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1.
J Med Educ Curric Dev ; 7: 2382120520973212, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33283049

RESUMO

Given the dearth need for healthcare workers in the control of the ongoing COVID-19 pandemic, e-learning has been adopted in many settings to hasten the continuation of medical training. However, there is a paucity of data in low resource settings on the plausibility of online learning platforms to support medical education. We aimed to assess the awareness, attitudes, preferences, and challenges to e-learning among Bachelor of Medicine and Bachelor of Surgery (MBChB) and Bachelor of Nursing (B.NUR) students at Makerere University, Uganda. An online cross-sectional study was conducted between July and August 2020. Current MBChB and B.NUR students aged 18 years or older constituted the study population. Using Google forms, a web-based questionnaire was administered through the Makerere University mailing list and WhatsApp messenger. The questionnaire was developed using validated questions from previously published studies. Overall, 221 participants responded (response rate = 61%). Of the 214 valid responses, 195 (92.1%) were Ugandans, 123 (57.5% were male, and 165 (77.1%) were pursuing the MB ChB program. The median age was 23 (18 to 40) years. Ownership of computers, smartphones, and email addresses were at 131 (61.2%), 203 (94.9%), and 208 (97.2%), respectively. However, only 57 (26.6%) respondents had access to high or very high quality internet access. Awareness and self-reported usage of e-learning (MUELE) platforms were high among 206 (96.3%) and 177 (82.7%) respondents, respectively. However, over 50% lacked skills in using the Makerere University e-learning (MUELE) platform. About half (n = 104, 49%) of the students believed that e-learning reduces the quality of knowledge attained and is not an efficient method of teaching. Monthly income (P = .006), internet connectivity quality (P < .001), computer ownership (P = .015) and frequency of usage of academic websites or applications (P = .006) significantly affected attitudes towards e-learning. Moreover, internet costs and poor internet connectivity were the most important barriers to e-learning reported by 199 (93%) and 179 (84%) students, respectively. Sensitization and training of students and faculty on e-learning and use of existing learning platforms are important to improve the attitude and use of e-learning. Blended online and use of offline downloadable learning materials would overcome the challenges related to the variable quality of internet access in the country.

2.
Trop Med Health ; 48(1): 89, 2020 Nov 04.
Artigo em Inglês | MEDLINE | ID: mdl-33292804

RESUMO

BACKGROUND: Neonatal hypoglycemia is the most common endocrine abnormality in children, which is associated with increased morbidity and mortality. The burden and risk factors of neonatal hypoglycemia in rural communities in sub-Saharan Africa are unknown. OBJECTIVE: To determine the prevalence and risk factors for neonatal hypoglycemia in Lira District, Northern Uganda. METHODS: This was a community-based cross-sectional study, nested in a cluster randomized controlled trial designed to promote health facility births and newborn care practices in Lira District, Northern Uganda. This study recruited neonates born to mothers in the parent study. Random blood glucose was measured using an On Call® Plus glucometer (ACON Laboratories, Inc., 10125 Mesa Road, San Diego, CA, USA). We defined hypoglycemia as a blood glucose of < 47 mg/dl. To determine the factors associated with neonatal hypoglycemia, a multivariable linear regression mixed-effects model was used. RESULTS: We examined 1416 participants of mean age 3.1 days (standard deviation (SD) 2.1) and mean weight of 3.2 kg (SD 0.5). The mean neonatal blood glucose level was 81.6 mg/dl (SD 16.8). The prevalence of a blood glucose concentration of < 47 mg/dl was 2.2% (31/1416): 95% CI 1.2%, 3.9%. The risk factors for neonatal hypoglycemia were delayed breastfeeding initiation [adjusted mean difference, - 2.6; 95% CI, - 4.4, - 0.79] and child age of 3 days or less [adjusted mean, - 12.2; 95% CI, - 14.0, - 10.4]. CONCLUSION: The incidence of neonatal hypoglycemia was low in this community and was predicted by delay in initiating breastfeeding and a child age of 3 days or less. We therefore suggest targeted screening and management of neonatal hypoglycemia among neonates before 3 days of age and those who are delayed in the onset of breastfeeding.

