Death after cure: mortality among pulmonary tuberculosis survivors in rural Uganda.

OBJECTIVE: To determine the incidence of mortality and its predictors among pulmonary TB (PTB) survivors treated at a rural Ugandan tertiary hospital. METHODS: We conducted a retrospective chart review of data between 2013 and 2023. We included all people that met the WHO's definition of tuberculosis cure and traced them or their next of kin to determine vital status (alive/deceased). We estimated the cumulative incidence of mortality per 1,000 population, crude all-cause mortality rate per 1,000 person-years, and median years of potential life lost (YPLL) for deceased individuals. Using Cox proportional hazard models, we investigated predictors of mortality. RESULTS: Of 334 PTB survivors enrolled, 38 (11.4%) had died. The cumulative incidence of all-cause mortality was 113.7 per 1,000 population, and the crude all-cause mortality rate was 28.5 per 1,000 person-years. The median YPLL for deceased individuals was 23.8 years (IQR: 9.6-32.8). Hospitalization (aHR: 4.3, 95% CI: 1.1-16.6) and unemployment (aHR: 7.04, 95% CI: 1.5-31.6) at TB treatment initiation predicted mortality. CONCLUSION: PTB survivors experience post high mortality rates after TB cure. Survivors who were hospitalized and unemployed at treatment initiation were more likely to die after cure. Social protection measures and long-term follow-up of previously hospitalized patients could improve the long-term survival of TB survivors.

Prevalence, Clinical Features, and Predictors of Adrenal Insufficiency in Adults With Tuberculosis or HIV: A Systematic Review and Meta-analysis.

Background: Despite the high frequency of adrenal insufficiency (AI) in patients with tuberculosis or HIV, its diagnosis is often missed or delayed resulting in increased mortality. This systematic review and meta-analysis aimed to document the prevalence, significant clinical features, and predictors of AI in adult patients with tuberculosis or HIV. Methods: We systematically searched databases (Medline, Embase, CINAHL, Cochrane Library, and Africa Journal Online) for published studies on AI in adult patients with tuberculosis or HIV. The pooled prevalence of AI was determined by a random-effect model meta-analysis. A narrative review was used to describe the significant clinical features and predictors of AI in adult patients with tuberculosis or HIV. Results: A total of 46 studies involving 4044 adults were included: 1599 with tuberculosis and 2445 with HIV. The pooled prevalence of AI was 33% (95% CI, 22%-45%; I2 = 97.7%, P < .001) in participants with tuberculosis and 28% (95% CI, 18%-38%; I2 = 98.9%, P < .001) in those with HIV. Presentation with multidrug-resistant tuberculosis, abdominal pain, salt craving, myalgia, increased severity and duration of tuberculosis disease, and the absence of nausea predicted AI in participants with tuberculosis in 4 studies. Cytomegalovirus antigenemia positivity, rifampicin therapy, and eosinophilia >3% predicted AI in participants with HIV in 2 studies. Conclusions: AI is relatively common in adults with tuberculosis or HIV. Its timely screening, diagnosis, and management in patients with these 2 conditions should be encouraged to avert mortality.

Readiness To Manage Ebola Virus Disease Among Emergency Healthcare Workers in Uganda: A Nationwide Multicenter Survey.

Background: Emerging infectious diseases like the Ebola Virus Disease (EVD) pose significant global public health threats. Uganda has experienced multiple EVD outbreaks, the latest occurring in 2022. Frontline healthcare workers (HCWs) are at increased risk, yet there isn't sufficient evidence of existing knowledge of EVD of these health workers. We aimed to assess the readiness of Uganda's emergency healthcare workers to manage Ebola virus disease (EVD) and identify their training needs to inform targeted capacity-building interventions for future outbreaks. Methods: This multicentre nationwide cross-sectional study was conducted from July to August 2023 among 691 HCWs providing emergency care in 14 secondary and tertiary hospitals across Uganda. Participants were consecutively recruited using the probability-proportional-to-size sampling technique, and data was collected using a self-reported questionnaire. Factors associated with EVD knowledge were identified through a mixed-effect linear model. Results: Data from 691 eligible HCWs with a median age of 32 (IQR: 28-38) was analyzed (response rate: 92%). Only one-third (34.4%, n = 238) had received EVD training in the past year. The median EVD knowledge score was 77.4% (IQR: 71.2% - 83.4%). EVD knowledge was associated with longer professional experience in years (ß: 0.21, 95% CI: 0.03 to 0.39, p = 0.024) and higher level of education: diploma (ß: 3.37, 95% CI: 1.49 to 5.25, p < 0.001), undergraduate degree (ß: 6.45, 95% CI: 4.11 to 8.79) and postgraduate degree (ß: 7.13, 95% CI: 4.01 to 10.25, p < 0.001). Being a doctor (ß: 2.55, 95% CI: 0.35 to 4.74, p = 0.023), providing care in the obstetrics/gynecology department (ß: -1.90, 95% CI: -3.47 to - 0.32, p = 0.018), previous EVD training (ß: 2.27, 95% CI: 0.96 to 3.59, p = 0.001) and accessing EVD information through social media (ß: 2.52, 95% CI: 1.17 to 3.88, p < 0.001) were also significantly associated with EVD knowledge. Conclusion: Our study reveals that Ugandan HCWs' EVD response readiness varies by individual factors and information sources. We recommend targeted training and suggest future research on educational innovations and social media's potential to fill knowledge gaps.

