Point of care obstetric ultrasound training for midwives and nurses: implementation and experiences of trainees at a rural based hospital in Sub-saharan Africa: a qualitative study.

BACKGROUND: Point of care ultrasound training has been successfully implemented in some settings. This has been done due to a shortage of radiology human resource gap especially in the rural areas of low-resource settings. The purpose of the study was to implement a point of care obstetric ultrasound training program for midwives and nurses and explore their experiences following the training at a rural based hospital in Uganda. METHODS: It was an exploratory qualitative study with some elements of implementation research design involving midwives and nurses that had undergone obstetric ultrasound training at Kiwoko hospital, a rural-based hospital in Uganda. Purposive sampling was used to select twenty-five midwives and nurses. These participants underwent a 6-weeks training in point of care obstetric ultrasound. Following the training, in-depth interviews were conducted to obtain the experiences of the participants. RESULTS: The training was conducted by qualified radiologists and sonographers and it involved both didactic sessions and rigorous practical and clinical demonstrations and eventually real-time scanning of the women. Three key themes emerged from the interviews: (1) Gaining important obstetric ultrasound skills, (2) Improving management of pregnant women and (3) Positive for task-shifting. CONCLUSION: The point of care obstetric ultrasound training program was successfully implemented at Kiwoko Hospital. The trainees reported positive experiences from the training and while only conducted at one rural health facility, the overwhelmingly positive experience from trainees underscores the importance of point of care obstetric ultrasound in delivering imaging services.

Diagnostic accuracy of chest ultrasound scan in the diagnosis of childhood tuberculosis.

Chest Ultrasound Scan (CUS) has been utilized in place of CXR in the diagnosis of adult pneumonia with similar or higher sensitivity and specificity to CXR. However, there is a paucity of data on the use of CUS for the diagnosis of childhood TB. This study aimed to determine the diagnostic accuracy of CUS for childhood TB. This cross-sectional study was conducted at the Mulago National Referral Hospital in Uganda. Eighty children up to 14 years of age with presumptive TB were enrolled. They all had CUS and CXR performed and interpreted independently by radiologists. The radiologist who performed the CXR was blinded to the CUS findings, and vice versa. Radiologists noted whether TB was likely or unlikely. A two-by-two table was developed to compare the absolute number of children as either TB likely or TB unlikely on CXR or CUS. This was used to calculate the sensitivity and specificity of CUS when screening for TB in children, with a correction to accommodate the use of CXR as a reference test. The sensitivity of CUS was 64% (95% CI 48.5%-77.3%), while its specificity was 42.7% (95% CI 25.5%-60.8%). Both the CUS and CXR found 29 children with a likelihood of TB, and 27 children unlikely to have TB. CUS met the sensitivity target set by the WHO TPP for Triage, and it had a sensitivity and specificity comparable to that of CXR.

Cardiovascular abnormalities in chest radiographs of children with pneumonia, Uganda.

Objective: To describe chest radiograph findings among children hospitalized with clinically diagnosed severe pneumonia and hypoxaemia at three tertiary facilities in Uganda. Methods: The study involved clinical and radiograph data on a random sample of 375 children aged 28 days to 12 years enrolled in the Children's Oxygen Administration Strategies Trial in 2017. Children were hospitalized with a history of respiratory illness and respiratory distress complicated by hypoxaemia, defined as a peripheral oxygen saturation (SpO2) < 92%. Radiologists blinded to clinical findings interpreted chest radiographs using standardized World Health Organization method for paediatric chest radiograph reporting. We report clinical and chest radiograph findings using descriptive statistics. Findings: Overall, 45.9% (172/375) of children had radiological pneumonia, 36.3% (136/375) had a normal chest radiograph and 32.8% (123/375) had other radiograph abnormalities, with or without pneumonia. In addition, 28.3% (106/375) had a cardiovascular abnormality, including 14.9% (56/375) with both pneumonia and another abnormality. There was no significant difference in the prevalence of radiological pneumonia or of cardiovascular abnormalities or in 28-day mortality between children with severe hypoxaemia (SpO2: < 80%) and those with mild hypoxaemia (SpO2: 80 to < 92%). Conclusion: Cardiovascular abnormalities were relatively common among children hospitalized with severe pneumonia in Uganda. The standard clinical criteria used to identify pneumonia among children in resource-poor settings were sensitive but lacked specificity. Chest radiographs should be performed routinely for all children with clinical signs of severe pneumonia because it provides useful information on both cardiovascular and respiratory systems.