3.
Front Immunol ; 11: 556695, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33042140

RESUMO

MR1-restricted T (MR1T) cells are defined by their recognition of metabolite antigens presented by the monomorphic MHC class 1-related molecule, MR1, the most highly conserved MHC class I related molecule in mammalian species. Mucosal-associated invariant T (MAIT) cells are the predominant subset of MR1T cells expressing an invariant TCR α-chain, TRAV1-2. These cells comprise a T cell subset that recognizes and mediates host immune responses to a broad array of microbial pathogens, including Mycobacterium tuberculosis. Here, we sought to characterize development of circulating human MR1T cells as defined by MR1-5-OP-RU tetramer labeling and of the TRAV1-2+ MAIT cells defined by expression of TRAV1-2 and high expression of CD26 and CD161 (TRAV1-2+CD161++CD26++ cells). We analyzed postnatal expansion, maturation, and functionality of peripheral blood MR1-5-OP-RU tetramer+ MR1T cells in cohorts from three different geographic settings with different tuberculosis (TB) vaccination practices, levels of exposure to and infection with M. tuberculosis. Early after birth, frequencies of MR1-5-OP-RU tetramer+ MR1T cells increased rapidly by several fold. This coincided with the transition from a predominantly CD4+ and TRAV1-2- population in neonates, to a predominantly TRAV1-2+CD161++CD26++ CD8+ population. We also observed that tetramer+ MR1T cells that expressed TNF upon mycobacterial stimulation were very low in neonates, but increased ~10-fold in the first year of life. These functional MR1T cells in all age groups were MR1-5-OP-RU tetramer+TRAV1-2+ and highly expressed CD161 and CD26, markers that appeared to signal phenotypic and functional maturation of this cell subset. This age-associated maturation was also marked by the loss of naïve T cell markers on tetramer+ TRAV1-2+ MR1T cells more rapidly than tetramer+TRAV1-2- MR1T cells and non-MR1T cells. These data suggest that neonates have infrequent populations of MR1T cells with diverse phenotypic attributes; and that exposure to the environment rapidly and preferentially expands the MR1-5-OP-RU tetramer+TRAV1-2+ population of MR1T cells, which becomes the predominant population of functional MR1T cells early during childhood.

4.
Pediatr Nephrol ; 2020 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-32737578

RESUMO

BACKGROUND: Limited data exist about causes of chronic kidney disease (CKD) and impact on health-related quality of life (HRQoL) in African children. We evaluated types of kidney disease in Ugandan children 0-18 years and compared HRQoL in children with CKD or with benign or resolving kidney disease (non-CKD) to assess predictors of HRQoL. METHODS: Demographic, socioeconomic, and clinical data were obtained for this cross-sectional study. Pediatric Quality of Life Core Scale™ (PedsQL) was used to survey 4 domains and overall HRQoL. CKD and non-CKD scores were compared using unpaired t test. HRQoL predictors were evaluated using linear and logistic regression analyses. RESULTS: One hundred forty-nine children (71 CKD, 78 non-CKD; median age 9 years; male 63%) had the following primary diseases: nephrotic syndrome (56%), congenital anomalies of the urinary tract (CAKUT) (19%), glomerulonephritis (17%), and other (8%). CAKUT was the predominant etiology (39%) for CKD; 63% had advanced stages 3b-5. Overall HRQoL scores were significantly lower for CKD (57 vs. 86 by child report, p < 0.001; 63 vs. 86 by parent proxy report, p < 0.001). Predictors of lower HRQoL were advanced CKD stages 3b-5, primary caregiver non-parent, vitamin D deficiency, and anemia. CONCLUSION: Like other parts of the world, CAKUT was the main cause of CKD. Most CKD children presented at late CKD stages 3b-5. Compared with non-CKD, HRQoL in CKD was much lower; only two-thirds attended school. Vitamin D deficiency and anemia were potentially modifiable predictors of low HRQoL. Interventions with vitamin D, iron, and erythropoietin-stimulating agents might lead to improved HRQoL.

5.
OAlib ; 7(6)2020 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-32661500

RESUMO

Sub-Saharan Africa has the worst global shortage of health professionals. The use of eLearning interventions, that lead to increased interactions according to the Interaction Equivalency theorem, is a potential means of addressing this shortage of health professionals. In this audit we set out to determine the effect of an eLearning general histology and general embryology intervention on student's summative examination scores. The audit compared the written and practical summative examination scores of three sets of student examinations one of which had a five-week eLearning intervention. Two of the examinations were for the same students in one year but different courses while the other two were for students doing the same subject but in different years. In each of the above pair of examinations there was one group from the course that had the eLearning intervention. A Bayesian multilevel regression modelling approach was used to analyse the student scores. The course with the online eLearning intervention had significantly better scores (p-value < 0.01), than the course on a different subject offered at the same time to the same students without the intervention and the same course with students from the previous academic year. On controlling for other factors, the eLearning intervention led to higher examination scores though this was not significant. Student's nationality, sponsorship and program significantly affected the examination scores, controlling for other factors. Overall the students in the course with the online eLearning intervention had significantly better examination scores. The student's nationality, sponsorship and program significantly affect their examination scores. Future, larger and or qualitative studies, are needed to further explore the effect of these factors on student's examination scores.

