Validation of Lung Ultrasound for COVID-19 Prognostication in an International Multicenter Cohort Study.

BACKGROUND: Despite many studies evaluating lung ultrasound (LUS) for COVID-19 prognostication, the generalizability and utility across clinical settings is uncertain. METHODS: Adults (≥18 years of age) with COVID-19 were enrolled at two military hospitals, an emergency department, home visits, and a homeless shelter in the United States, and in a referral hospital in Uganda. Participants had a 12-zone LUS scan performed at time of enrollment and clips were read off-site. The primary outcome was progression to higher level of care after the ultrasound scan. We calculated the cross-validated area under the curve for the validation cohort for individual LUS features. RESULTS: We enrolled 191 participants with COVID-19 were enrolled (57.9% female, median age 45.0 years, interquartile range [IQR]: 31.5, 58.0). Nine participants clinically deteriorated. The top predictors of worsening disease in the validation cohort measured by cross-validated area under the curve (cvAUC) were B-lines (0.88, 95% confidence interval [CI]: 0.87, 0.90), discrete B-lines (0.87, 95% CI: 0.85, 0.88), oxygen saturation (0.82, 95%: CI:0.81, 0.84), and A-lines (0.80, 95% CI: 0.78, 0.81). CONCLUSIONS: In an international multisite POCUS cohort, LUS parameters had high discriminative accuracy. Ultrasound can be applied towards triage across a wide breadth of care settings during a pandemic.

Feasibility Assessment of a Novel Isolation Care Tent in Uganda During the 2022 Sudan ebolavirus Outbreak.

This case study describes a feasibility assessment of a novel isolation care tent used in health facilities in Uganda during the 2022 Sudan ebolavirus outbreak. The Isolation System for Treatment and Agile Response to High-Risk Infections Model 1B (ISTARI 1B) is a single-occupancy, portable, negative-pressure isolation tent designed for the safe delivery of standard care to patients with a communicable disease, including Ebola disease (Sudan). At the request of the Uganda Ministry of Health, the Makerere University Infectious Diseases Institute and University of Nebraska Medical Center partnered to evaluate 7 health facilities across 4 districts in Uganda for infrastructure, case management, and infection prevention and control (IPC) capacity relevant to isolation care and ISTARI 1B use. A 3-day workshop was held with IPC leaders to provide familiarization and hands-on experience with the ISTARI 1B, delineate appropriate use scenarios in Ugandan healthcare settings, contextualize ISTARI 1B use in case management and IPC workflows, develop a framework for site assessment and implementation readiness, and consider ongoing monitoring, assessment, and intervention tools. Workshop participants performed a comprehensive site assessment and mock deployment of the ISTARI 1B. In this case study, we describe lessons learned from health facility assessments and workshop outcomes and offer recommendations to support successful ISTARI 1B implementation. Use scenarios and implementation strategies were identified across facility levels, including tools for site assessment, training, risk communication, and ongoing quality and safety monitoring.

The effect of a tuberculosis chest X-ray image reference set on non-expert reader performance.