Typical Diagnostic Reference Levels of Common Indications for Computed Tomography Scans Among Adult Patients in Uganda: a Cross-sectional Study.

Background: Medical exposure to ionizing radiation has increased due to an increase in the number of computerized tomography (CT) scan examinations performed. The International Commission on Radiological Protection (ICRP) recommends indication-based diagnostic reference levels (IB-DRLs) as an effective tool that aids in optimizing CT scan radiation doses. In many low-income settings, there is a lack of IB-DRLs to support optimization of radiation doses. Objective: To establish typical DRLs for common CT scan indications among adult patients in Kampala, Uganda. Methodology: A cross sectional study design was employed involving 337 participants enrolled from three hospitals using systematic sampling. The participants were adults who had been referred for a CT scan. The typical DRL of each indication was determined as the median value of the pooled distribution of CTDIvol (mGy) data and the median value of the pooled distribution of total DLP (tDLP)(mGy.cm) data from three hospitals. Comparison was made to anatomical, and indication based DRLs from other studies. Results: 54.3% of the participants were male. The following were typical DRLs for: acute stroke (30.17mGy and 653mGy.cm); head trauma (32.04mGy and 878mGy.cm); interstitial lung diseases/ high resolution chest CT scan (4.66mGy and 161mGy.cm); pulmonary embolism (5.03mGy and 273mGy.cm); abdominopelvic lesion (6.93mGy and 838mGy.cm) and urinary calculi (7.61mGy and 975mGy.cm). Indication based total Dose Length Product (tDLP) DRLs was lower than tDLP DRLs of a whole anatomical region by 36.4% on average. Most of the developed typical IB-DLP DRLs were lower or comparable to values from studies in Ghana and Egypt in all indications besides urinary calculi while they were higher than values in a French study in all indications besides acute stroke and head trauma. Conclusion: Typical IB-DRLs is a good clinical practice tool for optimization of CT doses and therefore recommended for use to manage CT radiation dose. The developed IB-DRLs varied from international values due to differences in selection of CT scan parameters and standardization of CT imaging protocols may narrow the variation. This study can serve as baseline for establishment of national indication-based CT DRLs in Uganda.

Sex modulates the association between inflammation and coronary atherosclerosis among older Ugandan adults with and without HIV.

OBJECTIVE: Inflammation is key in the pathogenesis of atherosclerotic coronary artery disease (CAD). Distinct sex-specific inflammatory mechanisms may contribute to CAD in sub-Saharan Africa (SSA), where environmental and biological determinants of systemic inflammation may differ from those in high-income settings. APPROACH AND RESULTS: We investigated sex differences in inflammatory markers and CAD in a 2-year prospective cohort of Ugandan adults enriched for cardiometabolic risk factors (RFs) and HIV. Seven plasma biomarkers were quantified at the baseline visit among 125 females and 75 males (50% with HIV) at least 45 years old at enrollment with one or more major cardiovascular RF. In year 2, coronary CT angiography (CCTA) was performed in 82 females and 50 males returning for follow-up (52% with HIV). In sex-specific models adjusted for cardiovascular RFs and HIV, tumor necrosis factor-alpha (TNF-α) RII and sCD163 predicted subsequent CAD in females, while only fibrinogen was predictive in males ( P  < 0.05). Interleukin-6 (IL-6) and sCD14 were inversely associated with CAD in males ( P  < 0.05). Sex modified the associations of TNF-α RII, sCD14, and sCD163 with CAD ( P  < 0.05 for interaction). In multivariable multiple imputation models applied to missing year 2 CCTA data to test associations between serum biomarkers in the baseline cohort ( n  = 200) and subsequent CAD, higher sCD163 was predictive in females only ( P  < 0.05). CONCLUSIONS: The positive link between inflammation and subclinical CAD was stronger among females than males in Uganda. Mechanisms by which sex modulates the relationship between inflammation and CAD should be further investigated in SSA.

Brain magnetic resonance imaging findings among children with epilepsy in two urban hospital settings, Kampala-Uganda: a descriptive study.