6.
BMC Med Educ ; 20(1): 192, 2020 Jun 15.
Artigo em Inglês | MEDLINE | ID: mdl-32539860

RESUMO

BACKGROUND: Mentorship has become a routine part of undergraduate training in health professions education. Although many health professions training institutions have successfully incorporated faculty-student mentorship in their formal training, many others especially in Sub-Saharan Africa have not fully embraced this. Institutionalized mentorship programmes are effective methods of enhancing student learning experiences. Faculty, who are the mentors have an active role to play in driving the mentorship agenda and ensure that students benefit from this important activity. The aim of this study was to explore the knowledge, attitudes and practices of faculty about student mentorship at Makerere University College of Health Sciences. METHODS: It was an exploratory qualitative study using interviewer-administered semi-structured questionnaires. The study participants included faculty at Makerere University College of Health Sciences. Thematic analysis was used to analyse the data using pre-determined themes. RESULTS: Four themes were identified: 1) Knowledge of mentorship, 2) Attitude towards mentorship, 3) Practice of mentorship and 4) Improving the mentorship process. Majority of the faculty reported being less knowledgeable on mentorship regardless of seniority. The level of knowledge seemed to influence the practice of mentorship. Despite the observed knowledge gap, all faculty demonstrated a positive attitude to participate in mentoring. CONCLUSION: Faculty demonstrated a positive attitude towards mentorship despite the knowledge gap of mentorship identified. Continuous faculty development in mentorship as well as using peer mentorship were identified as key in sustaining the mentorship programme.

7.
J Pediatr Hematol Oncol ; 42(7): e593-e600, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32287095

RESUMO

Sickle cell disease (SCD) in Africa has high prevalence, morbidity, and early mortality. Difficulties in reaching parents following infant SCD screening dampen program effectiveness. Text messaging may support initial postscreening parental notification. We explored SCD awareness, and feasibility and acceptability of text messaging about screening follow-up among convenience samples of caretakers with children under 5 years (n=115) at 3 sites: a SCD family conference or 2 general pediatric clinics in urban or rural Uganda. Two thirds of the conference-based participants and 8% at clinic sites had affected children. At the clinics, 64% of caretakers were aware of SCD. In all, 87% claimed current possession of mobile phones; 89% previously had received messages. A sample text on the availability of screening results and need to bring their child to SCD clinic was at least partially understood by 82%. Overall, 52% preferred communication for initial follow-up by telephone over text message. Concerns about texting included phone access, privacy or cost, and readability of messages. Caretakers identified concerns about distance, cost, or preference for another clinic as additional barriers to SCD follow-up. Findings suggest that text messaging to caretakers may be feasible, but less acceptable compared with a telephone call about initial follow-up from newborn SCD screening.

9.
Crit Care ; 23(1): 377, 2019 11 27.
Artigo em Inglês | MEDLINE | ID: mdl-31775837

RESUMO

BACKGROUND: African children hospitalised with severe febrile illness have a high risk of mortality. The Fluid Expansion As Supportive Therapy (FEAST) trial (ISCRTN 69856593) demonstrated increased mortality risk associated with fluid boluses, but the temporal relationship to bolus therapy and underlying mechanism remains unclear. METHODS: In a post hoc retrospective analysis, flexible parametric models were used to compare change in mortality risk post-randomisation in children allocated to bolus therapy with 20-40 ml/kg 5% albumin or 0.9% saline over 1-2 h or no bolus (control, 4 ml/kg/hour maintenance), overall and for different terminal clinical events (cardiogenic, neurological, respiratory, or unknown/other). RESULTS: Two thousand ninety-seven and 1041 children were randomised to bolus vs no bolus, of whom 254 (12%) and 91 (9%) respectively died within 28 days. Median (IQR) bolus fluid in the bolus groups received by 4 h was 20 (20, 40) ml/kg and was the same at 8 h; total fluids received in bolus groups at 4 h and 8 h were 38 (28, 43) ml/kg and 40 (30, 50) ml/kg, respectively. Total fluid volumes received in the control group by 4 h and 8 h were median (IQR) 10 (6, 15) ml/kg and 10 (10, 26) ml/kg, respectively. Mortality risk was greatest 30 min post-randomisation in both groups, declining sharply to 4 h and then more slowly to 28 days. Maximum mortality risk was similar in bolus and no bolus groups; however, the risk declined more slowly in the bolus group, with significantly higher mortality risk compared to the no bolus group from 1.6 to 101 h (4 days) post-randomisation. The delay in decline in mortality risk in the bolus groups was most pronounced for cardiogenic modes of death. CONCLUSIONS: The increased risk from bolus therapy was not due to a mechanism occurring immediately after bolus administration. Excess mortality risk in the bolus group resulted from slower decrease in mortality risk over the ensuing 4 days. Thus, administration of modest bolus volumes appeared to prevent mortality risk declining at the same rate that it would have done without a bolus, rather than harm associated with bolus resulting from a concurrent increased risk of death peri-bolus administration. TRIAL REGISTRATION: ISRCTN69856593. Date of registration 15 December 2008.


