A qualitative study on informed consent decision-making at two tertiary hospitals in Uganda: Experiences of patients undergoing emergency surgery and their next of kin.

Background: In emergency situations, patients and their next of kin must make complex medical and ethical decisions in a quick and timely way. Objectives: To describe the decision-making process during informed consent for emergency surgery among patients and the next of kin of patients who have undergone emergency surgery. Methods: Consecutive sampling of 39 participants and in-depth semi-structured interviews were conducted at two tertiary teaching hospitals in Uganda. There were 22 patients and 17 next of kin of patients who had undergone emergency surgery within 24-72 h. Responses about decision-making were coded into themes using the social constructivist theory and phenomenological approach. Results: There were four emergent themes; decision-makers, people consulted, documentation of the consent and factors influencing decision-making. Most patients and next of kin made decisions on their own and documented the consent for themselves. Other family members and doctors were consulted during the decision-making process. Decision-making was influenced by reassurance of good outcomes of surgery and disclosure by the doctors. Conclusion: Decisions were made collaboratively with the patient at the center but with input of health personnel, the next of kin and other family members. A communitarian approach combined with shared decision-making between the doctor and the patient and next of kin with adequate discussion and disclosure of information in simple language would improve decision-making for patients and their next of kin.

Exploration of Clinical Ethics Consultation in Uganda: A case study of Uganda Cancer Institute.

Introduction: Globally, healthcare providers (HCPs), hospital administrators, patients and their caretakers are increasingly confronted with complex moral, social, cultural, ethical, and legal dilemmas during clinical care. In high-income countries (HICs), formal and informal clinical ethics support services (CESS) have been used to resolve bioethical conflicts among HCPs, patients, and their families. There is limited evidence of mechanisms used to resolve these issues as well as experiences and perspectives of the stakeholders that utilize them in most African countries including Uganda. Methodology: This qualitative study utilized in-depth-interviews (IDIs) and focus group discussions (FGDs) to collect data from Uganda Cancer Institute (UCI) staff, patients, and caretakers, who were purposively selected. Data was analyzed deductively and inductively yielding themes and sub-themes that were used to develop a codebook. Results: There was no formal committee nor mechanism utilized to resolve ethical dilemmas at the UCI. The study uncovered six fora where ethical dilemmas were addressed: individual consultations, tumor board meetings, morbidity and mortality meetings, core management meetings, rewards and sanctions committee meetings, and clinical departmental meetings. Participants expressed apprehension regarding the efficacy of these fora due to their non-ethics related agendas as well as members lacking training in medical ethics and the necessary experience to effectively resolve ethical dilemmas. Conclusion: The fora employed at the UCI to address ethical dilemmas were implicit, involving decisions made through various structures without the guidance of personnel well-versed in medical or clinical ethics. There was a strong recommendation from participants to establish a multidisciplinary clinical ethics committee comprising members who are trained, skilled, and experienced in medical and clinical ethics.

A Cross-Sectional Study on Knowledge and Attitudes About Organ Donation and Transplantation in an Urban Population in a Low-Income Country.

BACKGROUND: Uganda's Health Sector Development Plan (2015/16 through 2019/2020) noted that most referrals for treatment abroad were for organ transplant services that cost the government >5.6 million USD. The government of Uganda has invested in building the capacity for organ donation and transplantation services by training human resources personnel and setting up infrastructure in Kampala, where these services can be accessed. However, there is no information on the readiness of communities and the scientific community to embrace (communities) or undertake (science) organ transplantation in the country. We set out to assess knowledge and attitudes about organ donation and transplantation among the urban population in Kampala. METHODS: We conducted a cross-sectional survey among 395 participants from the urban population of Kampala at Garden City Mall, Wandegeya market, and Nakawa market from 28 May through 7 June 2021. We asked about knowledge of organ donation and transplantation, collected sociodemographic data, and performed a sentiment analysis of participants' attitudes toward organ donation and transplantation. RESULTS: The M:F ratio of participants was 1:1; the majority (55.9%) of participants were Baganda, two-thirds of participants knew about organ donation, and 90% of participants did not know of any government policy on organ donation and transplantation. Radio/television was the most common source of information, and the kidney was the most frequently transplanted organ. Overall, there were 94.3% and 93.2% positive sentiments toward organ transplantation and organ donation, respectively. The need for stricter laws governing organ donation and transplantation, corruption, and fear were the main negative sentiments expressed by participants. CONCLUSIONS: Sensitization of the community is required regarding government policy on organ donation and transplantation, and this should be communicated through radio/television and social media. There was a positive attitude toward organ donation and transplantation.

