TB infection in adults with diabetes mellitus in Uganda.

BACKGROUND: The diabetes mellitus (DM) and TB dual epidemic is growing in sub-Saharan Africa (SSA), yet the underlying mechanisms of increased TB risk in DM are incompletely understood. We determined the prevalence and factors associated with TB infection (TBI) among DM patients at a tertiary hospital outpatient clinic in Uganda.METHODS: Eligible consenting adults were recruited for this cross-sectional study at an outpatient diabetes clinic using systematic random sampling. Data were collected using a pre-tested case report form. TBI was defined as a positive QuantiFERON® Gold Plus test (QFT-Plus) result. Factors associated with TBI were determined using modified Poisson regression analysis in Stata BE v.16.0.RESULTS: Among the 185 study participants, over two thirds were female and 87.6% (n = 162) were receiving metformin therapy. More than two thirds (143/185) had poor glycaemic control. TBI prevalence was 57.8% (107/185). Concurrent calcium channel blocker (adjusted prevalence ratio [aPR] 1.33, 95% CI 1.05-1.69) and pregabalin therapies (aPR 1.45, 95% CI 1.15-1.84) were independently associated with TBI.CONCLUSIONS: DM individuals on calcium channel blocker and pregabalin therapies should be routinely screened for TBI. Further studies should investigate the mechanisms of commonly used drugs for TBI in patients with DM in Uganda.

Randomised controlled trial of oxygen therapy and high-flow nasal therapy in African children with pneumonia.

PURPOSE: The life-saving role of oxygen therapy in African children with severe pneumonia is not yet established. METHODS: The open-label fractional-factorial COAST trial randomised eligible Ugandan and Kenyan children aged > 28 days with severe pneumonia and severe hypoxaemia stratum (SpO2 < 80%) to high-flow nasal therapy (HFNT) or low-flow oxygen (LFO: standard care) and hypoxaemia stratum (SpO2 80-91%) to HFNT or LFO (liberal strategies) or permissive hypoxaemia (ratio 1:1:2). Children with cyanotic heart disease, chronic lung disease or > 3 h receipt of oxygen were excluded. The primary endpoint was 48 h mortality; secondary endpoints included mortality or neurocognitive sequelae at 28 days. RESULTS: The trial was stopped early after enrolling 1852/4200 children, including 388 in the severe hypoxaemia stratum (median 7 months; median SpO2 75%) randomised to HFNT (n = 194) or LFO (n = 194) and 1454 in the hypoxaemia stratum (median 9 months; median SpO2 88%) randomised to HFNT (n = 363) vs LFO (n = 364) vs permissive hypoxaemia (n = 727). Per-protocol 15% of patients in the permissive hypoxaemia group received oxygen (when SpO2 < 80%). In the severe hypoxaemia stratum, 48-h mortality was 9.3% for HFNT vs. 13.4% for LFO groups. In the hypoxaemia stratum, 48-h mortality was 1.1% for HFNT vs. 2.5% LFO and 1.4% for permissive hypoxaemia. In the hypoxaemia stratum, adjusted odds ratio for 48-h mortality in liberal vs permissive comparison was 1.16 (0.49-2.74; p = 0.73); HFNT vs LFO comparison was 0.60 (0.33-1.06; p = 0.08). Strata-specific 28 day mortality rates were, respectively: 18.6, 23.4 and 3.3, 4.1, 3.9%. Neurocognitive sequelae were rare. CONCLUSIONS: Respiratory support with HFNT showing potential benefit should prompt further trials.

Development of a feedback framework within a mentorship alliance using activity theory.

Background: Mentorship is useful in enhancing student learning experiences. The provision of feedback by faculty mentors is a central activity within a fruitful mentorship relationship. Therefore, effective feedback delivery by mentors is key to the development of successful mentorship relationships. Mentorship is a social interactive relationship between mentors and mentees. Therefore, activity theory, a sociocultural theory, has been applied in this study to develop a framework for feedback delivery within the mentorship educational alliance between mentors and mentees. Objective: The purpose of the study was to explore experiences of students and faculty mentors regarding feedback in a mentorship relationship, and to develop a feedback delivery framework in a mentorship relationship underpinned by activity theory. Methods: This was a mixed-method sequential study conducted at Makerere University College of Health Sciences using both quantitative and qualitative data collection methods. The study involved undergraduate medical students and faculty mentors. Data were collected through self-administered questionnaires, focus group discussions and interviews. Descriptive statistics were used for quantitative data, while thematic analysis was used for qualitative data. Results: Most students reported negative experiences with feedback received during the mentorship process. Of the total of 150, a significant number of students (n=60) reported receiving no feedback at all from their mentors. One hundred students reported that feedback received from mentors focused on only weaknesses, and 80 reported that the feedback was not timely. A total of 130 students reported that the feedback sessions were a one-way process, with limited involvement of mentees. The feedback also tended to focus on academics, with limited emphasis on psychosocial contextual aspects that may potentially influence student learning. The focus group discussions with students confirmed most of the quantitative findings. The interviews with faculty mentors led to the emergence of two key themes, namely: (i) limited understanding of feedback delivery during mentorship; and (ii) need for feedback guidelines for faculty mentors. Based on the findings of the mixed-method study as well as the theory guiding the study, a feedback framework for mentorship interactions has been suggested. Conclusion: While students generally reported low satisfaction with feedback received from mentors, faculty suggested the need to have feedback guidelines for mentors to frame their feedback during mentorship interactions. A feedback framework to guide mentorship interactions has therefore been suggested as a result of this study, guided by principles of activity theory.