Assuntos
Hidratação , Infecções , Criança , Humanos , Ressuscitação , Estudos Retrospectivos , Tempo
10.
BMC Pediatr ; 19(1): 381, 2019 10 25.
Artigo em Inglês | MEDLINE | ID: mdl-31651270

RESUMO

BACKGROUND: Children with sickle cell anemia (SCA) are highly susceptible to stroke and other manifestations of pediatric cerebral vasculopathy. Detailed evaluations in sub-Saharan Africa are limited. METHODS: We aimed to establish the frequency and types of pediatric brain injury in a cross-sectional study at a large SCA clinic in Kampala, Uganda in a randomly selected sample of 265 patients with HbSS ages 1-12 years. Brain injury was defined as one or more abnormality on standardized testing: neurocognitive impairment using an age-appropriate test battery, prior stroke by examination or transcranial Doppler (TCD) velocities associated with stroke risk in children with SCA (cerebral arterial time averaged mean maximum velocity ≥ 170 cm/second). RESULTS: Mean age was 5.5 ± 2.9 years; 52.3% were male. Mean hemoglobin was 7.3 ± 1.01 g/dl; 76.4% had hemoglobin < 8.0 g/dl. Using established international standards, 14.7% were malnourished, and was more common in children ages 5-12. Overall, 57 (21.5%) subjects had one to three abnormal primary testing. Neurocognitive dysfunction was found in 27, while prior stroke was detected in 15 (5.7%). The most frequent abnormality was elevated TCD velocity 43 (18.1%), of which five (2.1%) were in the highest velocity range of abnormal. Only impaired neurocognitive dysfunction increased with age (OR 1.44, 95%CI 1.23-1.68), p < 0.001). In univariate models, malnutrition defined as wasting (weight-for-height ≤ -2SD), but not sex or hemoglobin, was modestly related to elevated TCD (OR 1.37, 95%CI 1.01-1.86, p = 0.04). In adjusted models, neurocognitive dysfunction was strongly related to prior stroke (OR 6.88, 95%CI 1.95-24.3, p = .003) and to abnormal TCD (OR 4.37, 95%CI 1.30, p = 0.02). In a subset of 81 subjects who were enriched for other abnormal results, magnetic resonance imaging and angiography (MRI/MRA) detected infarcts and/or arterial stenosis in 52%. Thirteen subjects (25%) with abnormal imaging had no other abnormalities detected. CONCLUSIONS: The high frequency of neurocognitive impairment or other abnormal results describes a large burden of pediatric SCA brain disease in Uganda. Evaluation by any single modality would have underestimated the impact of SCA. Testing the impact of hydroxyurea or other available disease-modifying interventions for reducing or preventing SCA brain effects is warranted.

11.
Lancet Glob Health ; 7(10): e1435-e1447, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31537373

RESUMO

BACKGROUND: Severe anaemia is a leading cause of paediatric admission to hospital in Africa; post-discharge outcomes remain poor, with high 6-month mortality (8%) and re-admission (17%). We aimed to investigate post-discharge interventions that might improve outcomes. METHODS: Within the two-stratum, open-label, multicentre, factorial randomised TRACT trial, children aged 2 months to 12 years with severe anaemia, defined as haemoglobin of less than 6 g/dL, at admission to hospital (three in Uganda, one in Malawi) were randomly assigned, using sequentially numbered envelopes linked to a second non-sequentially numbered set of allocations stratified by centre and severity, to enhanced nutritional supplementation with iron and folate-containing multivitamin multimineral supplements versus iron and folate alone at treatment doses (usual care), and to co-trimoxazole versus no co-trimoxazole. All interventions were administered orally and were given for 3 months after discharge from hospital. Separately reported randomisations investigated transfusion management. The primary outcome was 180-day mortality. All analyses were done in the intention-to-treat population; follow-up was 180 days. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN84086586, and follow-up is complete. FINDINGS: From Sept 17, 2014, to May 15, 2017, 3983 eligible children were randomly assigned to treatment, and followed up for 180 days. 164 (4%) were lost to follow-up. 1901 (95%) of 1997 assigned multivitamin multimineral supplement, 1911 (96%) of 1986 assigned iron and folate, and 1922 (96%) of 1994 assigned co-trimoxazole started treatment. By day 180, 166 (8%) children in the multivitamin multimineral supplement group versus 169 (9%) children in the iron and folate group had died (hazard ratio [HR] 0·97, 95% CI 0·79-1·21; p=0·81) and 172 (9%) who received co-trimoxazole versus 163 (8%) who did not receive co-trimoxazole had died (HR 1·07, 95% CI 0·86-1·32; p=0·56). We found no evidence of interactions between these randomisations or with transfusion randomisations (p>0·2). By day 180, 489 (24%) children in the multivitamin multimineral supplement group versus 509 (26%) children in the iron and folate group (HR 0·95, 95% CI 0·84-1·07; p=0·40), and 500 (25%) children in the co-trimoxazole group versus 498 (25%) children in the no co-trimoxazole group (1·01, 0·89-1·15; p=0·85) had had one or more serious adverse events. Most serious adverse events were re-admissions, occurring in 692 (17%) children (175 [4%] with at least two re-admissions). INTERPRETATION: Neither enhanced supplementation with multivitamin multimineral supplement versus iron and folate treatment or co-trimoxazole prophylaxis improved 6-month survival. High rates of hospital re-admission suggest that novel interventions are urgently required for severe anaemia, given the burden it places on overstretched health services in Africa. FUNDING: Medical Research Council and Department for International Development.