Experiences of patients and next of kin on informed consent process for emergency surgery in two Urban university teaching hospitals in Uganda: a comparative cross sectional study.

Informed consent for emergency surgery is a process in which a patient or their next of kin must make quick decisions required for surgery in a life-threatening situation or surgery that may have life-altering outcomes. The objective of the study was to describe patients and their next of kin experiences and factors influencing the informed consent process in two urban university teaching hospitals in Uganda. METHODS: A cross-sectional survey involving patients who underwent emergency surgery and their next of kin was conducted in two tertiary care hospitals; one public and one private-not-for profit institution. A questionnaire was administered to collect sociodemographic information, type of Surgery that was done, how informed consent was obtained and experiences and expectations from the informed consent process. Univariate and multivariate analyses of the variables was done. RESULTS: We collected data from 210 patients from a public hospital and 170 from a private-not-for profit hospital. Overall, most patients did not have the risks of the surgery communicated to them (79.7%), were not given alternative options (87.6%) and had no opportunity to ask questions (57.4%). Patients at the private institution had 3.35 times the odds of expecting the consent form to be explained to them than those at the public institution. Patients at the public hospital had 0.12 times the odds of preferring to have consent administered by a nurse than patients at the private institution OR 0.12 (0.05-0.29, p < 0.001). Patients in the public institution had 0.18 times the odds of preferring to have consent administered by a doctor than patients in the private institution OR 0.18 (0.08-0.45, p < 0.001). CONCLUSION: Patients in both public and private institutions are not informed about the risks of surgery, alternative options and are not given the opportunity to ask questions. Interpretation of the findings of this study on patient preferences on who administered consent though statistically significant were inconclusive due to the responses not being mutually exclusive.

Informed consent process for emergency surgery: A scoping review of stakeholders' perspectives, challenges, ethical concepts, and policies.

Background: A scoping review of literature about the informed consent process for emergency surgery from the perspectives of the patients, next of kin, emergency staff, and available guiding policies. Objectives: To provide an overview of the informed consent process for emergency surgery; the challenges that arise from the perspectives of the patients, emergency staff, and next of kin; policies that guide informed consent for emergency surgery; and to identify any knowledge gaps that could guide further inquiry in this area. Methods: We searched Google Scholar, PubMed/MEDLINE databases as well as Sheridan Libraries and Welch Medical Library from 1990 to 2021. We included journal articles published in English and excluded non-peer-reviewed journal articles, unpublished manuscripts, and conference abstracts. The themes explored were emergency surgery consent, ethical and theoretical concepts, stakeholders' perceptions, challenges, and policies on emergency surgery. Articles were reviewed by three independent reviewers for relevance. Results: Of the 65 articles retrieved, 18 articles were included. Of the 18 articles reviewed, 5 addressed emergency informed consent, 9 stakeholders' perspectives, 7 the challenges of emergency informed consent, 3 ethical and theoretical concepts of emergency informed consent, and 3 articles addressed policies of emergency surgery informed consent. Conclusion: There is poor satisfaction in the informed consent process in emergency surgery. Impaired capacity to consent and limited time are a challenge. Policies recommend that informed consent should not delay life-saving emergency care and patient's best interests must be upheld.

Surgical Apgar score as a predictor of outcomes in patients following laparotomy at Mulago National Referral Hospital, Uganda: a prospective cohort study.

