may be useful to clinicians in distinguishing microbiological CM relapse from other causes of recurrence of symptoms in patients with prior history of CM.

Chemotherapy associated cardiotoxicity in adult patients initiating chemotherapy at Moi Teaching and Referral Hospital

B.K. Kurui — 2024-11-08

Background: Cardiotoxicity, manifesting as Left Ventricular Systolic Dysfunction (LVSD), is a recognized cancer chemotherapy adverse effect. t may manifest acutely or chronically, ranging from subclinical heart failure to cardiogenic shock and death. Timely identification, and initiation of guideline-directed medical therapy, can result in full recovery. The incidence and associated risk factors among patients initiating chemotherapy in Western Kenya are currently uncharacterized.
Objectives: To determine the incidence and predictors of left ventricular systolic dysfunction in cancer patients being initiated on chemotherapy at Moi Teaching and Referral Hospital (MTRH).
Methods: A prospective study, at MTRH oncology clinic from October 2021 to December 2022. Ninety nine consenting adults with confirmed cancer initiating chemotherapy were consecutively recruited. A questionnaire captured socio-demographic information, cancer type, and relevant Cardiovascular Risk Factors (CVRF). Blood samples were taken for lipid profile analysis. Electrocardiograms and echocardiograms were performed at recruitment and 5 months post-chemotherapy initiation.
Results: The mean age was 53.5 years. Fifty seven point seven percent were females. Most common malignancies were ENT, 16.5%, cervical, 16.5%, and breast, 13.4%. Majority (72.7%) had advanced disease (Stage 3,4). Three participants (3.0%) developed LVSD at follow-up; one was symptomatic, and two were asymptomatic. ECG abnormalities included left ventricular hypertrophy (12%), pathological Q waves (5%). Thirty-nine participants (39%) were lost to follow up. Baseline CVRF; hypertension (13.4%), obesity (13.4%), high LDL (50.5%), and diabetes mellitus (1%). Given the low LVSD incidence, no additional statistical analysis was performed to establish their associations.
Conclusion: The incidence of chemotherapy associated cardiotoxicity at 5 months among patients initiated on chemotherapy at MTRH was low at 3.0%. The contribution of the known cardiovascular risk factors to the observed incidence could not be established due to the low numbers.
Recommendations: We recommend future large longitudinal studies with more sensitive methods for the detection of LVSD to determine the exact incidence of the problem.

Incidence and predictors of castration resistant prostate cancer among prostate cancer patients on androgen deprivation therapy at Mbarara Regional Referral Hospital

A. Muhumuza — 2024-11-08

Background: Prostate cancer is a big threat globally and locally. An advanced form of prostate cancer is CRPC, in which there is disease progression after ADT, poor prognosis and reduced survival.
Objective: This study was to determine the incidence and predictors of CRPC among prostate cancer patients on ADT at MRRH. Methods: Two hundred and fifty patients with prostate cancer, receiving ADT from 2014 to 2021 were followed up retrospectively at MRRH oncology clinic. Baseline characteristics and follow-up PSA were obtained from the patient charts. CRPC was defined by disease progression biochemically (rising PSA) or radiologically (new metastatic lesions on CT or MRI scan) despite successful castration (testosterone <0.5ng/mL). The incidence rate was obtained as number of events (CRPC) out of total person-time, and cox regression analysis was used to determine the predictors of CRPC.
Results: The incidence rate of CRPC was 232 (95% CI, 195 – 276) per 1000 person-years. Obesity with adjusted hazard ratio of 2.3 (95% CI, 1.1 – 4.7), PS(ECOG) >1 with 1.7 (95% CI, 1.1 – 2.7), and nadir PSA >4ng/mL, time to nadir PSA <14 months, PSA velocity ≥11, and bone metastasis at ADT initiation with 2.7 (95% CI, 1.6 – 4.5), 3.6 (95% CI, 2.4 – 5.5), 2.1 (95% CI, 1.3 – 3.5), and 1.8 (95% CI, 1.1-3.0) respectively were predictors of CRPC.
Conclusion and recommendation: The incidence rate of CRPC is high at MRRH. Obesity, PS (ECOG)>1, nadir PSA >4ng/mL, time to nadir PSA <14 months, PSA velocity ≥11ng/mL/month, and bone metastasis at ADT initiation are predictors of CRPC. This study highlights the need for close monitoring of PSA kinetics and imaging (CT or MRI) for early diagnosis of CRPC with early therapy modification, and patient education on modifiable factors such as obesity to improve outcomes. Future larger prospective studies should also be done to further study CRPC in MRRH.