Association between biomarkers of inflammation and dyslipidemia in drug resistant tuberculosis in Uganda.

BACKGROUND: Active tuberculosis (TB) significantly increases the risk of cardiovascular disease, but the underlying mechanisms remain unclear. This study aimed to investigate the association between inflammation biomarkers and dyslipidemia in patients with drug-resistant TB (DR-TB). METHODS: This was a secondary analysis of data from a cross-sectional multi-center study in Uganda conducted 2021. Participants underwent anthropometric measurements and laboratory tests included a lipid profile, full haemogram and serology for HIV infection. Dyslipidemia was defined as total cholesterol > 5.0 mmol/l and/or low-density lipoprotein cholesterol > 4.14 mmol/l, and/or triglycerides (TG) ≥ 1.7 mmol/l, and/or high density lipoprotein cholesterol (HDL-c) < 1.03 mmol/l for men and < 1.29 mmol/l for women. Biomarkers of inflammation were leukocyte, neutrophil, lymphocyte, monocyte, and platelet counts, as well as neutrophil/lymphocyte (NLR), platelet/lymphocyte, and lymphocyte/monocyte (LMR) ratios, mean corpuscular volume (MCV), and the systemic immune inflammation index (SII) (neutrophil × platelet/lymphocyte). Modified Poisson Regression analysis was used for determining the association of the biomarkers and dyslipidemia. RESULTS: Of 171 participants, 118 (69.0%) were co-infected with HIV. The prevalence of dyslipidemia was 70.2% (120/171) with low HDL-c (40.4%, 69/171) and hypertriglyceridemia (22.5%, 38/169) being the most common components. Patients with dyslipidemia had significantly higher lymphocyte (P = 0.008), monocyte (P < 0.001), and platelet counts (P = 0.014) in addition to a lower MCV (P < 0.001) than those without dyslipidemia. Further, patients with dyslipidemia had lower leucocyte (P < 0.001) and neutrophil (P = 0.001) counts, NLR (P = 0.008), LMR (P = 0.006), and SII (P = 0.049). The MCV was inversely associated with low HDL-C (adjusted prevalence ratio (aPR) = 0.97, 95% CI 0.94-0.99, P = 0.023) but was positively associated with hypertriglyceridemia (aPR = 1.04, 95% CI 1.00-1.08, P = 0.052). CONCLUSIONS: Individuals with dyslipidemia exhibited elevated lymphocyte, monocyte, and platelet counts compared to those without. However, only MCV demonstrated an independent association with specific components of dyslipidemia. There is need for further scientific inquiry into the potential impact of dyslipidemia on red cell morphology and a pro-thrombotic state among patients with TB.

Tuberculosis and diabetes mellitus comorbidity in an adult Ugandan population.

BACKGROUND: Diabetes mellitus (DM) has a direct impact on the clinical manifestation and prognosis of active tuberculosis disease (TB) and is known to increase the chance of developing the condition. We sought to determine the prevalence of DM in adult Ugandan patients with recently diagnosed TB and the associated sociodemographic, anthropometric, and metabolic characteristics of TB-DM comorbidity. METHODS: In this cross-sectional study conducted at the adult TB treatment centres of three tertiary healthcare facilities in Uganda, we screened adult participants with recently diagnosed TB (diagnosed in < 2 months) for DM. All participants were screened with five tests; initially with a random blood glucose (RBG) test, and then later with fasting blood glucose (FBG), laboratory-based glycated hemoglobin (HbA1c), point-of-care (POC) HbA1c, and oral glucose tolerance test (OGTT) if the RBG was ≥ 6.1 mmol/l. The WHO guidelines for diagnosing and managing DM were used to support the DM diagnosis. To identify the factors associated with DM-TB comorbidity, logistic regression was used. RESULTS: A total of 232 participants with recently diagnosed TB were screened for DM. Of these, 160 (69%) were female. The median (IQR) age, body mass index, and RBG of all study participants was 35 (27-42) years, 19.2 (17.6-21.3) kg/m2, and 6.1 (5.5-7.2) mmol/l, respectively. About half of the participants (n = 117, 50.4%) had RBG level ≥ 6.1 mmol/l. Of these, 75 (64.1%) participants returned for re-testing. Diabetes mellitus was diagnosed in 32 participants, corresponding to a prevalence of 13.8% (95% CI 9.9-18.9). A new diagnosis of DM was noted in 29 (90.6%) participants. On logistic regression, age ≥ 40 years was associated with increased odds of TB and DM comorbidity (AOR 3.12, 95% CI 1.35-7.23, p = 0.008) while HIV coinfection was protective (AOR 0.27, 95% CI 0.10-0.74, p = 0.01). CONCLUSION: TB and DM comorbidity was relatively common in this study population. Routine screening for DM in adult Ugandan patients with recently diagnosed TB especially among those aged ≥ 40 years and HIV-negative patients should be encouraged in clinical practice.

Diagnostic Accuracy of Clinical Diagnostic Scoring Systems for Childhood Tuberculosis: A Systematic Review and Meta-analysis.