BACKGROUND: Postoperative complications and mortality following laparotomy have remained high worldwide. Early postoperative risk stratification is essential to improve outcomes and clinical care. The surgical Apgar score (SAS) is a simple and objective bedside prediction tool that can guide a surgeon's postoperative decision making. The objective of this study was to evaluate the performance of SAS in predicting outcomes in patients undergoing laparotomy at Mulago hospital. METHOD: A prospective observational study was conducted among eligible adult patients undergoing laparotomy at Mulago hospital and followed up for 4 months. We collected data on the patient's preoperative and intraoperative characteristics. Using the data generated, SAS was calculated, and patients were classified into 3 groups namely: low (8-10), medium (5-7), and high (0-4). Primary outcomes were in-hospital major complications and mortality. Data was presented as proportions or mean (standard deviation) or median (interquartile range) as appropriate. We used inferential statistics to determine the association between the SAS and the primary outcomes while the SAS discriminatory ability was determined from the receiver-operating curve (ROC) analysis. RESULTS: Of the 151 participants recruited, 103 (68.2%) were male and the mean age was 40.6 ± 15. Overall postoperative in-hospital major complications and mortality rates were 24.2% and 10.6%, respectively. The participants with a high SAS category had an18.4 times risk (95% CI, 1.9-177, p = 0.012) of developing major complications, while those in medium SAS category had 3.9 times risk (95% CI, 1.01-15.26, p = 0.048) of dying. SAS had a fair discriminatory ability for in-hospital major complications and mortality with the area under the curve of 0.75 and 0.77, respectively. The sensitivity and specificity of SAS ≤ 6 for major complications were 60.5% and 81.14% respectively, and for death 54.8% and 81.3%, respectively. CONCLUSION: SAS of ≤ 6 is associated with an increased risk of major complications and/or mortality. SAS has a high specificity with an overall fair discriminatory ability of predicting the risk of developing in-hospital major complications and/or death following laparotomy.

Comparison of QSOFA and sirs scores for the prediction of adverse outcomes of secondary peritonitis among patients admitted on the adult surgical ward in a tertiary teaching hospital in Uganda: a prospective cohort study.

BACKGROUND: SIRS and qSOFA are two ancillary scoring tools that have been used globally, inside and outside of ICU to predict adverse outcomes of infections such as secondary peritonitis. A tertiary teaching hospital in Uganda uses SIRS outside the ICU to identify patients with secondary peritonitis, who are at risk of adverse outcomes. However, there are associated delays in decision making given SIRS partial reliance on laboratory parameters which are often not quickly available in a resource limited emergency setting. In response to the practical limitations of SIRS, the sepsis-3 task force recommends qSOFA as a better tool. However, its performance in patients with secondary peritonitis in comparison to that of SIRS has not been evaluated in a resource limited setting of a tertiary teaching hospital in a low and middle income country like Uganda. OBJECTIVE: To compare the performance of qSOFA and SIRS scores in predicting adverse outcomes of secondary peritonitis among patients on the adult surgical wards in a tertiary teaching hospital in Uganda. METHODS: This was a prospective cohort study of patients with clinically confirmed secondary peritonitis, from March 2018 to January 2019 at the Accident and Emergency unit and the adult surgical wards of a tertiary teaching hospital in Uganda. QSOFA and SIRS scores were generated for each patient, with a score of ≥2 recorded as high risk, while a score of < 2 recorded as low risk for the adverse outcome respectively. After surgery, patients were followed up until discharge or death. In-hospital mortality and prolonged hospital stay were the primary and secondary adverse outcomes, respectively. Sensitivity, specificity, PPV, NPV and accuracy at 95% confidence interval were calculated for each of the scores using STATA v.13. RESULTS: A total of 153 patients were enrolled. Of these, 151(M: F, 2.4:1) completed follow up and were analysed, 2 were excluded. Mortality rate was 11.9%. Fourty (26.5%) patients had a prolonged hospital stay. QSOFA predicted in-hospital mortality with AUROC of 0.52 versus 0.62, for SIRS. Similarly, qSOFA predicted prolonged hospital stay with AUROC of 0.54 versus 0.57, for SIRS. CONCLUSION: SIRS is superior to qSOFA in predicting both mortality and prolonged hospital stay among patients with secondary peritonitis. However, overall, both scores showed a poor discrimination for both adverse outcomes and therefore not ideal tools.

High rates of gastroesophageal cancers in patients with dyspepsia undergoing upper gastrointestinal endoscopy in Uganda.