Assuntos
Anemia , Combinação Trimetoprima e Sulfametoxazol , Criança , Suplementos Nutricionais , Humanos , Lactente , Malaui , Alta do Paciente , Uganda
12.
N Engl J Med ; 381(5): 407-419, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31365799

RESUMO

BACKGROUND: The World Health Organization recommends not performing transfusions in African children hospitalized for uncomplicated severe anemia (hemoglobin level of 4 to 6 g per deciliter and no signs of clinical severity). However, high mortality and readmission rates suggest that less restrictive transfusion strategies might improve outcomes. METHODS: In this factorial, open-label, randomized, controlled trial, we assigned Ugandan and Malawian children 2 months to 12 years of age with uncomplicated severe anemia to immediate transfusion with 20 ml or 30 ml of whole-blood equivalent per kilogram of body weight, as determined in a second simultaneous randomization, or no immediate transfusion (control group), in which transfusion with 20 ml of whole-blood equivalent per kilogram was triggered by new signs of clinical severity or a drop in hemoglobin to below 4 g per deciliter. The primary outcome was 28-day mortality. Three other randomizations investigated transfusion volume, postdischarge supplementation with micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. RESULTS: A total of 1565 children (median age, 26 months) underwent randomization, with 778 assigned to the immediate-transfusion group and 787 to the control group; 984 children (62.9%) had malaria. The children were followed for 180 days, and 71 (4.5%) were lost to follow-up. During the primary hospitalization, transfusion was performed in all the children in the immediate-transfusion group and in 386 (49.0%) in the control group (median time to transfusion, 1.3 hours vs. 24.9 hours after randomization). The mean (±SD) total blood volume transfused per child was 314±228 ml in the immediate-transfusion group and 142±224 ml in the control group. Death had occurred by 28 days in 7 children (0.9%) in the immediate-transfusion group and in 13 (1.7%) in the control group (hazard ratio, 0.54; 95% confidence interval [CI], 0.22 to 1.36; P = 0.19) and by 180 days in 35 (4.5%) and 47 (6.0%), respectively (hazard ratio, 0.75; 95% CI, 0.48 to 1.15), without evidence of interaction with other randomizations (P>0.20) or evidence of between-group differences in readmissions, serious adverse events, or hemoglobin recovery at 180 days. The mean length of hospital stay was 0.9 days longer in the control group. CONCLUSIONS: There was no evidence of differences in clinical outcomes over 6 months between the children who received immediate transfusion and those who did not. The triggered-transfusion strategy in the control group resulted in lower blood use; however, the length of hospital stay was longer, and this strategy required clinical and hemoglobin monitoring. (Funded by the Medical Research Council and Department for International Development; TRACT Current Controlled Trials number, ISRCTN84086586.).


Assuntos
Anemia/terapia , Transfusão de Sangue , Hemoglobinas/análise , Tempo para o Tratamento , Anemia/complicações , Anemia/mortalidade , Transfusão de Sangue/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Seguimentos , Custos de Cuidados de Saúde , Humanos , Lactente , Tempo de Internação/economia , Malária/complicações , Malaui/epidemiologia , Masculino , Readmissão do Paciente/estatística & dados numéricos , Reação Transfusional/epidemiologia , Uganda/epidemiologia
13.
N Engl J Med ; 381(5): 420-431, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-31365800

RESUMO

BACKGROUND: Severe anemia (hemoglobin level, <6 g per deciliter) is a leading cause of hospital admission and death in children in sub-Saharan Africa. The World Health Organization recommends transfusion of 20 ml of whole-blood equivalent per kilogram of body weight for anemia, regardless of hemoglobin level. METHODS: In this factorial, open-label trial, we randomly assigned Ugandan and Malawian children 2 months to 12 years of age with a hemoglobin level of less than 6 g per deciliter and severity features (e.g., respiratory distress or reduced consciousness) to receive immediate blood transfusion with 20 ml per kilogram or 30 ml per kilogram. Three other randomized analyses investigated immediate as compared with no immediate transfusion, the administration of postdischarge micronutrients, and postdischarge prophylaxis with trimethoprim-sulfamethoxazole. The primary outcome was 28-day mortality. RESULTS: A total of 3196 eligible children (median age, 37 months; 2050 [64.1%] with malaria) were assigned to receive a transfusion of 30 ml per kilogram (1598 children) or 20 ml per kilogram (1598 children) and were followed for 180 days. A total of 1592 children (99.6%) in the higher-volume group and 1596 (99.9%) in the lower-volume group started transfusion (median, 1.2 hours after randomization). The mean (±SD) volume of total blood transfused per child was 475±385 ml and 353±348 ml, respectively; 197 children (12.3%) and 300 children (18.8%) in the respective groups received additional transfusions. Overall, 55 children (3.4%) in the higher-volume group and 72 (4.5%) in the lower-volume group died before 28 days (hazard ratio, 0.76; 95% confidence interval [CI], 0.54 to 1.08; P = 0.12 by log-rank test). This finding masked significant heterogeneity in 28-day mortality according to the presence or absence of fever (>37.5°C) at screening (P=0.001 after Sidak correction). Among the 1943 children (60.8%) without fever, mortality was lower with a transfusion volume of 30 ml per kilogram than with a volume of 20 ml per kilogram (hazard ratio, 0.43; 95% CI, 0.27 to 0.69). Among the 1253 children (39.2%) with fever, mortality was higher with 30 ml per kilogram than with 20 ml per kilogram (hazard ratio, 1.91; 95% CI, 1.04 to 3.49). There was no evidence of differences between the randomized groups in readmissions, serious adverse events, or hemoglobin recovery at 180 days. CONCLUSIONS: Overall mortality did not differ between the two transfusion strategies. (Funded by the Medical Research Council and Department for International Development, United Kingdom; TRACT Current Controlled Trials number, ISRCTN84086586.).