Background: Diagnosis of childhood tuberculosis (TB) poses several challenges. Therefore, point-based scoring systems and diagnostic algorithms have been developed to improve the diagnostic yields in this population. However, there are no updated systematic reviews of the existing childhood TB scoring systems and algorithms. Hence, we systematically reviewed the diagnostic accuracy of the childhood TB diagnostic scoring systems and algorithms. Methods: We systematically searched PubMed, CINAHL, Embase, Scopus, and Google Scholar databases for relevant articles published until 30 March 2023. QUADAS-2 was used to assess their study quality. Diagnostic accuracy measures (ie, sensitivity, specificity, diagnostic odds ratio, positive and negative likelihood ratios) were pooled using a random-effects model. Results: We included 15 eligible studies, with a total of 7327 study participants aged <15 years, with 10 evaluations of childhood TB diagnostic scoring systems and algorithms. Among these algorithms and scoring systems, only 3 were evaluated more than once. These were the Keith Edwards scoring system with 5 studies (sensitivity, 81.9%; specificity, 81.2%), Kenneth Jones criteria with 3 studies (sensitivity, 80.1%; specificity, 45.7%), and the Ministry of Health-Brazil algorithm with 3 studies (sensitivity, 79.9%; specificity, 73.2%). Conclusions: We recommend using the Keith Edwards scoring system because of its high sensitivity and specificity. Further research is necessary to assess the effectiveness of scoring systems and algorithms in identifying TB in children with HIV and malnutrition.

A rare case of multi-drug resistant Raoultella ornithinolytica-induced sepsis in a healthy young man in Uganda.

Key Clinical Message: Antimicrobial resistance (AMR) is a public health challenge. It causes unresponsiveness to treatment with antimicrobials, leads to sepsis, septic shock, and increased hospital mortality. This is compounded by new multidrug resistant organisms. We present and discuss a case of sepsis caused by a rare multi-drug resistant bacterium Raoultella ornithinolytica. Abstract: Antimicrobial resistance is a major public health concern worldwide, associated with nearly 5 million deaths. The highest mortality attributed to AMR is seen in sub-Saharan Africa. Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa contribute to most deaths attributed to AMR globally. However, other uncommon microorganisms have been implicated. Few cases of resistant, extended-spectrum beta-lactamase (ESBL) producing Raoultella ornithinolytica have been reported to cause sepsis worldwide. To our knowledge, no case of R. ornithinolytica-induced sepsis has been reported in our settings. We report a case of sepsis due to R. ornithinolytica in an injured young adult. We received a 36-year-old man, a professional banker involved in a road traffic accident 2 h before admission. He sustained a deep degloving wound on the right ankle with exposure of the lateral malleolus and presented with severe pain, and bleeding at the injury site. x-Rays confirmed a comminuted intra-articular distal tibia and fibular fracture. Surgical debridement and external fixation were aseptically done on the same day. Below knee amputation was done on the 7th day post-admission due to extensively injured and infected limb with sepsis. Local pus culture isolated ESBL-positive R. ornithinolytica susceptible only to meropenem, ciprofloxacin, and amikacin. Introducing these antibiotics on the 11th post-admission day averted sepsis and enhanced patient recovery. With the threat of AMR, newly emerging highly resistant microbes should be expected and suspected. Early recognition of sepsis and its focus and precise intervention with antimicrobials guided by specimen culture and susceptibility profile is highly recommended and should be standard practice. It highly reduces morbidity and mortality due to sepsis.

Stigma and Associated Sex Disparities Among Patients with Tuberculosis in Uganda: A Cross-Sectional Study.

Background: Tuberculosis (TB) is one of the leading causes of death from a single infectious agent globally. Stigma associated with TB encompassing self-, anticipated-, and public-stigma has significant negative effects on treatment adherence. In Uganda, limited data exist on the prevalence of stigma and its relationship with sex among patients with TB. We evaluate prevalence of three types of stigma and their relationship with the sex of patients undergoing TB treatment. Methods: This cross-sectional study was conducted between July 2020 to March 2021 at selected TB clinics in Kampala, Uganda. Eligible participants were aged 18-65 with confirmed TB and starting their prescribed treatment. We collected data on socio-demographics and used 13 items to capture the self-, anticipated-, and public-stigma from which we composed the dependent variables. The primary independent variable was sex. We employed multivariable logistic regression analysis to evaluate the association between sex and the three stigma types. Additionally, we considered potential confounders such as age, HIV, and employment status. Statistical significance was defined as p<0.05. Results: In this study we enrolled 144 participants with a mean age of 35.8 years (standard deviation = 12). Half of the participants (50%, n=72) were female, 44% had a secondary education, 37.5% were unemployed, and 32.6% were co-infected with HIV. The prevalence of self-stigma was 71.1%, anticipated stigma was 75.7%, and public stigma was 41.7%. Significant factors were associated with self-stigma were female sex (adjusted odds ratio (AOR): 2.35 95% CI: 1.02-5.74) and unemployment (AOR: 2.95 95% CI: 1.16-8.58). HIV-positive status was significantly associated with anticipated stigma (AOR: 3.58 95% CI: 1.38-11.23). However, none of the variables we evaluated showed a significant association with public stigma. Conclusions: Our study showed a high prevalence of self, anticipated and public stigma among TB patients. Notably, females and unemployed individuals were at a higher risk of self-stigma, while those with HIV/AIDS and TB were more likely to report anticipated stigma. To combat stigma effectively, interventions should be tailored to cater to sex-specific needs and persons living with HIV. Future research should delve further in determinants of TB-related stigma in high-burden settings.