Prevalence of carotid atherosclerosis and its association with lipid abnormalities and ten-year predicted atherosclerotic cardiovascular disease risk in diabetes mellitus: a cross-sectional study in Southwestern Uganda

P.K. Saasita — 2024-11-08

Background: Type 2 Diabetes Mellitus (T2DM) poses an increased risk for Cardiovascular Disease (CVD) through atherosclerosis. The apolipoprotein B (apoB) / apolipoprotein A-I (apoA-I) ratio is a powerful predictor of atherosclerotic CVD and is associated with Carotid Atherosclerosis (CA) in T2DM; however, this association has never been studied in our setting.
Objective: This study set out to determine the prevalence and factors associated with CA, including but not limited to apoB/apoA-I and non-high-density lipoprotein cholesterol (non-HDL-c) / high-density lipoprotein cholesterol (non-HDL-c/HDL-c) ratios among patients with T2DM in Southwestern Uganda.
Methods: A cross-sectional study conducted at Mbarara Regional Referral Hospital included 212 patients with T2DM aged ≥40 years. Socio-demographic, clinical, and behavioural characteristics were determined. Carotid Intima-Media Thickness (CIMT) was measured bilaterally at three points by high-resolution B-mode ultrasound. A mean value of six measurements from the right and left carotid arteries was used as a measure of the mean CIMT. CA was defined as a mean CIMT≥1.0 mm. A stepwise multivariate logistic regression analysis, and Pearson’s correlation were used to find the association between factors with CA and/or CIMT.
Results: The prevalence of CA was 35.9%. Age ≥55 years (OR 3.1; 95% CI:1.4 – 7.1; p<007), being on antiretroviral treatment (OR 3.8; 95% CI: 1.1–12.5; p-value = 0.030), high waist circumference (OR 2.7; 95% CI: 1.2 – 6.5; p-value = 0.022) and non-HDL-c/HDL-c ratio ≥ 4 (OR 3.0; 95% CI 1.0–8.5; p = 0.045) were associated with CA. ApoB/ apoA-I ratio was not significantly associated with CA. The different lipid ratios (TC/HDL, non-HDL-c/HDL-c, apoB/apoA-I) except for atherogenic index plasma correlated positively with CIMT. There was a positive correlation between lipid ratios and the 10-year predicted Atherosclerotic Cardiovascular Disease (ASCVD) risk. However, the correlation between traditional lipid ratios including TC/ HDL-c, non-HDL/HDL-c with the 10-year predicted ASCVD risk was stronger than that of apoB/apoA-I ratio.
Conclusion: There is a high prevalence of CA among patients with T2DM. The non-HDL-c/ HDL-c ratio seems to correlate better with both the CIMT and the 10-year predicted ASCVD risk than the apoB/apoA-I ratio among patients with T2DM in southwestern Uganda.

Serum levels of C-Peptide and oral hypoglycemic failure in Type 2 diabetes

F. Awadh — 2024-11-08

Objective: The study was conducted at St. Francis Hospital Nsambya in Uganda and aimed to evaluate the predictive value of fasting serum C-peptide levels for oral hypoglycemic failure in patients with Type 2 Diabetes Mellitus (T2DM).
Methods: The researchers conducted a prospective cohort study from January 1, 2023, to October 1, 2023, involving participants aged 40 years and above with poorly controlled T2DM (HbA1c > 10.0%) on oral hypoglycemic agents. After obtaining informed consent, participants underwent a semistructured questionnaire to gather demographic and health-related information. Blood samples were collected for Fasting Blood Sugar (FBS) and C-peptide level determination. Participants were then prescribed a regimen of metformin, glimepiride, and teneglyptine, alongside diet and exercise counseling. Follow-up assessments were conducted monthly for three months, including FBS measurements and HbA1c at the study’s end. The study enrolled 35 participants with T2DM, with an average age of 59.6 years and predominantly female (77.1%). Most participants were overweight or obese (42.9% and 45.7%, respectively), and 62.9% had a family history of diabetes. Clinical assessments revealed a median diabetes duration of 7 years and high blood pressure in 62.9% of participants. Metformin was the primary medication used (97.1%), followed by glibenclamide (28.6%) and vildagliptin (22.9%).
Results: At baseline, the mean fasting serum C-peptide level was 1.72 ng/ml, showing a statistically significant negative correlation with HbA1c at three months. There was a significant reduction in median fasting blood glucose levels from baseline (10.6 mmol/L) to three months (7.8 mmol/L) after targeted treatments. The Area Under the Curve (AUC) for C-peptide in predicting oral hypoglycemic response was 0.85, with an optimal cut-off of 1.7 ng/ml, showing high diagnostic accuracy. This level accurately identified individuals
with good glycemic control (sensitivity of 89.5%, specificity of 81.2%).
Conclusions: The study concludes that fasting serum C-peptide levels could serve as a pivotal marker in guiding treatment decisions for T2DM patients not achieving desired glycemic control with oral agents, especially those with diabetes duration of five years or more. Clinicians are recommended to incorporate fasting serum C-peptide measurement into T2DM management protocols for better-tailored treatment strategies. Future research should focus on longitudinal studies to validate the prognostic value of
C-peptide levels across diverse populations and explore mechanistic pathways influencing glycemic control for potential therapeutic targets in T2DM management.