OBJECTIVES: In low-resource settings, limitations in diagnostic accuracy of chest X-rays (CXR) for pulmonary tuberculosis (PTB) relate partly to non-expert interpretation. We piloted a TB CXR Image Reference Set (TIRS) to improve non-expert performance in an operational setting in Malawi. METHODS: Nineteen doctors and clinical officers read 60 CXR of patients with suspected PTB, at baseline and using TIRS. Two officers also used the CXR Reading and Recording System (CRRS). Correct treatment decisions were assessed against a "gold standard" of mycobacterial culture and expert performance. RESULTS: TIRS significantly increased overall non-expert sensitivity from 67.6 (SD 14.9) to 75.5 (SD 11.1, P = 0.013), approaching expert values of 84.2 (SD 5.2). Among doctors, correct decisions increased from 60.7 % (SD 7.9) to 67.1 % (SD 8.0, P = 0.054). Clinical officers increased in sensitivity from 68.0 % (SD 15) to 77.4 % (SD 10.7, P = 0.056), but decreased in specificity from 55.0 % (SD 23.9) to 40.8 % (SD 10.4, P = 0.049). Two officers made correct treatment decisions with TIRS in 62.7 %. CRRS training increased this to 67.8 %. CONCLUSION: Use of a CXR image reference set increased correct decisions by doctors to treat PTB. This tool may provide a low-cost intervention improving non-expert performance, translating into improved clinical care. Further evaluation is warranted. KEY POINTS: • Tuberculosis treatment decisions are influenced by CXR findings, despite improved laboratory diagnostics. • In low-resource settings, CXR interpretation is performed largely by non-experts. • We piloted the effect of a simple reference training set of CXRs. • Use of the reference set increased the number of correct treatment decisions. This effect was more marked for doctors than clinical officers. • Further evaluation of this simple training tool is warranted.

Transverse colon volvulus presenting as bowel obstruction, atelectasis, and displacement of the right lobe of the liver into the left upper abdominal quadrant: a case report.

BACKGROUND: Transverse colon volvulus is an uncommon cause of intestinal obstruction. It is a surgical emergency that can lead to bowel infarction, peritonitis, and death. CASE PRESENTATION: We report a case of transverse colon volvulus in a 35-year-old Congolese immigrant man who had a rare presentation with features of intestinal obstruction associated with right lung collapse and left mediastinal shift. CONCLUSION: This case is unusual because it presented with respiratory features that mimicked a pneumothorax in addition to features of intestinal obstruction. The use of point-of-care lung ultrasound was helpful in ruling out a pneumothorax, and this could help avoid situations such as unintentional chest drain insertions by other professionals who may encounter a similar case. Because transverse colon volvulus is rare, a high level of suspicion and awareness is required to make an accurate diagnosis.

Optimizing Highly Infectious Disease Isolation Unit Management: Experiences From the Infectious Diseases Isolation and Research Unit, Fort Portal, Uganda.

Infectious disease outbreaks on the scale of the current coronavirus disease 2019 (COVID-19) pandemic are a new phenomenon in many parts of the world. Many isolation unit designs with corresponding workflow dynamics and personal protective equipment postures have been proposed for each emerging disease at the health facility level, depending on the mode of transmission. However, personnel and resource management at the isolation units for a resilient response will vary by human resource capacity, reporting requirements, and practice setting. This study describes an approach to isolation unit management at a rural Uganda Hospital and shares lessons from the Uganda experience for isolation unit managers in low- and middle-income settings.

Diagnosis of cryptococcal and tuberculous meningitis in a resource-limited African setting.

OBJECTIVES: Cryptococcal meningitis (CM) and tuberculous meningitis (TBM) are common in HIV-infected adults in Africa and difficult to diagnose. Inaccurate diagnosis results in adverse outcomes. We describe patterns of meningitis in a Malawian hospital, focusing on features which differentiate CM and TBM with the aim to derive an algorithm using only clinical and basic laboratory data available in this resource-poor setting. METHODS: Consecutive patients admitted with meningitis were prospectively recruited, clinical features were recorded and cerebrospinal fluid (CSF) was examined. RESULTS: A total of 573 patients were recruited, and 263 (46%) had CSF consistent with meningitis. One hundred and twelve (43%) had CM and 46 (18%) had TBM. CM was associated with high CSF opening pressure and low CSF leukocyte count. Fever, neck stiffness and reduced conscious level were associated with TBM. A diagnostic index was constructed demonstrating sensitivity 83%and specificity 79% for the differentiation of CM and TBM. An algorithm was derived with 92% sensitivity for the diagnosis of CM, but only 58% specificity. CONCLUSIONS: Although we demonstrate features associated with CM and TBM, a sufficiently sensitive and specific diagnostic algorithm could not be derived, suggesting that the diagnosis of CM and TBM in resource-limited settings still requires better access to laboratory tools.