"I thought I was going to die": Experiences of COVID-19 patients managed at home in Uganda.

BACKGROUND: In Uganda, approximately 170,000 confirmed COVID-19 cases and 3,630 deaths have been reported as of January 2023. At the start of the second COVID-19 wave, the Ugandan health system was overwhelmed with a sudden increase in the number of COVID-19 patients who needed care, and the Ministry of Health resorted to home-based isolation and care for patients with mild to moderate disease. Before its rollout, the COVID-19 home-based care strategy had neither been piloted nor tested in Uganda. OBJECTIVE: To explore the experiences of COVID-19 patients managed at home in Uganda. METHODS: This was a qualitative study that was conducted to explore the lived experiences of COVID-19 patients managed at home. The study was carried out among patients who presented to three hospitals that were designated for treating COVID-19 patients in Uganda. COVID-19 patients diagnosed at these hospitals and managed at home were followed up and contacted for in-depth telephone interviews. The data were analysed using thematic content analysis with the aid of NVIVO 12.0.0 (QRS International, Cambridge, MA). RESULTS: Participants experienced feelings of fear and anxiety: fear of death, fear of losing jobs, fear of infecting loved ones and fear of adverse events such as loss of libido. Participants also reported feelings of loneliness, hopelessness and depression on top of the debilitating and sometimes worsening symptoms. In addition to conventional medicines, participants took various kinds of home remedies and herbal concoctions to alleviate their symptoms. Furthermore, COVID-19 care resulted in a high economic burden, which persisted after the COVID-19 illness. Stigma was a major theme reported by participants. Participants recommended that COVID-19 care should include counselling before testing and during and after the illness to combat the fear and stigma associated with the diagnosis. Another recommendation was that health workers should carry out home visits to patients undergoing home-based care and that COVID-19 treatment should be free of charge. CONCLUSION: COVID-19 home-based care was associated with fear, anxiety, loneliness, depression, economic loss and stigma. Policymakers should consider various home-based follow-up strategies and strengthen counselling of COVID-19 patients at all stages of care.

Isolated renal and urinary tract aspergillosis: a systematic review.

Background: Aspergillosis localized to the kidneys and the urinary tract is uncommon. We conducted a comprehensive systematic review to evaluate risk factors and clinical outcomes of patients with isolated renal and genito-urinary tract aspergillosis. Methods: We systematically searched Medline, CINAHL, Embase, African Journal Online, Google Scholar, and the Cochrane Library, covering the period from inception to August 2023 using the key terms 'renal' OR 'kidney*' OR 'prostate' OR 'urinary bladder' OR 'urinary tract*AND 'aspergillosis' OR 'aspergillus' OR 'aspergilloma' OR 'mycetoma'. We included single case reports or case series. Review articles, guidelines, meta-analyses, animal studies, protocols, and cases of genitourinary and /or renal aspergillosis occurring as a part of disseminated disease were excluded. Results: We identified 91 renal and urinary aspergillosis cases extracted from 76 publications spanning 1925-2023. Among the participants, 79 (86.8%) were male, with a median age of 46 years. Predominantly, presentations consisted of isolated renal infections (74 instances, 81.3%), followed by prostate (5 cases, 5.5%), and bladder (7 cases, 7.7%) involvement. Aspergillus fumigatus (42.9%), Aspergillus flavus (9.9%), and Aspergillus niger/glaucus (1.1% each) were isolated. Underlying risk factors included diabetes mellitus (29.7%), HIV (12.1%), haematological malignancies (11%), and liver cirrhosis (8.8%), while common symptoms encompassed flank pain (36.3%), fever (33%), and lower urinary tract symptoms (20.9%). An autopsy was conducted in 8.8% of cases. Diagnostic work-up involved histopathology (70.5%), renal CT scans and urine microscopy and culture (52.6% each), and abdominal ultrasound (17.9%). Treatments included amphotericin B (34 cases, 37.4%) and azole-based regimens (29 cases, 31.9%). Nephrectomy was performed in 16 of 78 renal cases (20.5%). All-cause mortality was 24.4% (19 cases). No significant mortality rate difference was observed among antifungal regimens (p = 0.739) or nephrectomy status (p = 0.8). Conclusion: Renal and urinary aspergillosis is an important cause of morbidity and mortality, particularly in immunocompromised and people with diabetes mellitus. While varied treatment strategies were observed, mortality rates showed no significant differences based on treatments or nephrectomy status. Further research is needed to refine diagnostics, optimize treatments, and enhance awareness among clinicians for early detection and management. PROSPERO registration number: CRD42023430959.