The clinical response of patients with bloodstream infections caused by bacterial pathogens resistant to antibiotics used for empiric treatment at The University Teaching Hospital, Lusaka, Zambia

K, Sikakena — 2024-11-08

Background: Bloodstream Infections (BSI) are infectious diseases characterized by the presence of viable bacterial or fungal microorganisms in the bloodstream and an inflammatory response leading to alterations of clinical, laboratory and hemodynamic parameters. The disease burden caused by BSI is comparable to diseases such as major stroke, acute myocardial infarction, and trauma.
Objective: This study aims to determine antimicrobial susceptibility patterns and elucidate the clinical response to empiric antibiotic therapy and outcome in drug resistant and sensitive BSI pathogens in patients admitted at the University Teaching Hospital. In this study empiric therapy is defined as the initial antimicrobial therapy given to a patient with suspected BSI prior to confirmation of its microbiological aetiology.
Methods: This was an observational prospective cohort study in which 160 suspected BSI patients were enrolled from the university teaching hospital. Blood cultures, day one and three full blood counts were collected to evaluate aetiology and clinical response. The patients were followed up to day 14 to establish the clinical outcome. STATA version 14 was used to analyse the data. Out of the 160 suspected BSI participants enrolled in the study only 34 had bacteriologically confirmed BSI. The gender composition was 23 (67.65%)) male and 11 (32.35%) females. The median (IQR) age was 39.5 (28.25-49.75) years.
Results: There were 24 bacteriologically confirmed BSI isolates that were resistant to third generation cephalosporins while 10 bacteriologically confirmed BSI isolates were found to be drug susceptible to the empiric therapy. Gram Negative Bacteria (GNB) were the leading cause of BSI followed by staphylococcal species. Mortality in drug resistance BSI was 50% while susceptible BSI was 10% and overall mortality was 38.24%. The aetiology of BSI has changed from being predominantly caused by gram positive microorganisms to gram negative microorganisms. Mortality was higher among those with drug resistant BSI (50%) than among drug susceptible BSI (10%).
Conclusion: It is therefore necessary that robust antimicrobial stewardship programs aimed at rational antimicrobial use and enhanced laboratory support are undertaken to prevent the emergency of antimicrobial resistance.

The incidence of acute kidney injury, its predictors and 30-day outcomes among stroke patients admitted at Mbarara Regional Referral Hospital

M. Orionga — 2024-11-08

Background: Acute kidney disease contributes a significant proportion to the global burden of admitted patients. Among patients with stroke, AKI is linked with increased short and long-term morbidity, mortality, more time spent in the hospital, and higher hospital expenses. Despite the high economic and mortality burden of AKI, studies on the incidence and predictors of AKI among patients with stroke in MRRH are scarce considering their importance to identify some modifiable risk factors and improve patient prognosis.
Objective: This study was done in MRRH to fill the identified gaps.
Methods: This prospective analysis was done on 126 patients whose data obtained between October 2023 and March 2024 at MRRH. The relevant socio- demographics information, clinical and biochemical data was collected. The incidence of AKI among patients with stroke was calculated as a proportion and the predictors of AKI were determined using logistic regression and level of significance was established at p-value ≤ 0.05.
Results: The study found a high incidence of AKI among patients with stroke which was 35.71%. A considerable number of patients who had stroke were females 79 (62.7%). The mean age of the patients was 65.43 (±17.24) years, the mean time to hospital was 5.08 (±2.91) days with mean NHISS score 17.52 (±7.63). The predictors of AKI were, infections (OR=7.415, p=0.003, CI=2.014-27.294), Fever (OR=1.928, p=0.038, CI=1.037-3.582), and dysphagia (OR=3.941, p=0.024, CI=1.198-12.957). The patients who had AKI had a significantly higher mortality compared to those without (40% vs. 24.7%), (Chi-square (3.90)=0.048).
Conclusions: We found that AKI is a very common complication in hospitalized patients with stroke and is linked to higher mortality. The important predictors for AKI following stroke were infections, dysphagia and fever. We recommend that patients with stroke should be carefully assessed for risks for AKI (dehydration and infections) and promptly treated in addition to AKI screening.

Assessment of surveillance systems attributes for leprosy in Mpulungu District of Zambia

C. Phiri — 2024-11-08

Background: Neglected tropical diseases continue to remain in the shadows of many health systems globally and locally due to the growing burden of other infectious and emerging diseases with a duo burden of non-communicable diseases. Despite achieving elimination status in 2010, leprosy cases continue to be reported with chances of underreporting due to the structure of health surveillance systems. Gray data demonstrates that at least 120 cases of leprosy were reported annually between 2019 and 2021 in Northern province alone. Though the numbers may seem insignificant the burden placed on patients and their families is huge and not limited to physical health but also family economics.
Objective: The study aimed to assess the attributes of the surveillance systems currently in place for leprosy in Mpulungu district. Methods: We carried out a cross- sectional descriptive survey at five health facilities. Sixty four purposively sampled respondents were administered a five Likert point questionnaire adapted from Centre for Disease Control and prevention (CDC). Descriptive analysis was done and median scores were used to estimate if each attribute was sufficiently met. We applied the pearsons chi- square and Fishers exact test to measure associations between categorical variables.
Results: The study showed that of the 64 respondents, majority worked at the district hospital 27 (42.19%) and the Mpulungu urban clinic 22 (34.38%). Twenty one (32.81%) of the respondents had been in practice for three to five years. Sufficiently met attributes were acceptability (64.04%) and usefulness (54.69%) while simplicity (29.69%), stability (29.69%), flexibility (32.8%) and data quality (37.5%) were not sufficiently met. Years of experience and facility of origin was associated perceived sufficiently met flexibility (0 – 2 years,
31.58% vs. 2 – 3 years, 33.33% vs. 52.38%, p=0.40), (Lupongwe, 100% vs. Mpulungu clinic, 63.64% vs. Mpulungu District Hospital, 22.22% vs. Kaizya, 0% vs. Kasakalawe, 0%, p=0.001) and usefulness (Lupongwe, 100% vs. Kasakalawe, 87.5% vs.Mpulungu clinic, 59.09% vs. Mpulungu District Hospital, 51.85% vs. Kaizya, 0% vs., p=0.001). Timeliness and sensitivity were not assessed due to lack of data standardised reporting structures at all surveyed facilities.
Conclusion: This study shows that the current surveillance system is perceived only as acceptable and simple. Regular assessment of the surveillance system attributes and trainings of health personnel responsible for leprosy surveillance is therefore important for improving the overall performance of the surveillance system.

