Incidence of Status Migrainosus in Olmsted County, Minnesota, United States: Characterization and Predictors of Recurrence.

BACKGROUND AND OBJECTIVES: SM is recognized as a complication of migraine in which pain and/or associated symptoms are unremitting and debilitating for more than 72 hours. The epidemiology of SM in the general population is not known. The aim of this study is to determine the incidence, recurrence rate, and clinical associations of status migrainosus (SM) in care-seeking residents of Olmsted County, Minnesota. METHODS: The Rochester Epidemiology Project was used to identify the incident cases of SM according to the International Classification of Headache Disorders, Third Edition criteria and based on the first physician-encountered case in the record. The clinical characteristics of the incident cases were abstracted from the medical record. One-year recurrence-free survival was evaluated and compared between clinically relevant groups, including baseline demographics, migraine characteristics, and treatment exposures. RESULTS: Between January 1, 2012, and December 31, 2017, 237 incident cases of SM were identified. The median age was 35 (IQR 26-47) years, and 210 (88.6%) were female. A history of chronic migraine was recorded in 82/226 (36.3%) and a history of aura in 76/213 (35.7%). At the time of the incident case, medication reconciliation included a triptan or ergotamine in 127/233 (53.6%) and/or an opioid-containing analgesic in 43/233 (18.5%). The overall age- and sex-adjusted incidence rate was 26.60 per 100,000 [95% CI, 23.21-29.97], with a peak incidence between ages 40 and 49 years. The median (95% CI) attack duration was 5 (4.48-5.42) days. The most frequent triggers were stress (40/237, 16.9%) and too much or too little sleep (27/237, 11.4%). Recurrence occurred in 35/237 (14.8%) at a median of 58 (IQR 23-130) days following the initial attack. In our age- and sex-adjusted multivariable model, too much or too little sleep as a trigger was associated with 12-month risk of recurrence (adjusted OR 3.59 [95% CI 1.58-8.14], p = 0.0022). DISCUSSION: Our study provides a population-based estimate of SM incidence. We identified aberrant sleep patterns as a potentially modifiable risk factor for 1-year SM recurrence.

Incidence and predictors of early loss to follow up among patients initiated on protease inhibitor-based second-line antiretroviral therapy in southwestern Uganda.

BACKGROUND: Good adherence to antiretroviral therapy (ART) and retention in care are essential for the effectiveness of an HIV care program. With the current increase in numbers of people living with HIV taking second-line ART in sub-Saharan Africa, there is a need to establish their treatment outcomes and the rate of loss to follow up. In this study, we determined the incidence and predictors of loss to follow up among patients taking second-line ART at an experienced HIV treatment center in southwestern Uganda. METHODS: This was a retrospective review of an electronic database at Mbarara Regional Referral Hospital HIV clinic in southwestern Uganda. Second-line ART included at least two of the nucleoside reverse transcriptase inhibitors and a boosted protease inhibitor. Loss to follow-up was defined as failure to return to the health facility for care or treatment refill for 180 days or more from the previous visit. After excluding children less than 15 years, we pooled data that included socio-demographic, clinical, and laboratory data for patients who started second-line ART between 2002 and 2017. Multiple imputation was done for variables with missing data. Variables that had a p < 0.05 in unadjusted bivariate analyses were included in a multivariate binomial regression model using a stepwise backward selection procedure to describe the factors that independently predicted loss to follow-up. RESULTS: Between 2002 and 2017, 1121 patients had been initiated on second-line ART. We included data from 924 participants and of these, 518 (56.1%) were female, the mean age (SD) was 38.4 (± 10.5) years, and 433 (52.4%) had a CD4 count less than 100 cells/µl at the start of second-line ART. The incidence of loss to follow-up was 26.7 per 100 person-years. Male gender (Adjusted risk ratio (ARR) = 1.8, 95% CI 1.5-2.0) p < 0.001 and anemia ARR 1.4, 95% CI 1.1-1.6) p < 0.001 were strongly associated with loss to follow up. CONCLUSIONS: There is a high incidence of loss to follow up among patients taking protease-inhibitor based second-line ART at a tertiary HIV center in southwestern Uganda. There is a need to routinely measure hemoglobin during clinic reviews, and establish mechanisms to retain males initiated on second-line ART in care. The association of anemia and loss to follow up needs to be investigated.

Prevention of cardiovascular disease among people living with HIV in sub-Saharan Africa.

As longevity has increased for people living with HIV (PLWH) in the United States and Europe, there has been a concomitant increase in the prevalence of cardiovascular disease (CVD) risk factors and morbidity in this population. Whereas the availability of HIV antiretroviral therapy has resulted in dramatic increases in life expectancy in sub-Saharan Africa (SSA), where over two thirds of PLWH reside, if and how these trends impact the epidemiology of CVD is less clear. In this review, we describe the current state of the science on how both HIV and its treatment impact CVD risk factors and outcomes among PLWH in sub-Saharan Africa, including regional factors (unique to SSA) likely to differentiate these relationships from the global North. We then outline how current regional guidelines address CVD prevention among PLWH and which clinical and structural interventions are best poised to confront the co-epidemics of HIV and CVD in the region. We conclude with a discussion of key research gaps that need to be addressed to optimally develop an actionable public health response.