BACKGROUND: Epilepsy is one of the most common neurological conditions in children worldwide. Its presentation is heterogeneous, with diverse underlying aetiology, clinical presentation, and prognosis. Structural brain abnormalities are among the recognized causes of epilepsy. Brain Magnetic Resonance Imaging (MRI) is the imaging modality of choice for epilepsy workup. We aimed to determine the prevalence and describe the structural abnormalities identified in the brain MRI studies performed on children with epilepsy from two urban hospitals in Kampala, Uganda. METHODS: This was a cross-sectional descriptive study performed at two urban hospital MRI centres. The study population was 147 children aged 1 day to 17 years with confirmed epilepsy. Brain MRI was performed for each child and a questionnaire was used to collect clinical data. RESULTS: The prevalence of structural abnormalities among children with epilepsy was 74.15% (109 out of 147). Of these, 68.81% were male, and the rest were female. Among these, the majority, 40.14% (59 of 144) were aged 1 month to 4 years. Acquired structural brain abnormalities were the commonest at 69.22% with hippocampal sclerosis (HS) leading while disorders of cortical development were the most common congenital causes. An abnormal electroencephalogram (EEG) was significant for brain MRI abnormalities among children with epilepsy with 95% of participants with an abnormal EEG study having epileptogenic structural abnormalities detected in their brain MRI studies. CONCLUSION AND RECOMMENDATION: Two-thirds of children with epilepsy had structural brain abnormalities. Abnormal activity in the EEG study was found to positively correlate with abnormal brain MRI findings. As such, EEG study should be considered where possible before MRI studies as a determinant for children with epilepsy who will be having imaging studies done in the Ugandan setting.

Myxoid Dermatofibrosarcoma Protuberans of the Scrotum: Rare Tumor in an Uncommon Location.

Background: Dermatofibrosarcoma protuberans (DFSP) is an uncommon tumor that involves the skin with a low metastatic rate; however, this tumor has a tendency to recur locally. Myxoid DFSP is a rare variant, with a few cases mentioned in the literature, and may present diagnostic difficulties on histopathological examination. Case Presentation: We present a 9-year-old male with a history of a left scrotal mass for 3 years. An enhanced computed tomography (CT) scan of the pelvis showed a heterogeneously enhancing mass in the scrotum with extension into both inguinal regions. Histology showed spindle-shaped cells forming a storiform pattern in the hypercellular area and myxoid stroma with prominent thin-walled vessels. Immunohistochemically, the cluster of differentiation 34 (CD34) was positive. The mass was removed by surgical excision with negative resection edges, and then adjuvant radiotherapy of 60 Gy was given. The patient had a good outcome with treatment and was doing well on follow-up. Conclusion: This variant of sarcoma is rare and often presents a diagnostic challenge. Early detection is crucial to prevent both undertreatment and overtreatment.

Sex-specific performance of the ASCVD pooled cohort equation risk calculator as a correlate of coronary artery calcium in Kampala, Uganda.

INTRODUCTION: The prevalence of cardiovascular disease (CVD) is rising in Sub-Saharan Africa, but it is not known whether current risk assessment tools predict coronary atherosclerosis in the region. Furthermore, sex-specific performance and interaction with HIV serostatus has not been well studied. METHODS: This cross-sectional study compared ASCVD risk scores and detectable coronary artery calcium (CAC>0) by sex in Kampala, Uganda (n = 200). The cohort was enriched for persons living with HIV, and all participants had at least one CVD risk factor. We fit log binomial regression models and constructed ROC curves to assess the correlation between ASCVD scores and CAC>0. RESULTS: The mean age was 56. 62% were female and 50% of both men and women were living with HIV. The median 10-year ASCVD risk score was significantly higher in men (11.0%, IQR 7.6-19.4%) than in women (5.1%, IQR 3.2-8.7%), although the prevalence of CAC>0 was similar (8.1 vs 10.5%, p = 0.63). Each 10% increase in ASCVD risk was associated with increased risk of CAC>0 in men (PR 1.59, 95% CI 1.00-2.55, p = 0.05) but not women (PR 1.15, 95% CI 0.44-3.00, p = 0.77). ROC curves demonstrated an AUC of 0.57 for women vs 0.70 for men. Adjustment for HIV serostatus improved the predictive value of ASCVD in women only (AUC 0.78, p = 0.02). CONCLUSIONS: ASCVD risk score did not correlate with the presence of CAC in women. When HIV status was added to the ASCVD risk score, correlation with CAC was improved in women but not in men.

Adult Computed Tomography examinations in Uganda: Towards determining the National Diagnostic Reference Levels.