Assuntos
Anemia/terapia , Transfusão de Sangue , Hemoglobinas/análise , Anemia/complicações , Anemia/mortalidade , Transfusão de Sangue/economia , Criança , Pré-Escolar , Análise Custo-Benefício , Feminino , Febre/complicações , Seguimentos , Custos de Cuidados de Saúde , Humanos , Lactente , Tempo de Internação/economia , Malária/complicações , Malaui/epidemiologia , Masculino , Readmissão do Paciente/estatística & dados numéricos , Reação Transfusional/epidemiologia , Uganda/epidemiologia
15.
Vox Sang ; 114(4): 340-348, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30838664

RESUMO

BACKGROUND AND OBJECTIVES: Paediatric blood transfusion for severe anaemia in hospitals in sub-Saharan Africa remains common. Yet, reports describing the haematological quality of donor blood or storage duration in routine practice are very limited. Both factors are likely to affect transfusion outcomes. MATERIALS AND METHODS: We undertook three audits examining the distribution of pack types, haematological quality and storage duration of donor blood used in a paediatric clinical trial of blood at four hospitals in Africa (Uganda and Malawi). RESULTS: The overall distribution of whole blood, packed cells (plasma-reduced by centrifugation) and red cell concentrates (RCC) (plasma-reduced by gravity-dependent sedimentation) used in a randomised trial was 40·7% (N = 1215), 22·4% (N = 669) and 36·8% (N = 1099), respectively. The first audit found similar median haematocrits of 57·0% (50·0,74·0), 64·0% (52·0,72·5; P = 0·238 vs. whole blood) and 56·0% (48·0,67·0; P = 0·462) in whole blood, RCC and packed cells, respectively, which resulted from unclear pack labelling by blood transfusion services (BTS). Re-training of the BTS, hospital blood banks and clinical teams led to, in subsequent audits, significant differences in median haematocrit and haemoglobins across the three pack types and values within expected ranges. Median storage duration time was 12 days (IQR: 6, 19) with 18·2% (537/2964) over 21 days in storage. Initially, 9 (2·8%) packs were issued past the recommended duration of storage, dropping to 0·3% (N = 7) in the third audit post-training. CONCLUSION: The study highlights the importance of close interactions and education between BTS and clinical services and the importance of haemovigilance to ensure safe transfusion practice.


Assuntos
Anemia/terapia , Bancos de Sangue/normas , Doadores de Sangue , Transfusão de Sangue/métodos , Controle de Qualidade , Anemia/sangue , Criança , Hematócrito , Hematologia/normas , Hemoglobinas , Hospitais , Humanos , Malaui , Pediatria/métodos , Garantia da Qualidade dos Cuidados de Saúde , Ensaios Clínicos Controlados Aleatórios como Assunto , Refrigeração , Reprodutibilidade dos Testes , Manejo de Espécimes , Uganda
16.
BMC Pediatr ; 18(1): 355, 2018 11 13.
Artigo em Inglês | MEDLINE | ID: mdl-30424740

RESUMO

BACKGROUND: Neonatal sepsis is one of the most important causes of mortality in developing countries and yet the most preventable. In developing countries clinical algorithms are used to diagnose clinical neonatal sepsis because of inadequate microbiological services. Most information on incidence and risk factors of neonatal sepsis are from hospital studies which may not be generalized to communities where a significant proportion of mothers do not deliver from health facilities. This study, conducted in urban Uganda, sought to determine the community based incidence of clinical neonatal sepsis and the factors associated. METHODS: This was a cohort of mother-neonate pairs in Kampala, Uganda from March to May 2012. The enrolled neonates were assessed for clinical sepsis and factors associated, and followed up till the end of the neonatal period. STATA version 10 was used to analyse the data. RESULTS: The community based incidence of neonatal sepsis was 11% (95% CI: 7.6-14.4). On bivariate analysis, lack of financial support from the father (OR 4.09, 95% CI 1.60-10.39) and prolonged rupture of membranes more than 18 h prior to delivery (OR 11.7, 95% CI 4.0-31.83) were significantly associated with neonatal sepsis. Maternal hand washing prior to handling the baby was found to be protective of neonatal sepsis (OR 0.41, 95% CI 0.18-0.94). Of the 317 infants who completed the follow up period, one died within the neonatal period giving a neonatal mortality of 0.003%. CONCLUSION: The high incidence of clinical neonatal sepsis in this urban community with high rates of antenatal care attendance and health facility delivery places a demand on the need to improve the quality of antenatal, perinatal and postnatal care in health facilities with regards to infection prevention including promoting simple practices like hand washing. The astoundingly low mortality rate is most likely because this was a low risk cohort. However it may also suggest that the neonatal mortality in developing countries may be reduced with promotion of simple low cost interventions like community follow up of neonates using village health teams or domiciliary care.


