Otolaryngology Training in Uganda: The Mbarara University of Science and Technology Experience.

Sub-Saharan Africa has a high otolaryngologic disease burden exacerbated by an inadequate number of otolaryngologists. The Otolaryngology department at Mbarara University of Science & Technology in Uganda is addressing this problem by having created Uganda's second national residency training program in 2010. We chronicled an early period in the program's development by reporting surgical case quantity and complexity, as defined by "key indicator procedure" classification per the United States Accreditation Council for Graduate Medical Education, and interpreting it with respect to a timeline of significant events. Procedure complexity, but not total number per year, increased over the study period-KIPs increased from 3% in 2012 (6 of 175 total procedures) to 29% in 2016 (35 of 135 total procedures). During this period of complexity increase, operating room capacity expanded, faculty received advanced training and increased in number, and operative equipment improved.

Tracheostomy-related indications, early complications and their predictors among patients in low resource settings: a prospective cohort study in the pre-COVID-19 era.

BACKGROUND: Tracheostomy is a life-saving procedure whose outcomes may vary between hospitals based on disparities in their existing expertise. We aimed at establishing the indications, early tracheostomy-related complications and their associated factors in Uganda. METHODS: In a prospective cohort study, we consecutively enrolled one-hundred patients, both adults and children 2 h post-tracheostomy procedure. At baseline, information on patients' socio-demographics, tracheostomy indications, pre- and post-procedural characteristics was collected through researcher administered questionnaires and from medical records. Clinical examination was performed at baseline but also at either day 7 or whenever a tracheostomy-related complication was suspected during the 7 days follow-up. Comparison of patients' baseline characteristics, tracheostomy indications and complications across two hospitals was done using Pearson's chi-square. For predictors of early tracheostomy complications, bivariate and multivariate analysis models were fitted using binomial regression in STATA 13.0 software. RESULTS: All patients underwent surgical tracheostomy. Majority were adults (84%) and males (70%). The commonest tracheostomy indications were; pulmonary toilet (58%) and anticipated prolonged intubation (42%). Overall, 53% (95% CI: 43.0 - 62.7) had early complications with the commonest being tube obstruction (52.6%). Independent predictors of early tracheostomy-related complications were; anticipated prolonged intubation as an indication (RR = 1.8, 95%CI: 1.19 - 2.76), Bjork flap tracheal incision (RR = 1.6, 95%CI: 1.09 - 2.43), vertical tracheal incision (RR = 1.53, 95%CI: 1.02 - 2.27), and age below 18 years (RR = 1.22, 95%CI: 1.00 - 1.47). CONCLUSION: Pulmonary toilet is the commonest tracheostomy indication at major hospitals in Uganda. The incidence of early tracheostomy complications is high and majorly related to post-procedure tracheostomy tube management. Having anticipated prolonged intubation as an indication for tracheostomy, a Bjork flap or vertical tracheal incisions and being a child were associated with increased risk of complications. Emphasis on multidisciplinary team care, standardization of tracheostomy care protocols, and continuous collection of patient data as well as paying attention to patient quality of life factors such as early return to oral feeding, ambulation and normal speech may have great potential for improved quality of tracheostomy care in low resource settings.

Factors Associated with 30-Day in-Hospital Mortality Among Patients Admitted with Severe Covid-19 in Mbarara Regional Referral Hospital.

Background: COVID-19 has created a burden on the healthcare system globally. Severe COVID-19 is linked with high hospital mortality. Data regarding 30-day in-hospital mortality and its factors has not been explored in southwestern Uganda. Methods: We carried out a retrospective, single-center cohort study, and included all in-patients with laboratory-confirmed, radiological, or clinical severe COVID-19 admitted between April 2020 and September 2021 at Mbarara Regional Referral Hospital (MRRH). Demographic, laboratory, treatment, and clinical outcome data were extracted from patients' files. These data were described comparing survivors and non-survivors. We used logistic regression to explore the factors associated with 30-day in-hospital mortality. Results: Of the 283 patients with severe COVID-19 admitted at MRRH COVID-19 unit, 58.1% were male. The mean age ± standard deviation (SD) was 61±17.4 years; there were no differences in mean age between survivors and non-survivors (59 ± 17.2 versus 64.4 ±17.3, respectively, p=0.24) The median length of hospital stay was 7 (IQR 3-10) days (non-survivors had a shorter median length of stay 5 (IQR 2-9) days compared to the survivors; 8 (IQR 5-11) days, p<0.001. The most frequent comorbidities were hypertension (30.5%) and diabetes mellitus (30%). The overall 30-day in-hospital mortality was 134 of 279 (48%) mortality rate of 47,350×105 with a standard error of 2.99%. The factors associated with 30-day in-hospital mortality were age: 65 years and above (aOR, 3.88; 95% CI, 1.24-11.70; P =0.020) a neutrophil to lymphocyte ratio above 5 (aOR, 4.83; 95% CI, 1.53-15.28; P =0.007) and oxygen requirement ≥15L/min (aOR, 15.80; 95% CI, 5.17-48.25; P <0.001). Conclusion: We found a high 30-day in-hospital mortality among patients with severe forms of COVID-19. The identified factors could help clinicians to identify patients with poor prognosis at an early stage of admission.

Factors Associated With In-Hospital Post-Cardiac Arrest Survival in a Referral Level Hospital in Uganda.