Case presentation of belly dancer dyskinesia

R.G. Teny — 2024-11-08

Background: Belly Dancer Dyskinesia (BDD), also known as diaphragmatic flutter, is characterized by rhythmic, involuntary contractions of the diaphragm resulting in rhythmic movements of the abdomen resembling a belly dance. BDD is a rare presentation with only few cases reported.
Case report: This was a case report of a 26 year old female para 3+0, who presented with four-day history of involuntary abdominal movement, no associated pain, bloating or altered bowel movement. She had no convulsions, headache or drugs abuse. Her laboratory examination and abdominal U/S were all normal, the movement subsided with the administration of carbamazepine and haloperidol.

Effect of pre- Ramadan risk assessment and education on fasting- related patient outcomes in ambulant adults living with Diabetes Mellitus: a multi-center case control study

S Sokwalla — 2024-11-08

Background: Diabetes Mellitus (DM) is associated with increased risk of dehydration, hyperglycemia, thrombosis and hypoglycemia in patients who fast during the month of Ramadan. However, this risk is not universal, and therefore pre- Ramadan risk stratification and education of all People Living With Diabetes (PLWD) is recommended to achieve safe fasting.
Objectives: This study aimed to describe the differences among fasting related patient outcomes based on two groups: those that received the pre-Ramadan risk stratification and patient education versus those that did not.
Methods: Retrospective un-matched, case-control study, at three health-care facilities, included adult Muslims with a diagnosis of DM who attended the facilities from February 2022 (pre- Ramadan) to July 2022 (post- Ramadan). Cases were individuals who attended the clinics pre- Ramadan and received pre- Ramadan risk stratification and education, fasted in Ramadan and followed up post- Ramadan for post- Ramadan evaluation of outcomes. Controls were individuals who did not attend the clinic before Ramadan but attended post-Ramadan.
Results: Eighty eight participants completed both the pre and post Ramadan evaluation, amongst whom, 59 (67%) fasted during Ramadan (cases), versus a total of 81 controls. Fifty two point five percent of cases were in the moderate-high risk categories, 18.6% of the cases and controls (combined) had daytime hypoglycaemia, mostly between 3.00 pm and Maghrib time and 1/3rd of these participants had to break their fast. Seventeen point nine percent had a hyperglycaemic episode, 1/3rd of which occurred during both eating and fasting hours, and 20% of them broke their fast; only one patient required admission for hyperglycaemia. Median HbAIC was 8.5% [IQR 2.4]. There was no significant difference in type of diabetes, fast breaking during Ramadan, number of days fasted post- Ramadan, hypoglycaemic and hyperglycaemic outcomes, medication use, glycaemic control, diabetes related comorbidities and complications amongst the cases (n=59) and controls (n=81). However, cases had significantly higher rates of Self-Monitoring of Blood Glucose (SMBG) (98.3% vs 75.3%, p <0.001) and pre- Ramadan diabetes education compared to controls. We found that almost a quarter of the controls had also received pre- Ramadan diabetes education.
Conclusion: In this pioneer study in our region, we found a higher frequency of SMBG in those that received pre- Ramadan risk stratification and education, and a lower threshold of breaking the fast due to hyperglycaemia in all participants that had received any form of pre- Ramadan diabetes education. We recommend pre- Ramadan screening and education for all patients with diabetes, and larger, prospective studies, with structured diabetes education programs to further evaluate the gaps in our study.

Evaluation of metabolic age in assessment of cardiovascular risk in newly diagnosed diabetes patients in a Zimbabwean hospital