What you need to know now about kidney and urinary tract infections caused by the fungus aspergillus In this study, we investigated the rare occurrence of aspergillosis, a fungal infection caused by the mold Aspergillus, specifically affecting the kidneys and urinary tract (ureters, urinary bladder, prostate and urethra). This disease was first described in 1891 in Germany. To update our current understanding of this rare disease, we conducted a thorough review, examining risk factors and outcomes for individuals with Aspergillus infection of the kidney and/or urinary tract. We found 91 cases from 76 published articles spanning nearly a century, identifying common features such as predominantly male patients (almost every 9 in 10 cases) and isolated infection of one or both kidneys being the most common (8 in 10 cases). Diabetes mellitus, HIV infection, and certain cancers were noted as underlying risk factors, with symptoms ranging from flank pain, passing of blood in urine, passing of fungal particles (bezoars) in urine, pain while passing urine to fever. Diagnostic methods included histopathology and imaging techniques, while treatments varied, involving antifungal medications such as voriconazole and amphotericin B, drainage of abscesses, and, in some cases, surgical removal of the affected kidney (nephrectomy). Overall, about 1 in every 4 of the affected people died. Despite diverse treatment approaches, the study found no significant difference in mortality rates, emphasizing the need for further research to improve diagnostics, refine treatments, and raise awareness for early detection and management, especially among immunocompromised individuals such as those with diabetes mellitus and HIV infection.

Prevalence of chronic pulmonary aspergillosis along the continuum of pulmonary tuberculosis care: A protocol for a living systematic review and meta-analysis.

INTRODUCTION: Chronic pulmonary aspergillosis (CPA) is a debilitating disease estimated to affect over 3 million people worldwide. Pulmonary tuberculosis (PTB) is the most significant risk factor for CPA. However, the true burden of CPA at the time of PTB diagnosis, during, and after PTB treatment remains unknown. In this paper, we present a protocol for a living systematic review aimed at estimating the current burden of CPA along the continuum of PTB care. MATERIALS AND METHODS: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) guidelines to formulate this protocol, which is registered with the International Prospective Register of Systematic Reviews (PROSPERO: CRD42023453900). We will identify primary literature through various electronic databases, including CINAHL, Ovid MEDLINE, MEDLINE (PubMed), EMBASE, Google Scholar, Cochrane Database of Systematic Reviews, and African Journal Online. The search will encompass articles from inception to December 31st, 2023, using medical subject heading search terms "pulmonary tuberculosis" AND "chronic pulmonary aspergillosis". Two reviewers will independently assess titles, abstracts, and full texts for eligibility using the Covidence web-based software. The eligible studies will comprise original observational research that reports on the prevalence of CPA diagnosed in individuals with PTB, based on established criteria, without language or geographic restriction. We intend to exclude single case reports and case series with fewer than 10 participants, as well as review articles, guidelines, and letters to the editors. Cochrane Risk of Bias Tools (ROB2 and ROBINS-I) will used to assess study quality and risk of bias and the quality of the evidence will be rated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. Our data syntheses will encompass meta-analysis and meta-regression, conducted using STATA version 18 and R- Studio version 4.0.2. This systematic review will be updated every 3-5 years as more data emerges. CONCLUSIONS: The findings of this proposed systematic review will summarize the available evidence on the occurrence of CPA, at the time of PTB diagnosis, during and after PTB treatment. The study results have the potential to guide healthcare policies regarding screening for CPA, enhance clinical decision-making, and catalyse further research into understanding the interplay between PTB and CPA. By shedding light on the current burden of CPA along the continuum of PTB care, we aspire to contribute to the betterment of patient care, disease management, and global health outcomes. PROSPERO REGISTRATION: CRD42023453900.

Diagnostic accuracy of two confirmatory tests for diabetes mellitus in adult Ugandans with recently diagnosed tuberculosis.

Objective: The optimal confirmatory tests for diabetes mellitus (DM) in patients with tuberculosis (TB) vary across populations. This study aimed to evaluate the performance of two confirmatory tests for DM against the oral glucose tolerance test (OGTT) as the reference test in adult Ugandans with recently diagnosed TB. Methods: A total of 232 adult participants receiving TB treatment underwent initial screening for DM with random blood glucose (RBG) measurement. Participants with a RBG level ⩾6.1 mmol/l received additional screening with fasting blood glucose (FBG), laboratory-measured glycated haemoglobin (HbA1c) and an OGTT. Using the latter as the gold standard and reference test, we evaluated the diagnostic accuracy of laboratory-measured HbA1c and FBG. Results: Of the 232 participants initially screened for DM using RBG measurement, 117 participants (50.4%) had RBG level ⩾6.1 mmol/l and were scheduled to return for additional blood glucose testing. Of these, 75 (64.1%) participants returned for FBG and HbA1c measurements. A diagnosis of DM was made in 32 participants, corresponding to a prevalence of 13.8% [95% CI 9.9-18.9].The areas under the curve (AUC) for FBG and laboratory-measured HbA1c were 0.69 [95% CI 0.47-0.90] and 0.65 [95% CI 0.43-0.87], respectively. The sensitivity and specificity of a FBG level of ⩾7 mmol/l were 57.1% [95% CI 18.4-90.1] and 74.6% [95% CI 62.5-84.5], respectively, whereas the sensitivity and specificity for laboratory-measured HbA1c of ⩾6.5 mmol/l (48 mmol/mol) were 14.3% [95% CI 0.40-57.9] and 95.3% (86.9-99.0%), respectively. Conclusion: FBG may be better than laboratory-measured HbA1c in confirming DM in adult Ugandans with recently diagnosed TB. However, because of the small study sample size, larger studies evaluating the diagnostic utility of these diabetes screening tests in adult Ugandans with TB are needed to confirm these findings.