INTRODUCTION: Diagnostic Reference Levels (DRLs), typically set at the 75th percentile of the dose distribution from surveys conducted across a broad user base using a specified dose-measurement protocol, are recommended for radiological examinations. There is a need to develop and implement DRLs as a standardisation and optimisation tool for the radiological protection of patients at Computed Tomography (CT) facilities. METHODS: This was a retrospective cross-sectional study conducted in seven (7) different CT scan facilities in which participants were recruited by systematic random sampling. The study variables were dose length product (DLP) and volume-weighted CTDI (CTDIvol) for the radiation doses for head, chest, abdomen and lumbar spine CT examinations. The DRLs for CTDIvol and DLP were obtained by calculating the 3rd quartiles of the radiation doses per study site by anatomical region. The national diagnostic reference levels were determined by computation of DRLs using the 75th centile of the median values. RESULTS: A total of 574 patients were examined with an average age of 47.1 years. For CTDIvol estimates; there was a strong positive significant relationship between the CTDIvol and examination mAs (rs = 0.9017, p-value < 0.001), and reference mAs (rs = 0.0.7708, p-value < 0.001). For DLP estimates; there was a moderate positive significant relationships between DLP and total mAs (rs = 0.6812, p-value < 0.001), reference mAs (rs = 0.5493, p-value < 0.001). The DRLs were as follows; for head CT scan - the average median CTDIvol was 56.02 mGy and the DLP was 1260.3 mGy.cm; for Chest CT, the CTDI volume was 7.82 mGy and the DLP was 377.0 mGy.cm; for the abdomen CT, the CTDI volume 12.54 mGy and DLP 1418.3 mGy.cm and for the lumbar spine 19.48 mGy and the DLP was 843 mGy.cm, respectively. CONCLUSION: This study confirmed the need to optimize the CT scan parameters in order to lower the national DRLs. This can be achieved by extensive training of all the CT scan radiographers on optimizing the CT scan acquisition parameters. Continuous dose audits are also advised with new equipment or after every three years to ensure that values out of range are either justified or further investigated.

Sex modifies the association between HIV and coronary artery disease among older adults in Uganda.

INTRODUCTION: Little is known about the epidemiology of coronary artery disease (CAD) in sub-Saharan Africa, where the majority of people living with HIV (PLHIV) live. We assessed the association of HIV with CAD and explored relationships with monocyte activation in sex-stratified analyses of older PLHIV and people without HIV (PWOH) in Uganda. METHODS: The Ugandan Study of HIV effects on the Myocardium and Atherosclerosis (mUTIMA) follows 100 PLHIV on antiretroviral therapy (ART) and 100 age- and sex-matched PWOH controls in Kampala, Uganda; all >45 years of age with >1 cardiovascular disease risk factor. At the year 2 exam (2017-2019), 189 participants had available coronary calcium score and 165 had coronary CT angiography (CCTA) for this analysis. A subset of participants (n = 107) had both CCTA and fresh whole blood flow cytometry for monocyte phenotyping. RESULTS: Median age was 57.8 years and 63% were females. Overall, 88% had hypertension, 37% had diabetes and 4% were smokers. Atherosclerotic cardiovascular disease (ASCVD) risk was modestly higher for PWOH, but not statistically significant (median 10-year ASCVD risk 7.2% for PLHIV vs. 8.6% for PWOH, p = 0.09). Median duration of ART was 12.7 years and 86% had suppressed viral load. Despite a high prevalence of risk factors, only 34/165 (21%, 95% CI 15-28%) had any coronary plaque. After adjustment for ASCVD risk score, HIV status was not associated with CAD (OR 0.55, 95% CI 0.23-1.30) but was associated with more severe CAD (segment severity score>3) among those with disease (OR 10.9, 95% CI 1.67-70.45). Females had a trend towards higher odds of CAD among PLHIV (OR 4.1, 95% CI 0.4-44.9), but a trend towards lower odds of CAD among PWOH (OR 0.30; 95% CI 0.07-1.3; HIV*sex interaction p = 0.019). CAD was positively correlated with classical monocytes (r = 0.3, p = 0.012) and negatively correlated with CX3CR1 expression (r = -0.31, p = 0.011) in PLHIV and negatively correlated with patrolling monocytes (r = -0.36, p = 0.031) and tissue factor expression (r = -0.39, p = 0.017) in PWOH. CONCLUSIONS: Our results suggest that HIV may be associated more with severity rather than the presence of CAD in Uganda. Sex differences in the HIV effect suggest that tailored CAD prevention strategies may be required in this setting.

HIV and pericardial fat are associated with abnormal cardiac structure and function among Ugandans.