R. Gwini — 2024-11-08

Background: Cardiovascular diseases are the major contributors to morbidity and mortality globally, with more than three quarters of the cases occurring in low to middle income countries. Well established risk factors for cardiovascular disease include chronological age, diabetes, obesity, smoking and hypertension.
Objectives: To determine whether the Body Mass Index (BMI) affect the metabolic age and to ascertain whether the metabolic and chronological age are equally associated with cardiovascular risk.
Methods: Cross sectional study of newly diagnosed diabetes patients evaluated between October 2021 and mid June 2024. Demographic information, clinical examination and anthropometric measurements were obtained using a questionnaire. Metabolic age was captured from the participant’s bioelectrical impedance body composition output data form. The qrisk3 score calculator (chronological age, ethnicity, gender, cholesterol/high density lipoprotein cholesterol, diabetes, hypertension, BMI and other chronic conditions) was used to calculate the cardiovascular risk using chronological and metabolic age. HbA1c, serum lipids, were measured.
Results: A total of 200 patients (148 women) were studied, 185 were analysed. Mean chronological age was 54.9±14 (95% CI, 52.8-56.9) years, metabolic age 57.5±14.6 (95% CI, 55.4-59.7) years, mean BMI 29.8±0.49 (95%CI 28.8-30.8). HbA1C 10.8 ± 3.39 % (95% CI, 10.39- 11.4). Mean chronological risk score 9.8 ±0.62 (95% CI 8.6-11.0), mean metabolic age risk score 11.1±0.69 (95% CI 9.7-12.5). There was a positive correlation between BMI and metabolic age (r =0.6, p<0.0001) and no correlation between chronological age and BMI (r=0.01, p=0.8). There was a significant difference in the association with cardiovascular disease risk between chronological age and metabolic age (p<0.0001) and metabolic risk score (p<0.0001), respectively.
Conclusion: Diabetes patients with a higher metabolic age at the time of diagnosis have a higher cardiovascular risk score than chronological age. Stringent lifestyle modifications needs to be included early in the management of patients with diabetes.

Influencers of deterioration to DMARDS in patients with rheumatoid arthritis

G.O. Oyoo — 2024-11-08

Objective: To identify the socio-demographic, clinical and health care factors that influence deterioration to DMARDS in patients with
rheumatoid arthritis.
Design: Prospective cohort study.
Setting: Ambulatory multicenter outpatient clinics at Kenyatta National Hospital in Nairobi, Mater Hospital Nairobi, Mombasa Hospital, Mombasa and The Aga Khan Hospital, Kisumu.
Subjects: Patients with rheumatoid arthritis diagnosed according to the criteria of the American College of Rheumatology (ACR) or ACR/EULAR criteria (score≥6) who consented to take part in the study.
Methods: Pre-coded data sheets (questionnaire) were used to capture socio-demographic characteristics and clinical characteristics. Baseline data was collected at time of patient recruitment into the study. They were then followed up over time while on treatment with DMARDS. Only patients who had complete data at 3 months follow up were included in the study analysis. The study’s outcome was achievement of remission (DAS -28 score < 2.6) or Low Disease Activity (LDA) (DAS-28 score ≥ 2.6 to ≤ 3.2) at 3 months follow-up. The study used the Adherence in Chronic Disease Scale (ACDS) by Kubica et al. respectively. European Task Force for Patient Evaluation of General Practice (EUROPEP) tool was used to evaluate patient assessments of health care received (the clinical performance of the physician and the organization of practice).
Results: A total of 206 patients were enrolled into the study; 52 (27.7%) patients deteriorated (had severe disease activity at follow up). In the multivariate regression analysis, a high baseline disease activity (DAS-28 score) (OR = 4.4, 95% CI 2.67-7.57, P<0.001) and non-adherence (OR=30.40, 95% CI 4.82-191.66, p<0.001) were identified as independent predictors of deterioration.
Conclusion: High baseline disease activity and non- adherence are independent predictors of disease deterioration in patients with RA.

Metformin-associated vitamin B12 deficiency in patients with Type 2 diabetes in Sub-Saharan Africa: a narrative review

A. Wairagu — 2024-11-08

Background: Metformin, a key therapy for T2DM in Sub-Saharan Africa (SSA) where T2DM is prevalent has been linked to VitB12 deficiency mainly due to malabsorption.
Objectives: To determine the prevalence of and risk factors for metformin-associated vitamin B12 deficiency in patients with T2DM in SSA and to provide an overview of the available guidelines on screening and treatment of vitamin B12 deficiency associated with metformin therapy.
Methods: Literature search: PubMed, MEDLINE, SCOPUS, AJOL, EMBASE and Cochrane Library databases were searched for relevant articles between January 2002 and December 2022. Additional articles were searched in Grey literature as well as manual searches in reference lists and citations. Clinical practice guidelines on diabetes management from SSA region were searched using key search words.
Inclusion criteria: Studies assessing effects of metformin on vitamin B12 in patients with T2DM in countries in SSA and all available clinical practice guidelines on diabetes management from SSA.
Exclusion criteria: Studies with insufficient data, review articles and non-English articles or guidelines.
Data extraction and synthesis: From articles: Relevant data including publication information, study characteristics, intervention details and outcome measures. Quality assessment of the articles was performed using the Center for Evidence-Based Management (CEBMa) (2014) Tool from guidelines: Relevant data including screening, diagnosis, and monitoring vitamin-B12 status and treatment of vitamin B12 deficiency.
Results: Article selection: Initial search yielded 24 articles. After screening titles and abstracts, 13 articles were eligible for full-text review but only seven met the inclusion criteria. All were cross-sectional studies except one case-control study.
Guidelines selection: Twenty-two guidelines from 18 countries were retrieved.
Key findings: N=1075 . Prevalence: 5-41%.
Risk factors: High metformin dose, long durationof metformin therapy and diabetes, advanced age, high BMI and body weight, better glycaemic control, non-black ethnicity
Guidelines: Few, non-evidence-based, nonrecommending routine screening and treatment.
Conclusions: The prevalence of vitamin B12 deficiency amongst metformin-treated T2DM in SSA varied considerably. The risk factors identified included; high dose metformin, a longer duration of metformin and diabetes, non-black ethnicity and a good glycaemic control. Guidelines for the screening, monitoring and treatment of vitamin B12 associated with metformin therapy are generally lacking in SSA and were not evidence-based.
Recommendations: Selective screening in high-risk symptomatic individuals with T2DM on metformin therapy. There is a need to conduct randomized clinical trials in SSA for evidencebased guidelines development.