Appropriate diabetes test in patients with tuberculosis Diabetes mellitus (DM) is a common condition in patients with tuberculosis and proactively screening for the condition is encouraged in all adult patients with tuberculosis. In this study, a total of 232 adult Ugandans with recently diagnosed tuberculosis were screened for DM using random glucose test, fasting blood glucose test, glycated haemoglobin test and an oral glucose tolerance test (OGTT), as the gold-standard and reference test. Compared with the OGTT, a fasting blood glucose test was noted to be a better screening test for diabetes mellitus than glycated haemoglobin in these patients and may be used as a follow-up test to random blood glucose in the screening and diagnosis of DM in adult Ugandans with tuberculosis.

Respiratory morbidity in Schistosoma mansoni infection: a rapid review of literature.

Background: Schistosomiasis contributes to 2.5 million disability-adjusted life years globally. Acute and chronic respiratory morbidity of Schistosoma mansoni (S. mansoni) is poorly documented in the literature. We conducted a rapid literature review of the burden of respiratory symptoms and lung function abnormalities among patients with S. mansoni. We also report the immunologic and lung imaging findings from the studies reviewed. Methods: We carried out a comprehensive literature search in Embase and MEDLINE from the inception of the databases to 13th March 2023. Results: A total of 2243 patients with S. mansoni were reported from 24 case reports, 11 cross-sectional studies, 7 case series, 2 cohort studies and 2 randomized controlled trials. The prevalence of any respiratory symptom was 13.3-63.3% (total number of patients studied, n = 149). The prevalence of the individual symptoms among patients with S. mansoni in whom respiratory symptoms were sought for was as follows: cough (8.3-80.6%, n = 338), dyspnea (1.7-100.0%, n = 200), chest pain (9.0-57.1%, n = 86), sputum production (20.0-23.3%, n = 30) and wheezing (0.0 - 20.0%, n = 1396). The frequency of the symptoms tended to be higher in acute schistosomiasis. Restrictive lung disease was prevalent in 29.0% (9/31). The commonest chest imaging findings reported were nodules (20-90%, n = 103) and interstitial infiltrates (12.5-23.0%, n = 89). Peripheral blood eosinophilia was prevalent in 72.0-100.0% of patients (n = 130) with acute schistosomiasis and correlated with symptoms and imaging abnormalities. Three case reports in chronic S. mansoni reported elevated C-reactive protein, leucocyte, neutrophil and absolute eosinophil counts, eosinophil percentage, IgE and IgG4. Conclusion: There is a high prevalence of respiratory morbidity among patients with S. mansoni, particularly in the acute stage of the infection, although the studies are relatively small. Larger studies are needed to characterize respiratory morbidity in chronic schistosomiasis and determine the underlying clinical and immunological mechanisms.

Respiratory problems in people with bilharzia Bilharzia causes significant health problems among those affected. However, little is known about respiratory problems associated with bilharzia. We systematically searched for studies published on bilharzia and respiratory problems in literature. We found that a high proportion of people with bilharzia report cough, difficulty in breathing, chest pain, sputum production and wheezing. Also, a good number have lung function impairment and abnormalities on X-ray imaging. Blood eosinophils tended to be associated with the respiratory symptoms and imaging abnormalities which suggests that eosinophils may be involved in causing respiratory problems. We conclude that lung problems are common among people with bilharzia although the studies reviewed were small and mostly among people with acute infection. Larger studies are needed to further characterise lung problems in Bilharzia.

Burden and associated phenotypic characteristics of tuberculosis infection in adult Africans with diabetes: a systematic review.

Diabetes mellitus (DM) increases the risk of developing tuberculosis infection (TBI). However, the evidence on the burden and phenotypic characteristics of TBI in African patients with DM is limited. This study aimed to determine the prevalence and characterisation of TBI in native African patients living with DM. We searched PubMed, EMBASE, and African Journals Online for original studies reporting information on the prevalence and characteristics of TBI in adult Africans with DM. A forest plot was used to describe the pooled prevalence estimate of TBI and the corresponding 95% confidence intervals (CI). Six studies conducted in four African countries involving 721 participants with DM were included in this systematic review. The pooled prevalence estimate of TBI was 40% (95% CI 20-60%, I2 = 98.52%, p < 0.001). Age ≥ 40 years and glycated haemoglobin levels independently predicted TBI positivity in patients with DM in three studies. Africans with DM have a high prevalence of TBI, especially those who are older or with poorly controlled diabetes. This justifies the need for studies to explore how to screen and manage TBI to avert the progression to active TB disease.

Clinical features, resistance patterns and treatment outcomes of drug-resistant extra-pulmonary tuberculosis: A scoping review.