OBJECTIVES: To examine the relationship between pericardial fat (PCF) and cardiac structure and function among HIV-infected patients in the sub-Saharan African country of Uganda. People living with HIV (PLHIV) have altered fat distribution and an elevated risk for heart failure. Whether altered quantity and radiodensity of fat surrounding the heart relates to cardiac dysfunction in this population is unknown. METHODS: One hundred HIV-positive Ugandans on antiretroviral therapy were compared with 100 age and sex-matched HIV-negative Ugandans; all were >45 years old with >1 cardiovascular disease risk factor. Subjects underwent ECG-gated non-contrast cardiac CT and transthoracic echocardiography with speckle tracking strain imaging. Multivariable linear and logistic regression models were used to explore the association of PCF with echocardiographic outcomes. RESULTS: Median age was 55% and 62% were female. Compared with uninfected controls, PLHIV had lower body mass index (27 vs 30, p=0.02) and less diabetes (26% vs 45%, p=0.005). Median left ventricular (LV) ejection fraction was 67%. In models adjusted for traditional risk factors, HIV was associated with 10.3 g/m2 higher LV mass index (LVMI) (95% CI 3.22 to 17.4; p=0.005), 0.87% worse LV global longitudinal strain (GLS) (95% CI -1.66 to -0.07; p=0.03) and higher odds of diastolic dysfunction (OR 1.96; 95% CI 0.95 to 4.06; p=0.07). In adjusted models, PCF volume was significantly associated with increased LVMI and worse LV GLS, while PCF radiodensity was associated with worse LV GLS (all p<0.05). CONCLUSIONS: In Uganda, HIV infection, PCF volume and density are associated with abnormal cardiac structure and function.

Coronary artery calcium, HIV and inflammation in Uganda compared with the USA.

Objectives: To compare the prevalence of detectable coronary artery calcium (CAC) among higher risk, older people living with HIV (PLWH) and uninfected persons in Uganda versus the USA, and second to explore associations of CAC with HIV-specific variables and biomarkers of inflammation. Methods: This cross-sectional study of 430 total subjects compared 100 PLWH on antiretroviral therapy and 100 age-matched and sex-matched HIV-uninfected controls in Uganda with 167 PLWH on antiretroviral therapy and 63 uninfected controls in the USA. Multivariable logistic regression was used to examine associations with detectable CAC (CAC >0). Results: Compared with US subjects, Ugandans were older (mean age 56 vs 52 years) and were more likely to have diabetes (36% vs 3%) and hypertension (85% vs 36%), but were less likely to be male (38% vs 74%) or smokers (4% vs 56%). After adjustment for HIV serostatus, age, sex and traditional risk factors, Ugandans had substantially lower odds of CAC >0 (adjusted OR 0.07 (95% CI 0.03 to 0.17), p<0.001). HIV was not associated with CAC >0 in either country (p>0.1). Among all PLWH, nadir CD4 count was associated with the presence of CAC, and among Ugandans soluble intercellular adhesion molecule (p=0.044), soluble CD163 (p=0.004) and oxidised low-density lipoprotein (p=0.043) were all associated with the presence of CAC. Conclusions: Ugandans had a dramatically lower prevalence of any coronary calcification compared with US subjects. The role of HIV infection and inflammation as risk factors for subclinical coronary disease in sub-Saharan Africa merits further investigation.

Clinical and cranial computed tomography scan findings in adults following road traffic accidents in Kampala, Uganda.

BACKGROUND: Globally, road traffic accidents are a major cause of death and disability. The developing countries bear a disproportionately large share of the RTAs which account for about 85% of the deaths. Most of these RTAs result in head injury, which globally, most scholars and medical practitioners consider a significant economic, social and medical problem. In Mulago National referral hospital, RTA is the leading cause of surgical admission. OBJECTIVE: To describe the cranial computed tomography (CT) scan findings in adults following RTA in Mulago hospital. METHODS: Using CT, detailed analysis of 178 adult patients with head injury following RTA was performed. Data was analyzed using SPSS version 16 and presented in tables and graphs. Data recorded included socio-demographic characteristics, clinical and CT variables. RESULTS: Seventy seven percent of the respondents were between 18-39 years. 52.6% of patients had open head injury. Headache was the most common clinical variable followed by dizziness and aphasia. The most common CT characteristic was extra cerebral haemorrhage followed by brain oedema and raised Intra-cranial pressure (ICP). Intra-cerebral haemorrhage was commonest in the frontal lobe followed by parietal lobe. CONCLUSION: Public health interventions like advocacy and education of the population on safe and responsible road usage should be emphasized to reduce on RTAs.