The African Clinical Research Network (ACRN) model for enhancing clinical research and clinical trial access and excellence

T. Makadzange — 2024-11-08

Understanding pharmacogenetics in African populations is crucial, as drugs such as antiretrovirals, cancer therapeutics, and cardiovascular medications are metabolized differently, potentially affecting their efficacy compared to non-Africans. Despite Africa representing 15% of the global population and 23% of the global disease burden, it accounts for only 2% of clinical trials. Expanding clinical research in Africa is vital to ensure appropriate drug dosing, formulations, and schedules, and to build trust in the medications used and the quality and integrity of studies conducted on the continent. A robust research ecosystem integrating world-class clinical trial capacity with healthcare systems will enhance our understanding of disease burdens and improve clinical care in Africa. The African Clinical Research Network (ACRN) proposes an inclusive model connecting sponsors to researchers and research entities, providing operational support while ensuring data integrity and offering diverse research opportunities. The network will engage in various trials, including registrational, global multi-country studies, investigator-initiated trials, implementation science, and real-world evidence studies. This pan-therapeutic approach aims to involve clinical specialists from various disciplines in clinical research. ACRN will drive operational efficiency and clinical trial excellence, providing both academic and non-academic researchers with the opportunity to engage in clinical research across their specialties. ACRN, as an African-led organization, will maintain high-quality research units to enable and manage clinical research and development. The network will collaborate closely with stakeholders, including pharmaceutical companies, governments, academic and private institutions, to shape priorities and facilitate studies. ACRN’s hubs will be based across the five African regions (in ML3 countries or soon-to-be ML3 countries) and will partner with affiliated research units, academic centers, public and private institutions, physicians from multiple specialties, and Key Opinion Leaders (KOLs). This approach ensures geographic representation, diverse populations, and access to the best disease experts, supporting local research and addressing the data gap for healthcare and health outcomes in African populations. We propose to share our model and obtain feedback from East, Central, and Southern African physicians across all clinical specialties. This will enable us to design a research network that meets the needs of Africa’s key stakeholders— governments and regulators aiming to build and strengthen biomedical capacity, physicians and clinicians striving to improve patient care and outcomes, and communities whose engagement is essential for ensuring equity and access during and after research.

The comorbidities associated with chronic kidney disease among young people living with HIV in Uganda: a case control study

E. Nasuuna — 2024-11-08

Background: Chronic Kidney Disease (CKD) is often complicated by disorders in multiple body systems as the kidneys play a pivotal role in homeostasis maintenance in the body. The most commonly affected systems are the haematological, cardiovascular, endocrine and musculoskeletal. CKD complications increase with reducing kidney function and are associated with higher mortality, morbidity and reduced quality of life. The spectrum of complications among young people living with HIV are unknown.
Objective: The study set out to explore the comorbidities that YPLHIV present with in Kampala, Uganda.
Methods: This was an unmatched nested case control study conducted in seven urban ART clinics. The cases were the YPLHIV (10 to 24
years) diagnosed with CKD defined as having an eGFR below 90ml/min/1.73m² on two separate occasions three or more months apart. The controls were the YPLHIV with an eGFR above 90ml/min/1.73m² at baseline. Data were collected on demographic and clinical factors as well as presence of blood pressure, fasting glucose levels, anaemia, electrolytes, parathyroid hormone and cognitive impairment. Demographic and clinical factors were summarised in means and standard deviations and multivariable logistic regression was done to find associations of comorbidities with CKD.
Results: A total of 292 participants (92 cases and 196 controls) were recruited. The majority of the cases were male 57 (59.4%) and the controls were female 125 (63.8%). More cases were aged less than 17 years 85 (88.5%) compared to controls 91 (46.4%). Cases had 3.73 (95% CI 1.53-9.12) times the odds of having a detectable HIV viral load compared to controls and 4.19 (95% CI 2.28-7.72) times odds of having proteinuria. The associated comorbidities were cognitive impairment, hypochloraemia, hyperphosphatemia, high mean corpuscular volume and haemoglobin. There was no association of CKD with hypertension or anaemia.
Conclusion: YPLHIV with CKD are developing comorbidities associated with reduced kidney function and damage with a different pattern from that observed in adults with CKD. Early diagnosis and management are crucial to slow down progression. HIV programs should routinely screen YPLHIV for CKD and its complications. Further research is needed to discern the pattern and why it is different from adults.