Mentors' and student nurses' experiences of the clinical competence assessment tool.

Background: The assessment tool for registered comprehensive nursing was introduced in nursing education in Uganda in 2005 with the main purpose of facilitating nurse mentors to easily assess the clinical competency of student nurses. The tool contributes to the formative and summative assessment of students. Despite continued use of the assessment tool over the years, no study has been conducted to explore the perceptions of nurse mentors and students regarding its use. Objective: To explore the experiences of nursing students and their mentors regarding the clinical competence assessment tool. Methods: A qualitative exploratory study design was used. The study was conducted at Masaka School of Comprehensive Nursing in Uganda. The participants included 48 final-year nursing students and 5 nurse/midwifery mentors. Purposive sampling was used to select the participants. Data were collected using 6 focus group discussions with students and 5 key informant interviews with mentors, and thematic analysis was used to interpret the data. Results: From the responses, the participants generally had mixed experiences of the tool and suggestions were put forward for improvement. Five major themes emerged from student responses: (i) the orientation process; (ii) using the assessment tool; (iii) strengths of the assessment tool; (iv) challenges with the assessment tool; and (v) suggestions for improvement. The nurse mentors generally corroborated what the students reported, i.e. that the tool had challenges when one assesses student performance and gives feedback. Conclusion: The participants reported satisfaction with the design of the assessment tool. However, some challenges were identified regarding its implementation by students and mentors. Key among these were the failure to have immediate assessment and feedback to students. Findings from the study could offer insights on how the tool could be improved.

Implementing the Angoff method of standard setting using postgraduate students: Practical and affordable in resource-limited settings.

BACKGROUND: Cut scores for students' assessments have always been arbitrarily determined in many institutions. Some institutions have adopted reliable methods of determining cut scores, such as the Angoff method. However, use of this method requires many experts, making it difficult to implement in resource-limited settings. The possibility of involving postgraduate students in implementing the Angoff method of setting cut scores could be the solution to this problem. OBJECTIVES: To explore the knowledge and practices of faculty regarding standard setting and the feasibility of using postgraduate students when implementing the Angoff method. METHODS: This was an exploratory operations research study in which data were collected during focus group discussions. Students were trained to use the Angoff method, i.e. a previous examination, in which the pass mark was 50%, was used to evaluate the method. RESULTS: Initial findings showed that faculty in the consortia of schools did not know what standard setting and the Angoff method entailed and had never used this approach. The postgraduate students involved in implementing the Angoff method of setting cut scores were excited and interested in engaging in the exercise; the pass mark they arrived at was 61.21%. CONCLUSION: The study demonstrated that it is feasible to use the Angoff method of determining pass marks, even in resource-limited settings. This can be made possible by involving postgraduate students in the absence of enough faculty experts.

Micro-albuminuria in Ugandan children with sickle cell anaemia: a cross-sectional study.

BACKGROUND: In patients with sickle cell anaemia (SCA), recurrent episodes of sequestration, micro-infarction, ischaemia and necrosis within the renal cortex cause nephron damage. Micro-albuminuria results from compensatory mechanisms aimed at preserving the glomerular filtration rate. AIMS: To establish the prevalence of micro-albuminuria among children with SCA and to describe associated factors. METHODS: A cross-sectional study of patients aged 2-18 years with SCA was undertaken at the sickle cell clinic, Mulago Hospital, Kampala between November 2007 and April 2008. Haemoglobin was measured and urine dipstick was used to determine protein, glucose, red blood cells and nitrites, serum creatinine and albumin and urine creatinine and albumin. Binary logistic regression was performed to determine factors associated with micro-albuminuria. RESULTS: Of 305 children studied, 48·2% were male. The mean (SD) age of the study participants was 9·7 (4·9) years. The prevalence of micro-albuminuria (30-300 µg/mg) was 28·2% (86/305, 95% CI 23·1-33·3). Use of diclofenac (p = 0·01) and ibuprofen (p = 0·001) were found to increase the risk of micro-albuminuria only by bivariate analysis. By multivariate analysis, increasing age (p = 0·001), a higher number of blood transfusions (p = 0·001) and presence of urine nitrites (p = 0·031) were associated with a risk of micro-albuminuria, whereas high levels of haemoglobin (p = 0·018) were protective. There was no association between estimated glomerular filtration rate and micro-albuminuria. CONCLUSIONS: The prevalence of micro-albuminuria among children with SCA is relatively high. SCA patients over 5 years of age should be screened for micro-albuminuria. Those with lower haemoglobin levels should be monitored closely because of its association with micro-albuminuria.