Assuntos
Sepse Neonatal/epidemiologia , Estudos de Coortes , Países em Desenvolvimento , Feminino , Humanos , Incidência , Recém-Nascido , Masculino , Mães , Sepse Neonatal/mortalidade , Cuidado Pré-Natal/estatística & dados numéricos , Qualidade da Assistência à Saúde , Fatores de Risco , Tamanho da Amostra , Uganda/epidemiologia , População Urbana
17.
Front Pediatr ; 6: 37, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29600241

RESUMO

Introduction: Under five mortality rates (UFMR) remain high for children in low- and middle-income countries (LMICs) in the developing world. Education for practitioners in these environments is a key factor to improve outcomes that will address United Nations Sustainable Development Goals 3 and 10 (good health and well being and reduced inequalities). In order to appropriately contextualize a curriculum using simulation, it is necessary to first conduct a needs assessment of the target learner population. The World Health Organization (WHO) has published a tool to assess capacity for emergency and surgical care in LMICs that is adaptable to this goal. Materials and methods: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was modified to assess pediatric resuscitation capacity in clinical settings in two LMICs: Uganda and Myanmar. Modifications included assessment of self-identified learning needs, current practices, and perceived epidemiology of disease burden in each clinical setting, in addition to assessment of pediatric resuscitation capacity in regard to infrastructure, procedures, equipment, and supplies. The modified tool was administered to 94 respondents from the two settings who were target learners of a proposed simulation-based curriculum in pediatric and neonatal resuscitation. Results: Infectious diseases (respiratory illnesses and diarrheal disease) were cited as the most common causes of pediatric deaths in both countries. Self-identified learning needs included knowledge and skill development in pediatric airway/breathing topics, as well as general resuscitation topics such as CPR and fluid resuscitation in shock. Equipment and supply availability varied substantially between settings, and critical shortages were identified in each setting. Current practices and procedures were often limited by equipment availability or infrastructural considerations. Discussion and conclusion: Epidemiology of disease burden reported by respondents was relatively consistent with WHO country-specific UFMR statistics in each setting. Results of the needs assessment survey were subsequently used to refine goals and objectives for the simulation curriculum and to ensure delivery of pragmatic educational content with recommendations that were contextualized for local capacity and resource availability. Effective use of the tool in two different settings increases its potential generalizability.

18.
BMC Med ; 16(1): 37, 2018 03 09.
Artigo em Inglês | MEDLINE | ID: mdl-29519240

RESUMO

BACKGROUND: Hyperlactataemia (HL) is a biomarker of disease severity that predicts mortality in patients with sepsis and malaria. Lactate clearance (LC) during resuscitation has been shown to be a prognostic factor of survival in critically ill adults, but little data exist for African children living in malaria-endemic areas. METHODS: In a secondary data analysis of severely ill febrile children included in the Fluid Expansion as Supportive Therapy (FEAST) resuscitation trial, we assessed the association between lactate levels at admission and LC at 8 h with all-cause mortality at 72 h (d72). LC was defined as a relative lactate decline ≥ 40% and/or lactate normalisation (lactate < 2.5 mmol/L). RESULTS: Of 3170 children in the FEAST trial, including 1719 children (57%) with Plasmodium falciparum malaria, 3008 (95%) had a baseline lactate measurement, 2127 (71%) had HL (lactate ≥ 2.5 mmol/L), and 1179 (39%) had severe HL (≥ 5 mmol/L). Within 72 h, 309 children (10.3%) died, of whom 284 (92%) had baseline HL. After adjustment for potential confounders, severe HL was strongly associated with mortality (Odds Ratio (OR) 6.96; 95% CI 3.52, 13.76, p < 0.001). This association was not modified by malaria status, despite children with malaria having a higher baseline lactate (median 4.6 mmol/L vs 3 mmol/L; p < 0.001) and a lower mortality rate (OR = 0.42; p < 0.001) compared to non-malarial cases. Sensitivity and specificity analysis identified a higher lactate on admission cut-off value predictive of d72 for children with malaria (5.2 mmol/L) than for those with other febrile illnesses (3.4 mmol/L). At 8 h, 2748/3008 survivors (91%) had a lactate measured, 1906 (63%) of whom had HL on admission, of whom 1014 (53%) fulfilled pre-defined LC criteria. After adjustment for confounders, LC independently predicted survival after 8 h (OR 0.24; 95% CI 0.14, 0.42; p < 0.001). Absence of LC (< 10%) at 8 h was strongly associated with death at 72 h (OR 4.62; 95% CI 2.7, 8.0; p < 0.001). CONCLUSIONS: Independently of the underlying diagnosis, HL is a strong risk factor for death at 72 h in children admitted with severe febrile illnesses in Africa. Children able to clear lactate within 8 h had an improved chance of survival. These findings prompt the more widespread use of lactate and LC to identify children with severe disease and monitor response to treatment. TRIAL REGISTRATION: ISRCTN69856593 Registered 21 January 2009.