The prevalence of kidney disease and associated factors among patients with Chronic Hepatitis B Virus infection at Mbarara Regional Referral Hospital

S. Jjunju — 2024-11-08

Background: Chronic Hepatitis B (CHB) virus infection is a global health problem and is highly prevalent in sub-Saharan Africa. It is well established that CHB is a primary cause of kidney disease that progresses through the course of the illness. Early detection of kidney disease is crucial and is an indication for earlier initiation of antiretroviral therapy, which could potentially slow down or halt its progression. Current screening biomarkers, like serum creatinine, have poor sensitivity, especially in the early stages. There is no data about kidney disease among patients with CHB in Uganda.
Objectives: The study aimed to identify kidney disease prevalence and associated factors among patients with CHB using a combination of kidney function biomarkers which included urine NGAL, a highly sensitive and specific kidney function biomarker.
Methods: This was a cross-sectional study conducted from November 2023 to April 2024 at the hepatitis clinic of Mbarara Regional Referral Hospital, recruiting patients 18 years and above being followed up for CHB. Data collected included: socio-demographic data, comorbidities, co-infections, and CHB-related data. Spot urine and blood were collected for dipstick, urine NGAL, and creatinine. GFR was estimated using the CKD-EPI 2021 equation. The prevalence of kidney disease was represented as a simple proportion with 95% CI. Logistic regression was used to determine factors associated with kidney disease. A p-value ≤ 0.05 was considered significant.
Results: One hundred and twenty six participants were enrolled, mean age of 36.2 ±12 years, 50% females. Overall kidney disease prevalence was 30.2% (95% CI: 22.7-38.8). Prevalence based on urine NGAL, eGFR <60ml/min/1.73m², and eGFR between 60- 89ml/min/1.73m² with either proteinuria or haematuria was 19.1% (95% C.I: 12.6-27.0), 6.4% (95% C.I: 2.8-12.1) and 11.1% (95% C.I:6.7-18.0) respectively. Factors associated to kidney disease included the female sex with odds ratio of 2.6 (95% CI: 1.1-6.2) and a p-value of 0.033.
Conclusion: The study found a 30.2% prevalence of kidney disease in patients with CHB, with a higher prevalence using urine NGAL (19.1%). Female sex was the only factor associated with kidney disease. The study recommends frequent monitoring of patients with CHB especially among women and using urine NGAL as a point-of-care test for kidney function.

Tuberculous pleuritis- a mimicker of postoperative chest pain in puerperium

E.N. Rugaatwa — 2024-11-08

Background: Tuberculosis (TB) is still one of the leading causes of morbidity and mortality globally. In 2022 alone 10.6 million people were infected with TB and 1.3 million died. Tuberculous pleuritis or pleurisy (TBP) is the second most common form of extra-pulmonary tuberculosis. It affects the pleura, in both immunocompetent and immunocomprised persons in as high as 25% of TB. Isolation of mycobacterium tuberculosis (MTB) in TBP is a challenge due to lack of thoracoscopy services, paucibacillary nature of effusion and lack of sputum (since the cough is usually non-productive). Adenosine Deaminase (ADA) test on pleural fluid has become famous in diagnosis of TBP, more so in patients with exudative and lymphocytic pleural effusion in high TB endemic areas.
Case report: We received a 28-year-old woman, HIV-seronegative with persistent right sided pleuritic chest pain for 2 months postpartum. She was managed as “post caesarean-section pain” without improvement. The pain was progressive, associated with evening fevers, lost appetite, and occasional difficulty in breathing while lying down and/or sleeping.
Chest exam: Stony dullness and reduced air entry in the right subscapular and basal lung zones. A diagnosis of right pleural effusion confirmed on chest radiography was made. Diagnostic thoracentesis and fluid ZN stain, Gene expert, Gram-stain, culture were negative for MTB. Fluid cytology revealed scattered lymphocytes and polymorphs on a serous background. Pleural fluid ADA test result was 58.6 U/L (Biological Reference Interval 0-40). TB chemotherapy was given for 6 months with complete clinical and radiological recovery. A differential of TBP should be considered and investigated in puerperium in mothers with persistent pleuritic chest pain. Pleural fluid ADA test can be employed in the diagnostic pathway especially in resource limited settings with no thoracoscopy/pleuroscopy services.
Conclusion: More research on disease burden and diagnostic accuracy of ADA test in this patient population is recommended.

Dancing abdomen

G.T. Ruot — 2024-11-08

Case report

• 26 years old female. Para 3+0, LD in 2019
• Presented with 4 days history of involuntary abdominal movement.
• She has no abdominal pain, bloating or altered bowel movement
• She has no convulsions, headache and any drugs abuse
• She has irregular cycle, no dysuria or PV discharge

Physical examination

Looks well, not pale, jaundiced, cyanosis or lower limbs edema
Abdomen: Normal contour, involuntary rhythmic movement, no organomegally or ascites
CVS/ RS: Normal
CNS: GCS 15/15, normal motor and cranial nerves examination

Differential diagnosis:

1. Focal seizures
2. Psychomotor disorders
3. Labs: CBC: normal
4. Electrolytes: Ca+2: 8.5, NA: 131, K: 4.0
5. Abdominal US: Unremarkable
6. Management: Carbamazepine 200 mg po bd
7. Patient reviewed in the clinic after 3 days, movement were reducing. Then her medications changed to haloperidol 5 mg bd

Belly Dancer Dyskinesia

Definition: Belly Dancer Dyskinesia (BDD), also known as diaphragmatic flutter, is characterized by rhythmic, involuntary contractions of the diaphragm resulting in undulating, rhythmic movements of the abdomen resembling a belly dance.
• BDD is a rare presentation with only few cases reported in literature.
• The name was given by Ilecito G et al in 1990
1. Aetiological and therapeutical observations in a case of belly dancer’s dyskinesia. Linazasoro G, Blercom NV, Lasa A, et al. Mov
Disord. 2005; 20:251–253
2. belly dancer’s” dyskinesia. Iliceto G, Thompson PD, Day BL, et al. Mov Disord. 1990;5:15–22.