Research on medical migration from sub-Saharan medical schools: usefulness of a feasibility process to define barriers to data collection and develop a practical study.

CONTEXT: The maldistribution of physicians in sub-Saharan Africa is having serious impacts on population health. Understanding the effect requires investigation from both donor and recipient countries. However, investigation from the perspective of donor countries has been lacking. METHODS: This brief communication describes a model process for the design of a research project that addresses medical migration issues from the perspective of eight African medical schools. During an international meeting, the participants designed an initial "ideal" study, and then rapidly tested its feasibility through a brief survey, and group discussion through a listserv, teleconferences and one face-to-face meeting. FINDINGS AND PRACTICAL IMPLICATIONS: Innovative research ideas can be followed-up with surveys to test the feasibility of an "ideal" research design, modifying the design accordingly. This is currently occurring with our medical migration survey study.

Aetiology, risk factors and immediate outcome of bacteriologically confirmed neonatal septicaemia in Mulago hospital, Uganda.

BACKGROUND: Neonatal septicaemia remains a major cause of morbidity and mortality. The aetiology, risk factors and outcome of this problem need to understood. OBJECTIVE: To determine the aetiology, risk factors and immediate outcome of bacteriologically confirmed neonatal septicaemia in Mulago hospital. METHODS: Blood cultures were aseptically obtained from neonates presenting with clinical sepsis by WHO criteria to Mulago during a five month period between July and November 2002. Blood was placed in Brain Heart Infusion media and incubated within 30 minutes. Subcultures were plated daily up to 7 days on blood, chocolate and MacConkey agar and incubated in aerobic and 5% carbon dioxide conditions. Pure colonies were identified by Gram stain and biochemical tests and antibiotic sensitivities were obtained. RESULTS: Gram positive organisms were predominant (69.2%) followed by E. coli (17%) and Group B Streptococci (GBS) (7%). Staphylococcus aureus and E. coli dominated isolates in early and late onset sepsis. S. aureus was more sensitive to gentamicin than to cloxacillin. The sensitivity of E. coli to ceftriaxone was 94.1%. Factors significantly associated with neonatal septicaemia were male sex, history of convulsions, hypoglycaemia, lack of antenatal care, late onset sepsis and umbilical pus discharge. Mortality in sepsis cases was 18.1%, and 84% of deaths occurred in the first 2 days of admission. Hypoglycaemia was significantly associated with death (p < 0.01). CONCLUSION: S. aureus predominates the aetiology of neonatal septicaemia followed by E.coli. Most deaths occur in the first 48 hours of admission and hypoglycaemia is significantly associated with death.

Problem Based Learning, curriculum development and change process at Faculty of Medicine, Makerere University, Uganda.

INTRODUCTION: The faculty of Medicine, (FOM) Makerere University Kampala was started in 1924 and has been running a traditional curriculum for 79 years. A few years back it embarked on changing its curriculum from traditional to Problem Based Learning (PBL) and Community Based Education and Service (COBES) as well as early clinical exposure. This curriculum has been implemented since the academic year 2003/2004. The study was done to describe the steps taken to change and implement the curriculum at the Faculty of Medicine, Makerere University Kampala. OBJECTIVE: To describe the steps taken to change and implement the new curriculum at the Faculty of Medicine. METHODS: The stages taken during the process were described and analysed. RESULTS: The following stages were recognized characterization of Uganda's health status, analysis of government policy, analysis of old curriculum, needs assessment, adoption of new model (SPICES), workshop/retreats for faculty sensitization, incremental development of programs by faculty, implementation of new curriculum. CONCLUSION: The FOM has successfully embarked on curriculum change. This has not been without challenges. However, challenges have been taken on and handled as they arose and this has led to the implementation of new curriculum. Problem based learning can be adopted even in a low resourced country like Uganda.