Background and study aims Dyspepsia is the most common presenting symptom in the gastrointestinal clinic of Mulago National Referral hospital. The etiology is essentially not fully described in our patient population. This study was therefore conducted to establish the causes of dyspepsia based on endoscopic diagnosis among patients with dyspepsia seeking care at the National Referral hospital of Uganda. Patients and methods This retrospective study conducted in the endoscopy unit of Mulago hospital reviewed 356 patient endoscopy reports spanning January 2018 to July 2020 with a focus on those with a referral indication of dyspepsia. Age and sex were the independent variables of interest while the endoscopy findings as reported by the endoscopist were the outcome variable of interest. Results Of the 356 endoscopy reports reviewed, 159 met the inclusion criterion of dyspepsia as the indication. Participant mean age was 47.7 years (±â€Š16.53) with the majority (25.79 %) in the fifth decade while the male to female ratio was 1. The majority of patients had organic dyspepsia (90.57 %) while the commonest finding was gastritis 69 (43.4 %). Gastroesophageal cancers represented (18) 11.32 % of all findings. There was a positive association between age > 50 years with gastroesophageal cancers (7.639) as well as age < 50 years and functional dyspepsia (2.794); however, all these were not statistically significant ( P  = 0.006 and ( P  = 0.095, respectively). Conclusions Organic/structural dyspepsia comprises over 90 % of investigated dyspepsia with 11 % comprising cancer among patients seeking endoscopy at the National Referral Hospital of Uganda.

Intravascular Thrombolysis Followed by Stenting as Management of Retrohepatic Inferior Vena Caval Thrombosis due to a Twist in the Inferior Vena Cava after Deceased Donor Liver Transplant.

Inferior vena cava (IVC) occlusion due to acute thrombosis is a rare but important vascular complication after deceased donor liver transplantation (DDLT) that has been reported to occur up to 2% of recipients in a posttransplant period. This may be caused by direct instrumentation of the IVC stenosis at the anastomotic site, haematoma, and rarely by a twist in the retrohepatic IVC. The location of the thrombus, the timing after the surgery, and associated hemodynamic disturbances define the outcome of the patient. Without prompt diagnosis and timely intervention, the outcome after IVC thrombosis is usually dismal. Herein, we report a rare case of near-complete occlusion of the IVC secondary to intracaval thrombosis after DDLT associated with twisting of the IVC at the suprahepatic anastomosis which was successfully managed by intravascular thrombolysis and stenting.

Feasibility of Simulation-Based Medical Education in a Low-Income Country: Challenges and Solutions From a 3-year Pilot Program in Uganda.

STATEMENT: Simulation is relatively new in many low-income countries. We describe the challenges encountered, solutions deployed, and the costs incurred while establishing two simulation centers in Uganda. The challenges we experienced included equipment costs, difficulty in procurement, lack of context-appropriate curricula, unreliable power, limited local teaching capacity, and lack of coordination among user groups. Solutions we deployed included improvisation of equipment, customization of low-cost simulation software, creation of context-specific curricula, local administrative support, and creation of a simulation fellowship opportunity for local instructors. Total costs for simulation setups ranged from US $165 to $17,000. For centers in low-income countries trying to establish simulation programs, our experience suggests that careful selection of context-appropriate equipment and curricula, engagement with local and international collaborators, and early emphasis to increase local teaching capacity are essential. Further studies are needed to identify the most cost-effective levels of technological complexity for simulation in similar resource-constrained settings.

Intra-abdominal hypertension in severe burns: prevalence, incidence and mortality in a sub-Saharan African hospital.

BACKGROUND: Severe burns have been shown to be a risk factor for developing intra-abdominal hypertension (IAH). Fluid resuscitation practices used in burns management further predispose patients to intra-abdominal hypertension. The mortality associated with IAH in severe burns is estimated to be more than 74.5% once organ dysfunction occurs. Despite 95% of all burns occurring in Low and Middle income countries (LMIC), there is paucity of published data on this topic in sub-Saharan Africa. OBJECTIVES: To determine the prevalence, incidence, organ dysfunction and mortality of intra-abdominal hypertension among severe burns patients. METHODS: A prospective cohort study was conducted over a 6 months period in the Burns Unit of Mulago National Referral Hospital. Patients of all age groups with burns ≥25% and 20% in adults and children respectively were recruited and followed up for 7 days or until death occurred. Patients with burns older than 48 hours were excluded. The outcome variables were intra-abdominal pressure, organ dysfunction and seven day mortality. RESULTS: Of all the 335 burns patients admitted, 64 patients met the inclusion criteria. The overall prevalence of IAH was 57.8% while the prevalence in the children and adults was 54.5% and 61.3% respectively. The incidence of IAH was 13.1 cases/100 person days with the incidence in adults being twice that of the children. The one week mortality of patients with IAH was 82.6% with the risk of dying being 3.34 (p=0.0035) and seven day survival being less than 50%. CONCLUSION: One in two patients with severe burns exceeding 20% or 25% in children or adults respectively developed IAH. Adults had a higher prevalence and incidence of IAH. Mortality associated with IAH exceeded 80%.