Background: Drug-resistant tuberculosis (DR-TB) is a threat to tuberculosis (TB) control. Extra-pulmonary forms of DR-TB (DR-epTB) are not well characterized. This review summarizes the clinical features, resistance patterns and treatment outcomes of DR-epTB. Methods: We searched EMBASE to identify studies that reported drug-resistance among extra-pulmonary TB sites. All age groups were included in this review. Studies which did not describe drug-resistance patterns at extra-pulmonary TB sites were excluded. We summarized the proportion of resistance to individual anti-TB drugs as well as multi-drug resistant (MDR), pre-extensively drug resistant (pre-XDR) and extensively drug-resistant (XDR) TB. Results: Eighteen studies with a total of 10,222 patients with extra-pulmonary TB of whom 1,236 (12.0%) had DR-epTB, were included in this review. DR-epTB was mostly reported in young people aged 28 to 46 years. While TB meningitis is the most commonly studied form, adenitis is the commonest form of DR-epTB reported in 21% to 47%. Central nervous system TB (3.8% to 51.6%), pleural TB (11.3% to 25.9%), skeletal TB (9.4% to 18.1%), abdominal TB (4.3% to 6.5%), and disseminated TB (3.8%) are also encountered. The HIV co-infection rate is reported to be 5.0% to 81.3% while 2.6% to 25.4 % have diabetes mellitus. Clinical symptoms of DR-epTB are consistent with morbidity in the affected body system. Among patients with DR-epTB, the proportion of MDR TB was 5% to 53% while that for pre-XDR TB and XDR TB was 3% to 40% and 4% to 33%, respectively. Treatment success is achieved in 26% to 83% of patients with DR-epTB while death, treatment loss-to-follow up, and treatment failure occur in 2% to 76%, 7% to 15%, and 0% to 4% respectively. Patients with DR-epTB were reported to have poorer outcomes than those with pulmonary DR-TB and extra-pulmonary drug-susceptible TB. Conclusion: Clinical features of DR-epTB are similar to those observed among people with drug-susceptible EPTB but patients with DR-epTB post worse treatment outcomes.

Clinical characteristics and outcomes of patients hospitalized with measles during an outbreak in Somalia.

Objectives: Measles is a contagious disease associated with significant morbidity and mortality. This paper describes the clinical characteristics and outcomes of patients hospitalized with measles during an outbreak in Somalia from January 2018 to December 2021. Methods: This retrospective study was conducted at Mogadishu Somalia Turkey Recep Tayyip Erdogan Training and Research Hospital. Children aged 6 months to 17 years who were hospitalized with clinical signs and symptoms of measles and its complications were recruited. Results: In total, 110 participants were enrolled. The median age was 16 [interquartile range (IQR) 12-36] years, and 87 (79.1%) were male. All participants presented with fever, typical measles rash, cough and conjunctivitis, and 43 (39.1%) had received the measles vaccine. Overall, 104 (94.6%) participants were admitted with severe respiratory symptoms, and six (5.4%) were admitted due to poor feeding and/or significant dehydration. Overall, all-cause mortality was 1.8% (n=2). The median duration of hospitalization was longer among participants who died compared with those who survived [11 (IQR 8-14) vs 4 (IQR 2-6) days; P=0.046]. Unvaccinated participants were significantly younger than vaccinated participants [36 (IQR 24-72) vs 12 (IQR 9-16) months; P<0.001]. There was a trend towards higher mortality [0/43 (0%) vs 2/67 (3%); P=0.519] and longer length of hospitalization [3 (IQR 2-6) vs 4 (IQR 3-7) days; P=0.056] among unvaccinated participants compared with vaccinated participants. Both the median total leukocyte count [5.7 (IQR 3.9-8.5) vs 11.6 (IQR 5.9-46.3) x 109/L; P<0.001] and platelet count [239 (IQR 202-358) vs 308 (IQR 239-404) x 109/L; P=0.032] were significantly higher among unvaccinated participants compared with vaccinated participants. However, the median haemoglobin concentration was significantly higher among vaccinated participants compared with unvaccinated participants [11.1 (IQR 9.9-12.3) vs 10.1 (IQR 9.1-11.2) g/dL; P=0.006]. Conclusions: Patients with measles in Somalia have a short hospital stay, low mortality rate and low vaccination rate. Timely vaccination and the need for improved care of patients with measles, particularly vulnerable groups including children and those with undernutrition, are encouraged.

Effect of COVID-19 pandemic on inpatient service utilization and patient outcomes in Uganda.

COVID-19 has had devastating effects on health systems but reports from sub-Saharan Africa are few. We compared inpatient admissions, diagnostic tests performed, clinical characteristics and inpatient mortality before and during the COVID-19 pandemic at an urban tertiary facility in Uganda. We conducted a retrospective chart review of patients admitted at Kiruddu National Referral Hospital in Uganda between January-July 2019 (before the pandemic) and January-July 2020 (during the pandemic). Of 3749 inpatients, 2014 (53.7%) were female, and 1582 (42.2%) had HIV. There was a 6.1% decline in admissions from 1932 in 2019 to 1817 in 2020. There were significantly fewer diagnostic tests performed in 2020 for malaria, tuberculosis, and diabetes. Overall, 649 (17.3%) patients died. Patients admitted during the COVID-19 pandemic (adjusted odds ratio [aOR] 1.2, 95% confidence interval [CI] 1.04-1.5, p = 0.018), patients aged ≥ 60 years (aOR 1.6, 95% CI 1.2-2.1, p = 0.001), HIV co-infected (aOR 1.5, 95% CI 1.2-1.9, p < 0.001), and those admitted as referrals (aOR 1.5, 95% CI 1.2-1.9, p < 0.001) had higher odds of dying. The COVID-19 pandemic disrupted inpatient service utilization and was associated with inpatient mortality. Policy makers need to build resilience in health systems in Africa to cope with future pandemics.