Leveraging investments in Ebola preparedness for COVID-19 in Sub-Saharan Africa.

The emergence of SARS-CoV-2 in China and transmission to more than 80 territories worldwide, including nine countries in Africa, presents a delicate situation for low-resource settings. Countries in Eastern and Central Africa have been on high alert since mid-2018 in anticipation of regional spread of the Ebola virus from the Democratic Republic of Congo. Significant investment has been made to support enhanced surveillance at point of entry and hospitals, infection control practices, clinical case management, and clinical research. With a new threat on the horizon, African countries have an opportunity to leverage the existing capacities for Ebola preparedness to brace for the imminent threat.

Pre-positioned Outbreak Research: The Joint Medical Emerging Diseases Intervention Clinical Capability Experience in Uganda.

The West Africa Ebola virus disease outbreak of 2014-2016 demonstrated that responses to viral hemorrhagic fever epidemics must go beyond emergency stopgap measures and should incorporate high-quality medical care and clinical research. Optimal patient management is essential to improving outcomes, and it must be implemented regardless of geographical location or patient socioeconomic status. Coupling clinical research with improved care has a significant added benefit: Improved data quality and management can guide the development of more effective supportive care algorithms and can support regulatory approvals of investigational medical countermeasures (MCMs), which can alter the cycle of emergency response to reemerging pathogens. However, executing clinical research during outbreaks of high-consequence pathogens is complicated and comes with ethical and research regulatory challenges. Aggressive care and excellent quality control must be balanced by the requirements of an appropriate infection prevention and control posture for healthcare workers and by overcoming the resource limitations inherent in many outbreak settings. The Joint Mobile Emerging Disease Intervention Clinical Capability was established in 2015 to develop a high-quality clinical trial capability in Uganda to support rigorous evaluation of MCMs targeting high-consequence pathogens like Ebola virus. This capability assembles clinicians, laboratorians, clinical researchers, logisticians, and regulatory professionals trained in infection prevention and control and in good clinical and good clinical laboratory practices. The resulting team is prepared to provide high-quality medical care and clinical research during high-consequence outbreaks.

Validating a novel index (SWAT-Bp) to predict mortality risk of community-acquired pneumonia in Malawi.

BACKGROUND: Community-acquired pneumonia is a major cause of mortality worldwide. Early assessment and initiation of management improves outcomes. In higher-income countries, scores assist in predicting mortality from pneumonia. These have not been validated for use in most lower-income countries. AIM: To validate a new score, the SWAT-Bp score, in predicting mortality risk of clinical community-acquired pneumonia amongst hospital admissions at Queen Elizabeth Central Hospital, Blantyre, Malawi. METHODS: The five variables constituting the SWAT-Bp score (male [S]ex, muscle [W]asting, non-[A]mbulatory, [T]emperature (>38°C or <35°C) and [B]lood [p]ressure (systolic<100 and/or diastolic<60)) were recorded for all patients with clinical presentation of a lower respiratory tract infection, presumed to be pneumonia, over four months (N=216). The sensitivity and specificity of the score were calculated to determine accuracy of predicting mortality risk. RESULTS: Median age was 35 years, HIV prevalence was 84.2% amongst known statuses, and mortality rate was 12.5%. Mortality for scores 0-5 was 0%, 8.5%, 12.7%, 19.0%, 28.6%, 100% respectively. Patients were stratified into three mortality risk groups dependent on their score. SWAT-Bp had moderate discriminatory power overall (AUROC 0.744). A SWAT-Bp score of ≥2 was 82% sensitive and 51% specific for predicting mortality, thereby assisting in identifying individuals with a lower mortality risk. CONCLUSION: In this validation cohort, the SWAT-Bp score has not performed as well as in the derivation cohort. However, it could potentially assist clinicians identifying low-risk patients, enabling rapid prioritisation of treatment in a low-resource setting, as it helps contribute towards individual patient risk stratification.