A Case of a 4-Year-Old Boy with a Mesenteric Chylous Cyst Infected with Histoplasma capsulatum.

Mesenteric cysts are uncommon entities and chyle- (lymph-) containing cysts are the rarest of this group. This is a case report of a 4-year-old boy with a mesenteric chylous cyst who was later found to have Histoplasma capsulatum infection.

Intra-abdominal hypertension; prevalence, incidence and outcomes in a low resource setting; a prospective observational study.

BACKGROUND: Intra-abdominal hypertension (IAH) is defined as a sustained elevation in intra-abdominal pressure (IAP) greater than or equal to 12 mmHg. IAH has been shown to cause organ derangements and dysfunction in the body. Objective screening of IAH is neither done early enough nor at all thus leading to significant morbidity and mortality among surgical patients. The epidemiology and outcome of IAH among surgical patients has not been documented in Uganda. The aim of this study was to determine the prevalence, incidence and outcome of intra-abdominal hypertension among patients undergoing emergency laparotomy. METHODOLOGY: Prospective observational study, conducted from January to April 2015 among patients undergoing emergency laparotomy. Inclusion criteria was; age >7 yrs, scheduled for emergency laparotomy, able to lie supine. EXCLUSION CRITERIA: pregnant, failed urethral catheterization, known cardiac, renal and respiratory disorders. Consecutive sampling was used. IAP, blood pressure, heart rate, respiratory rate, Sp02, Serum creatinine, Serum urea, and Urine output were measured preoperatively and postoperatively at 0, 6, 24 and 48 h. IAH was defined as IAP > 12 mmHg on three consecutive readings 3 min apart. RESULTS: In total 192 patients were enrolled. Mean age ± SD was 14.25 (±3.16) yrs in the paediatrics and 34.4(±13.72) yrs in the adults with male preponderance 65 and 80.7 % respectively. The prevalence of IAH was 25 % paediatrics and 17.4 % adults and the cumulative incidence after surgery was 20 % paediatrics and 21 % adults. In paediatrics, IAH was associated with mortality at 0 h postoperatively, RRR = 1:24, 95 % CI (1.371-560.178), p-value 0.048. In adults, the statistically significant outcomes associated with IAH were respiratory system dysfunction RRR1:2.783, p-value 0.023, 95 % CI (1.148-6.744) preoperatively and mortality RRR 1:2.933, p-value 0.034, 95 % CI (1.017-8.464) at 6 h, RRR 1:3.769, p-value 0.033, 95 % CI (1.113-12.760) at 24 h postoperatively. CONCLUSION: The prevalence and incidence of IAH in the paediatrics and adults group in our study population were high. IAH was associated with mortality in both adult and paediatrics groups and respiratory system dysfunction in adult group. This calls for objective monitoring of intraabdominal pressure in patients undergoing emergency laparotomy with the aim of reducing associated mortality.

Serum interleukin-6 level as an early marker of injury severity in trauma patients in an urban low-income setting: a cross-sectional study.