Assuntos
Estado Terminal/mortalidade , Febre/mortalidade , Ácido Láctico/metabolismo , Malária/mortalidade , Sepse/mortalidade , África Oriental , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Malária/complicações , Masculino , Prognóstico , Fatores de Risco , Sepse/complicações
19.
BMC Med Educ ; 17(1): 231, 2017 Nov 25.
Artigo em Inglês | MEDLINE | ID: mdl-29178949

RESUMO

BACKGROUND: In most medical schools, graduate students, sometimes referred to as graduate teaching assistants, often participate in the training of undergraduate students. In developing countries like Uganda, are typically involved in undergraduate training. However, prior to this study there were no standard guidelines for this involvement. At the same time, the views and experiences of the graduate students in their role as educators had not been documented. Therefore, the aim of this study was to explore the views and experiences of graduate students about their involvement in undergraduate training in three Ugandan medical schools. The findings of this study will contribute to the development of policies for training in Ugandan medical schools. METHODS: This was a qualitative study in which thirty in-depth-interviews were conducted among second and third year graduate students in three Ugandan medical schools in the MESAU consortium (Medical Education Services to all Ugandans) including Mbarara University of Science and Technology, Makerere College of Health Sciences and Kampala International University, Western Campus. RESULTS: All graduate students from all the three medical schools viewed their involvement in undergraduate training as important. The study also revealed that graduate students increase available human resources and often compensate for the teaching missed when senior educators were absent. The graduate students expressed important views that need to be considered in the design of educational programs where they are to be involved. The respondents also reported a number of challenges in this undertaking that included lack of motivation, lack of orientation and having heavy workloads. The presence and commitment of senior educators to guide and support the graduate students in teaching activities was viewed as one significant intervention that would increase the effectiveness of their educational contributions. CONCLUSIONS: Graduate students enjoy their involvement in the training of undergraduate students despite the various challenges they face. In some departments, the involvement of postgraduate trainees is critical to the viability of undergraduate medical training.


Assuntos
Competência Clínica/normas , Educação de Pós-Graduação em Medicina , Educação de Graduação em Medicina , Faculdades de Medicina , Estudantes de Medicina , Ensino , Atitude do Pessoal de Saúde , Feminino , Humanos , Masculino , Motivação , Avaliação de Programas e Projetos de Saúde , Pesquisa Qualitativa , Faculdades de Medicina/normas , Estudantes de Medicina/psicologia , Uganda , Carga de Trabalho/psicologia , Adulto Jovem
20.
BMC Med Educ ; 17(1): 123, 2017 Jul 14.
Artigo em Inglês | MEDLINE | ID: mdl-28709464

RESUMO

BACKGROUND: The aim of mentorship is to build the mentees capacity, enhance their skills and improve their ability to produce desired outcomes. However, the mentoring relationship is vulnerable to a number of challenges that may undermine its effectiveness and sustainability. We aimed to explore the experiences and perceptions of student and junior faculty mentees and senior faculty mentors at the Makerere University College of Health Sciences and identify the key factors defined by mentees and mentors as necessary for a successful mentorship program. METHODS: A qualitative design involving focus group discussions (FGDs) and key informant interviews (KII) was used. A total of eight KII and four FGDs were conducted, audio recorded and transcribed verbatim. Open coding of the transcripts was performed, and major themes were identified through multiple readings based on thematic analysis. RESULTS: Six key themes were shared by the mentees and mentors including: 1) defining the role of the mentor; 2) desired characteristics of a mentor and a mentoring relationship, with an emphasis on mutual trust and respect; 3) overlapping roles of mentors and supervisors; 4) issues with the process for identifying mentors, including the benefits and drawbacks of the mentee selecting mentor vs. being assigned a mentor; 5) current barriers to mentoring, including lack of knowledge about current program, lack of formal structure, uncertainly about who should initiate relationship, and unclear roles and expectations and 6) recommendations for the future development of mentoring programme, including the need for a formalized programme, and training adapted to the local context. CONCLUSIONS: The mentees and mentors described the role of the mentor and desired characteristics of mentors and a mentoring relationship similarly. Most concerns about mentoring occurred when current mentoring programmes and practices were not well aligned with these desired characteristics. Recommendations for future development of mentoring included greater formalization of mentoring with mentoring programmes based on shared expectations and adapted to the local context.


Assuntos
Educação de Pós-Graduação em Medicina/normas , Tutoria , Mentores , Pesquisa Qualitativa , Desenvolvimento de Pessoal/normas , Estudantes de Medicina , Atitude do Pessoal de Saúde , Docentes de Medicina , Grupos Focais , Recursos em Saúde , Humanos , Satisfação Pessoal , Avaliação de Programas e Projetos de Saúde , Desenvolvimento de Pessoal/métodos , Uganda , Universidades
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