Aetiology:

• Tardive dyskinesia
• Spinal cord trauma
• Myelitis
• Malignancy
• Vascular lesions
• Drugs
3. Van der Salm SMA, Erro R, Cordivari C, et al. Propriospinal myoclonus: clinical reappraisal and review of literature. Neurology. 2014;
83(20): 1862–1870
4. Aldabbour B, E’Leimat I, Alhayek K, et al. Recurrent belly dancer’s dyskinesia with pregnancy. Mov Disord. 2019; 12(2): 128–129

Diagnosis

• Mainly clinical diagnosis
• Work up to r/o common etiologies (i.e; Brain CT scan, EEG, EMG, electrolytes etc..)2
2. belly dancer’s” dyskinesia. Iliceto G, Thompson PD, Day BL, et al. Mov Disord. 1990; 5:15–22.

Treatment

• Benzodiazepine
• AED (Carbamazepine and Na valproate)
5. Iliceto G, Thompson PD, Day BL, Rothwell JC, Lees AJ, Marsden CD. Diaphragmatic flutter, the moving umbilicus syndrome, and “belly dancer’s” dyskinesia. Mov Disord. 1990; 5(1):15–22.
6. Inghilleri M, Conte A, Frasca V, Vaudano AE, Meco G. Belly dance syndrome due to spinal myoclonus. Mov Disord. 2006; 21(3):394–396
7. Linazasoro G, Van Blercom N, Lasa A, Fernández JM, Aranzábal I. Etiological and therapeutical observations in a case of belly dancer’s dyskinesia.

Postpartum cardiomyopathy with congestive heart failure: a case report

M. Jayte — 2024-11-08

Background: Postpartum cardiomyopathy (PPCM) is a form of heart failure that manifests in late pregnancy or early postpartum without identifiable causes, presenting substantial health risks. Effective recognition and management are essential to enhance patient outcomes.
Case presentation: A 23-year-old woman from Uganda presented with symptoms indicative of heart failure one month post-delivery. Clinical examination revealed signs of congestive heart failure. Subsequent chest X-ray imaging demonstrated cardiomegaly, leading to a PPCM diagnosis based on established clinical criteria. The therapeutic regimen included diuretics, betablockers, angiotensin receptor blockers, SGLT2 inhibitors, and bromocriptine.
Discussion: This case emphasizes the necessity of considering PPCM as a differential diagnosis during the postpartum period. It underscores the importance of prompt diagnosis and the implementation of a multidisciplinary treatment strategy to improve patient outcomes.
Conclusion: PPCM remains a critical condition requiring awareness and swift intervention. Continued research is imperative to enhance our understanding and management of this disorder, thereby improving prognoses for affected individuals.

Unveiling surprising insights into determinants of COVID-19 outcomes: a retrospective cohort study from a private COVID treatment centre in Malawi

A. Moses — 2024-11-08

Background: Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2), the virus responsible for COVID-19, emerged at the end of 2019 and has presented significant global health challenges ever since. Understanding the demographic and clinical factors influencing COVID-19 outcomes is essential for effective management and public health response.
Objective: This retrospective cohort study was conducted at Partners in Hope (PIH) Hospital in Malawi. It aimed to examine the demographic and clinical profiles of hospitalised COVID-19 patients, evaluate variations in disease severity, and identify crucial factors influencing treatment outcomes.
Methods: Clinical data from 67 patients hospitalised from January 2021 to September 2021 were analysed, focusing on demographic characteristics, comorbidities, clinical presentations, and treatment responses. The statistical methods employed included descriptive analysis, chi-square tests, and multinomial logistic regression, which were used to elucidate factors associated with disease severity and outcomes.
Results: Among the 67 hospitalised COVID-19 patients, most presented with severe symptoms upon admission, including shortness of breath (83.58%) and fever (73.13%). Common comorbidities such as hypertension (39%) and HIV (33%) were prevalent. Overall, the majority of COVID-19 patients at PIH Hospital were discharged (80.6%), while 11.94% were referred and 7.46% died. Surprisingly, older age and the presence of comorbidities, particularly diabetes and HIV, were found to correlate with shorter hospital stays and favourable treatment outcomes. Multinomial logistic regression highlighted age, sex, comorbidities, and oxygen saturation as significant disease severity and mortality predictors.
Conclusions: Effective early interventions and management of underlying health conditions played pivotal roles in shaping COVID-19 outcomes at PIH Hospital. Tailored public health strategies aimed at vulnerable populations are crucial for mitigating the impact of COVID-19 in resource constrained settings like Malawi.