BACKGROUND: Trauma is still the leading cause of death in many regions of the world. Severity scores have been developed to assist in management of trauma victims. Immune response to trauma has been known to positively correspond to the severity of trauma. Part of this response involves release of cytokines into blood circulation which promote the acute inflammatory response commonly seen after trauma. Studies have shown that IL-6 levels commonly correlate positively with the Injury Severity Score (ISS). The aim of this cross-sectional study was to determine whether this kind of relationship exists between IL-6 levels and injury severity in trauma patients in Mulago Hospital as defined by the Kampala Trauma Score (KTSII) which is locally developed. METHODS: Trauma patients aged ≥18 years presenting to the Accident and Emergency unit of Mulago National Referral Hospital (MNRH) within 12 h after injury were recruited into the study after obtaining consent. Severity of injury was determined as per the Kampala Trauma Score (KTSII) and venous blood drawn for assay of serum IL-6 levels. Data obtained was entered and analyzed using Stata version 11 software focusing on the association between Serum IL-6 levels with Severity of trauma and duration of injury. RESULTS: A total of 159 patients were recruited (79 Mild and 80 Severe trauma) with a male to female ratio of 4.7:1. Road traffic crashes (67.92%) were the commonest cause of injury. Serum IL-6 levels were found to positively correspond with severity of injury (z = 4.718, p < 0.001). There was no significant correlation between serum IL-6 levels and duration of injury in both severe (r = 0.12, p = 0.29) and mild (r = 0.06, p = 0.62) trauma groups of patients. Only 9.43% of trauma patients were brought in an Ambulance. CONCLUSIONS: Serum IL-6 levels correspond with severity of injury. However, within the first twelve hours after injury, these levels did not vary significantly with duration of injury.

A qualitative analysis of health professionals' job descriptions for surgical service delivery in Uganda.

BACKGROUND: The ever increasing demand for surgical services in sub-Saharan Africa is creating a need to increase the number of health workers able to provide surgical care. This calls for the optimisation of all available human resources to provide universal access to essential and emergency surgical services. One way of optimising already scarce human resources for health is by clarifying job descriptions to guide the scope of practice, measuring rewards/benefits for the health workers providing surgical care, and informing education and training for health professionals. This study set out to determine the scope of the mandate to perform surgical procedures in current job descriptions of surgical care health professionals in Uganda. METHODS: A document review was conducted of job descriptions for the health professionals responsible for surgical service delivery in the Ugandan Health care system. The job descriptions were extracted and subjected to a qualitative content data analysis approach using a text based RQDA package of the open source R statistical computing software. RESULTS: It was observed that there was no explicit mention of assignment of delivery of surgical services to a particular cadre. Instead the bulk of direct patient related care, including surgical attention, was assigned to the lower cadres, in particular the medical officer. Senior cadres were assigned to perform predominantly advisory and managerial roles in the health care system. In addition, a no cost opportunity to task shift surgical service delivery to the senior clinical officers was identified. CONCLUSIONS: There is a need to specifically assign the mandate to provide surgical care tasks, according to degree of complexity, to adequately trained cadres of health workers. Health professionals' current job descriptions are not explicit, and therefore do not adequately support proper training, deployment, defined scope of practice, and remuneration for equitable surgical service delivery in Uganda. Such deliberate assignment of mandates will provide a means of increasing surgical service delivery through further optimisation of the available human resources for health.

High serum estradiol confers no risk for breast cancer: another disparity for sub Saharan Africa women.

INTRODUCTION: There are breast cancer epidemiological and tumor behaviour disparities between black women in sub Saharan Africa and their counter parts in western high resource countries. In Uganda, the incidence of breast cancer has nearly tripled in over a four decades for uncertain reasons. High serum estradiol is a known risk factor for breast cancer among women in high resourced nations. The objective of this study was to establish whether high serum estradiol is an associated risk for breast cancer amongst a group of black Ugandan women. METHODS: A case control study, conducted over eight month period with incident breast cancer as cases and the controls were without breast cancer but at risk and representative of the population from which the cases were chosen. Questionnaires were administered, clinical examination was done, serum estradiol level estimation was done using cobase immunoassay analyzer using Electro chemiluminescence Immuno assay (ECLIA). Data was analyzed using logistic regression model, and a p - value of less than 0.05 was considered significant. IRB approval was secured. RESULTS: A total of 140 women participated, 70 cases and 70 controls. The median estrogen levels was 43.2 pg/ml with IQR of 18.48 to 75.8 pg/ml, the value was higher among premenopausal women than those without cancer but with no statistical significance. No association was found between level of estradiol and breast cancer (p 0.647). The median oestrogen levels were significantly higher than normal levels in Caucasian women. CONCLUSION: There was no association between level of estradiol and breast cancer. This is yet another disparity between women of African origin and the non Africans in high resourced countries. There is need to explore more to explain this disparity.