Association of circulating serum free bioavailable and total vitamin D with cathelicidin levels among active TB patients and household contacts.

The free hormone hypothesis postulates that the estimation of free circulating 25 (OH)D may be a better marker of vitamin D status and is of clinical importance compared to total vitamin D fraction. The unbound fraction is involved in biological activities since it is able to penetrate into the cell. Studies have shown that cathelicidin/LL-37 inhibits the growth of Mycobacterium tuberculosis in a vitamin D-dependent manner and therefore adequate vitamin D is required for its expression. The study aimed to determine the association between serum bioavailable and total vitamin D with LL-37 levels in ATB patients, LTBI, and individuals with no TB infection. This was a cross-sectional study in which bioavailable vitamin D and LL-37 levels were measured using competitive ELISA kits and total vitamin D was measured using electrochemilumiscence and consequently determined their association. The mean (SD) bioavailable vitamin D levels of the study participants were 3.8 ng/mL (2.6) and the median (IQR) of LL-37 levels were 320 ng/mL (160, 550 ng/mL). The mean (SD) of total vitamin D levels was 19.0 ng/mL (8.3) ng/mL. Similar weak correlations were observed between the bioavailable and total vitamin D with LL-37 levels, therefore, deviating from our hypothesis.

Diagnostic accuracy of clinical diagnostic scoring systems for childhood tuberculosis: a systematic review and meta-analysis protocol.

INTRODUCTION: Diagnosis of childhood tuberculosis (TB) poses several challenges. Therefore, clinical signs and symptoms, radiological studies, laboratory examinations, point-based scoring systems or diagnostic algorithms have been developed to improve diagnostic yields in this population. However, there are limited data on the diagnostic test accuracy of paediatric TB scoring systems. Therefore, this systematic review and meta-analysis aims to synthesise the available evidence on the diagnostic accuracy of childhood TB diagnostic scoring systems. METHODS AND ANALYSIS: This protocol describes a systematic review, developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses of Diagnostic Test Accuracy. We will conduct a comprehensive literature search for relevant articles in the following databases: PubMed, CINAHL, Embase, Scopus and Cochrane Databases. The eligibility criteria for studies will be formulated based on the Participants (Population), Index Test, Comparator Test and Target Condition criteria for the review question. The index test will be defined as any attempt to diagnose childhood TB using either a scoring system or a diagnostic algorithm, whereas a composite reference standard will be used as a reference standard. This will include any attempt to confirm diagnosis of TB. Where bacteriological confirmation is not obtained and there are at least two of the following features: chest radiograph consistent with TB, immunological evidence of Mycobacterium tuberculosis infection and/or positive response to TB treatment will also be considered. The QUADAS-2 Tool will be used to assess the quality of the studies. The diagnostic accuracy measures (ie, sensitivity, specificity, negative predictive and positive predictive values) will be pooled with the random-effects or fixed-effects models, as appropriate. All statistical analyses will be performed using the Review Manager V.5.4. ETHICS AND DISSEMINATION: This research is exempt from ethics approval given that this is a protocol for a systematic review, which uses published data. The findings from this review will be disseminated through peer-reviewed publications and scientific conferences. PROSPERO REGISTRATION NUMBER: CRD42022367049.

Factors associated with prolonged hospitalization of patients with corona virus disease (COVID-19) in Uganda: a retrospective cohort study.

INTRODUCTION: Identification of factors predicting prolonged hospitalization of patients with coronavirus disease (COVID-19) guides the planning, care and flow of patients in the COVID-19 Treatment Units (CTUs). We determined the length of hospital stay and factors associated with prolonged hospitalization among patients with COVID-19 at six CTUs in Uganda. METHODS: We conducted a retrospective cohort study of patients admitted with COVID-19 between January and December 2021 in six CTUs in Uganda. We conducted generalized linear regression models of the binomial family with a log link and robust variance estimation to estimate risk ratios of selected exposure variables and prolonged hospitalization (defined as a hospital stay for 14 days or more). We also conducted negative binomial regression models with robust variance to estimate the rate ratios between selected exposures and hospitalization duration. RESULTS: Data from 968 participants were analyzed. The median length of hospitalization was 5 (range: 1-89) days. A total of 136/968 (14.1%: 95% confidence interval (CI): 11.9-16.4%) patients had prolonged hospitalization. Hospitalization in a public facility (adjusted risk ratio (ARR) = 2.49, 95% CI: 1.65-3.76), critical COVID-19 severity scores (ARR = 3.24: 95% CI: 1.01-10.42), and malaria co-infection (adjusted incident rate ratio (AIRR) = 0.67: 95% CI: 0.55-0.83) were associated with prolonged hospitalization. CONCLUSION: One out of seven COVID-19 patients had prolonged hospitalization. Healthcare providers in public health facilities should watch out for unnecessary hospitalization. We encourage screening for possible co-morbidities such as malaria among patients admitted for COVID-19.