Sepsis carries a high mortality among hospitalised adults in Malawi in the era of antiretroviral therapy scale-up: a longitudinal cohort study.

OBJECTIVE: To assess mortality risk among adults presenting to an African teaching hospital with sepsis and severe sepsis in a setting of high HIV prevalence and widespread ART uptake. METHODS: Prospective cohort study of adults (age ≥16 years) admitted with clinical suspicion of severe infection between November 2008 and January 2009 to Queen Elizabeth Central Hospital, a 1250-bed government-funded hospital in Blantyre, Malawi. Demographic, clinical and laboratory information, including blood and cerebrospinal fluid cultures were obtained on admission. RESULTS: Data from 213 patients (181 with sepsis and 32 with severe sepsis; M:F = 2:3) were analysed. 161 (75.6%) patients were HIV-positive. Overall mortality was 22%, rising to 50% amongst patients with severe sepsis. The mortality of all sepsis patients commenced on antiretroviral therapy (ART) within 90 days was 11/28 (39.3%) compared with 7/42 (16.7%) among all sepsis patients on ART for greater than 90 days (p = 0.050). Independent associations with death were hypoxia (OR = 2.4; 95% CI, 1.1-5.1) and systolic hypotension (OR 7.0; 95% CI: 2.4-20.4). CONCLUSIONS: Sepsis and severe sepsis carry high mortality among hospitalised adults in Malawi. Measures to reduce this, including early identification and targeted intervention in high-risk patients, especially HIV-positive individuals recently commenced on ART, are urgently required.

Pneumonia severity scores in resource poor settings.

Clinical prognostc scores are increasingly used to streamline care in well-resourced setngs. The potental benefts of identfying patents at risk of clinical deterioraton and poor outcome, delivering appropriate higher level clinical care, and increasing efciency are clear. In this focused review, we examine the use and applicability of severity scores applied to patents with community acquired pneumonia in resource poor setngs. We challenge clinical researchers working in such systems to consider the generalisability of existng severity scores in their populatons, and where performance of scores is suboptmal, to promote eforts to develop and validate new tools for the beneft of patents and healthcare systems.

Severity assessment of lower respiratory tract infection in Malawi: derivation of a novel index (SWAT-Bp) which outperforms CRB-65.

OBJECTIVE: To assess the validity of CRB-65 (Confusion, Respiratory rate >30 breaths/min, BP<90/60 mmHg, age >65 years) as a pneumonia severity index in a Malawian hospital population, and determine whether an alternative score has greater accuracy in this setting. DESIGN: Forty three variables were prospectively recorded during the first 48 hours of admission in all patients admitted to Queen Elizabeth Central Hospital, Malawi, for management of lower respiratory tract infection over a two month period (N = 240). Calculation of sensitivity and specificity for CRB-65 in predicting mortality was followed by multivariate modeling to create a score with superior performance in this population. RESULTS: Median age 37, HIV prevalence 79.9%, overall mortality 18.3%. CRB-65 predicted mortality poorly, indicated by the area under the ROC curve of 0.649. Independent predictors of death were: Male sex, "S" (AOR 2.6); Wasting, "W" (AOR 6.6); non-ambulatory, "A" (AOR 2.5); Temp >38°C or <35°C, "T" (AOR 3.2); BP<100/60, "Bp" (AOR 3.7). Combining these factors to form a severity index (SWAT-Bp) predicted mortality with high sensitivity and specificity (AUC: 0.867). Mortality for scores 0-5 was 0%, 3.3%, 7.4%, 29.2%, 61.5% and 87.5% respectively. A score ≥3 was 84% sensitive and 77% specific for mortality prediction, with a negative predictive value of 95.8%. CONCLUSION: CRB-65 performs poorly in this population. The SWAT-Bp score can accurately stratify patients; ≤2 indicates non-severe infection (mortality 4.4%) and ≥3 severe illness (mortality 45%).