BACKGROUND: Cardiac arrest (CA) is still associated with high mortality and morbidity across all practice settings despite resuscitation attempts and advancements in its management. Patient outcomes vary and are affected by multiple factors. Nonetheless, there is a paucity of information on survival after CA and associated factors in low-resource settings such as East Africa where Uganda is located. This study set out to describe post-CA survival, associated factors, and neurological outcome at a hospital in Southwestern Uganda. METHODS: This was a descriptive study in which we followed up with resuscitated CA patients from any of the selected hospital locations at Mbarara Regional Referral Hospital in Southwestern Uganda. We included all patients who were resuscitated after an index CA in the operating room (OR), intensive care unit (ICU), the pediatric ward, or accident and emergency (A&E) wards. Details of resuscitation were obtained from resuscitation team leader interviews and patient medical records. We followed up with patients with return of spontaneous circulation (ROSC) for up to 7 days after CA when neurological outcomes were measured using the age-appropriate Cerebral Performance Category (CPC) score. Factors affecting survival were then determined. RESULTS: A total of 74 participants were enrolled over 8 months. Seven-day survival was 14.86%. Eight of the 11 survivors had a CPC score of 1 seven days after CA. Admission with trauma was associated with increased mortality with an adjusted hazard ratio (HR) of 4.06; 95% confidence interval (CI), 1.19-13.82. Compared to the A&E ward, HR for index CA in OR, ICU, and pediatric ward was 0.15; 95% CI, 0.05-0.45; 0.67; 95% CI, 0.32-1.40, and 0.65; 95% CI, 0.25-1.69, respectively. Compared to cardiopulmonary resuscitation (CPR) <10 minutes, the HR for CPR duration between 10 and 20 minutes was 2.26; 95% CI, 0.78-3.24 and for >20 minutes was 2.26; 95% CI, 1.12-4.56. Prevention of hypotension after ROSC was associated with decreased mortality with an HR of 0.23; 95% CI, 0.08-0.58. CONCLUSIONS: Whereas 7-day survival of resuscitated CA patients at Mbarara Regional Referral Hospital (MRRH) was low, survivors had a good neurologic outcome. CA in the OR, CPR <20 minutes, and prevention of hypotension postarrest seemed to be associated with survival.

The burden of chronic rhinosinusitis and its effect on quality of life among patients re-attending an otolaryngology clinic in south western Uganda.

BACKGROUND: Worldwide, the burden of chronic rhinosinusitis (CRS) is variable, but not known in Uganda. CRS has significant negative impact on quality of life (QOL) and as such QOL scores should guide adjustments in treatment strategies. However, most of these studies have been done in the west. Our hypothesis was that QOL scores of the majority of CRS patients in low- to- middle income countries are poorer than those among patients without CRS. The aim of this study was to determine the burden of CRS among patients re-attending the Otolaryngology clinic and whether CRS is related to poor QOL. METHODS: A cross sectional study was conducted at Mbarara Regional Referral Hospital Otolaryngology clinic. One hundred and twenty-six adult re-attendees were consecutively recruited. Data was collected using a structured questionnaire and the Sinonasal Outcome Test 22 (SNOT 22) questionnaire measured QOL. RESULTS: The proportion of re-attendees with CRS was 39.0% (95% CI 30-48%). Majority of CRS patients had poor quality of life scores compared to non-CRS (88% versus 20% p < 01). The poor quality of life scores on the SNOT 22 were almost solely as a result of the functional, physical and psychological aspects unique to CRS. CONCLUSIONS: CRS is highly prevalent among re-attendees of an Otolaryngology clinic at a hospital in resource limited settings and has a significant negative impact on the QOL of these patients.

HIV status and hearing loss among children between 6 and 12 years of age at a large urban health facility in south western Uganda.

INTRODUCTION: Pediatric HIV infection and treatment may increase the risk for hearing loss (HL), both sensorineural (SNHL) and conductive hearing loss (CHL). There is limited data on this subject, especially from sub Saharan Africa. The aim of this study was therefore to compare the prevalence of hearing loss among HIV positive and negative children, to determine the types of hearing loss and whether Nevirapine (NVP) based antiretroviral therapy (ART) is associated with HL. METHODS: We conducted a cross sectional study at two tertiary health facilities in south western Uganda. We consecutively enrolled 79 HIV negative and 148 HIV positive children aged between 6 and 12 years. Inclusion criteria were completion of written consent, ability to follow instructions to perform an audiogram and absence of congenital HL. We conducted hearing screening using the iPad Shoebox® audiometer, and confirmatory assessments were conducted using pure tone audiometry. Hearing was classified as either normal hearing, CHL, SNHL or mixed. RESULTS: Of the 227 children enrolled, 115 (50.7%) were female. The mean age was 9.2 years (median = 9). Based on self-report, frequency of HL among HIV positive children was 6.8% and 20.3% among HIV negative children (p=<0.01). Using objective measures, prevalence of HL among the HIV positive children was 8.8% compared to 10.1% among the HIV negative children (p = 0.74). CHL was generally more frequent than SNHL but SNHL occurred more frequently among HIV positive (7.4%) compared to HIV negative children (3.8%). No association was found between NVP based ART and HL (p = 0.41). Logistic regression showed that older age of the child (p = 0.01), previous ear infection (p=<0.01), tuberculosis (TB) treatment (p=<0.01) and long term duration on ART (p=<0.01) were significantly associated with HL. Age (p = 0.02), previous ear infection (p = 0.01) and TB treatment (p = 0.005) remained significant in the multiple regression model. CONCLUSION: Prevalence of HL is similar among HIV positive and negative children. Older age of the child, previous ear infection, use of TB drugs and long duration on ART among the HIV positive children increase the odds of having hearing loss among children. However, use of NVP was not associated with HL.