A systematic review protocol of stigma among children and adolescents with epilepsy.

BACKGROUND: Epilepsy is a neurological condition that is highly prevalent among children and adolescents with 80% of the victims living in low- and middle-income countries (LMIC). Epilepsy is associated with high levels of both perceived and enacted stigma, which vary geographically and greatly affects the victims' quality of life and self-esteem. High rates of stigma are also a significant barrier to accessing medical care. Perceived and enacted epilepsy-related stigma is associated with various sociodemographic and clinical factors, which vary from place to place. Therefore, this review will determine the prevalence of stigma of epilepsy among children and adolescents and the associated factors worldwide. METHODS: We will search for literature in PubMed, EMBASE, PsycINFO, and CINAHL databases as well as grey literature. We will also search via Google Scholar to capture relevant literature that may not be in the searched databases. We will then screen reference lists of included studies for more studies. Studies that have documented the prevalence of epilepsy-related perceived or enacted stigma and the associated factors will be eligible for inclusion. Data will be extracted in duplicates using a pre-piloted tool consisting of study and participant characteristics as well as pre-determined factors associated with epilepsy. Heterogeneity will be assessed by a forest plot and quantified by I2 statistic, and in case it is high, results will be reported as a narrative and it will further be explored by subgroup analysis. In case of homogeneity, meta-analysis will be done. Bias will be assessed using a critical appraisal tool developed for prevalence studies. The strength of evidence among the studies will be assessed using the GRADE approach. DISCUSSION: Findings from this review will document the burden of stigma of epilepsy and the common contributing factors, which will form the building blocks of interventions that address this health challenge. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017058957.

Derivation and validation of a universal vital assessment (UVA) score: a tool for predicting mortality in adult hospitalised patients in sub-Saharan Africa.

BACKGROUND: Critical illness is a leading cause of morbidity and mortality in sub-Saharan Africa (SSA). Identifying patients with the highest risk of death could help with resource allocation and clinical decision making. Accordingly, we derived and validated a universal vital assessment (UVA) score for use in SSA. METHODS: We pooled data from hospital-based cohort studies conducted in six countries in SSA spanning the years 2009-2015. We derived and internally validated a UVA score using decision trees and linear regression and compared its performance with the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA) score. RESULTS: Of 5573 patients included in the analysis, 2829 (50.8%) were female, the median (IQR) age was 36 (27-49) years, 2122 (38.1%) were HIV-infected and 996 (17.3%) died in-hospital. The UVA score included points for temperature, heart and respiratory rates, systolic blood pressure, oxygen saturation, Glasgow Coma Scale score and HIV serostatus, and had an area under the receiver operating characteristic curve (AUC) of 0.77 (95% CI 0.75 to 0.79), which outperformed MEWS (AUC 0.70 (95% CI 0.67 to 0.71)) and qSOFA (AUC 0.69 (95% CI 0.67 to 0.72)). CONCLUSION: We identified predictors of in-hospital mortality irrespective of the underlying condition(s) in a large population of hospitalised patients in SSA and derived and internally validated a UVA score to assist clinicians in risk-stratifying patients for in-hospital mortality. The UVA score could help improve patient triage in resource-limited environments and serve as a standard for mortality risk in future studies.

Outcomes of patients with severe infection in Uganda according to adherence to the World Health Organization's Integrated Management of Adolescent and Adult Illness fluid resuscitation guidelines.

PURPOSE: We determined outcomes in hospitalized patients in Uganda with World Health Organization's Integrated Management of Adolescent and Adult Illness (IMAI) defined septic shock (IMAI-shock) or severe respiratory distress without shock (IMAI-SRD) based on whether they received recommended fluid resuscitation according to IMAI guidelines. MATERIALS AND METHODS: We performed a secondary analysis of a prospective cohort of adult septic patients in Uganda that included the volume of fluids patients received during the first 6h of resuscitation. We used logistic regression to determine predictors of outcomes. RESULTS: We evaluated 122 patients with IMAI-shock and 32 patients with IMAI-SRD. For patients with IMAI-shock or IMAI-SRD, there was no difference in mortality between those that received IMAI recommended fluid volume and those that did not (30% vs 36%, p=0.788; 22% vs 57%, p=0.08). For patients with IMAI-shock, in-hospital mortality was associated with mid-upper arm circumference (adjusted odds ratio [aOR] 0.841, 95% confidence interval [CI] 0.722-0.979, p=0.026) and ambulation (aOR 0.247, 95%CI 0.084-0.727, p=0.011). We found no associations with in-hospital mortality for patients with IMAI-SRD. CONCLUSION: IMAI recommended fluid resuscitation was not associated with better outcomes for patients with IMAI-shock or IMAI-SRD. Further studies are needed to optimize resuscitation for patients with severe infection in resource-limited settings such as Uganda.

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

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