Equitable Access to Health Professional Training in Uganda: A Cross Sectional Study.

OBJECTIVE: We set out to assess inequalities to access health professional education, and the impact of an education improvement program supported by MEPI (Medical Education Partnership Initiative). Inequalities in the higher education system in sub-Saharan Africa remain despite some transformative policies and affirmative action. METHODS: We reviewed enrollment data from four universities for the period 2001-2014 for various health professional training programs, and conducted group discussions through an iterative process with selected stakeholders, and including a group of education experts. Two time periods, 2001-2010 and 2011-2014, were considered. In 2010-11, the MEPI education program began. Gender ratios, regional representation, secondary schools, and the number of admissions by university and year were analysed. We used SPSS version 17 software to analyse these data with level of significance p < 0.05. We collated qualitative data along predetermined and emerging themes. RESULTS: The overall male-to-female ratio among the student population was 2.3:1. In total, there were 7,023 admissions, 4,403 between 2001-2010 (440 per annum) and 2,620 between 2011-2014 (655 per annum) with p = 0.018. There were no significant increases in admissions in the central and western regions over the two time periods, 1,708 to 849 and 1,113 to 867 respectively, both p = 0.713 and p = 0.253. We propose improving the university admission criteria and increasing enrollment to health professions training schools. CONCLUSION: There were significant inequalities for higher education training in Uganda by gender, regional representation and school attended. Modifying the admission criteria and increasing enrollment may reduce these inequalities.

Long term post PrePex male circumcision outcomes in an urban population in Uganda: a cohort study.

OBJECTIVE: The objective of this study was to determine the long term adverse events profile at least a year after safe male circumcision. RESULTS: A cohort study, investigating patients who had undergone a non surgical circumcision procedure called Prepex. The study variables included scar appearance and sexual experiences. Clients were contacted for a phone interview and data were collected using a questionnaire, for some, a physical examination was done. We obtained ethical committee approval. Data from 304 out of a possible 625 men were analyzed, the rest was lost to follow up. The follow up period was 12-24 months. The mean age was 28 years. Up to 97% were satisfied with the penile scar appearance and the absence of pain. There was no keloids formation, though one developed a hypertrophic scar. Participants reported improved sexual intercourse enjoyment (post circumcision). Up to 17% resumed sexual intercourse before the 6-week long mandatory abstinence period. The average self-reported healing time was 4.7 weeks. There was a high level of scar appearance satisfaction, there was no keloids formation. There was a perceived improvement of sexual enjoyment after circumcision. Trial registration ClinicalTrials. Gov Identifier: NCT02245126 (Date of registration: September 19, 2014).

Chest wall schwannoma presenting as a solitary malignant lesion: a case report.

BACKGROUND: Chest wall schwannomas are rare tumors arising from the intercostals nerves. Schwannomas are lobulated, encapsulated spherical masses, different from neurofibromas in that matter. Men and women are equally affected in their third and fourth decades. CASE PRESENTATION: A 42 year old female presented with a 6 month history of progressively worsening pain over the right shoulder and chest wall, aggravated by movement and with associated right arm oedema and paraesthesia. She believed mild symptoms began 2 years prior to presentation. The histopathological examination revealed a benign lesion; a schwannoma with degenerative changes. The section revealed a benign nerve sheath tumor characterized by a proliferation of band spindle cells arranged in fascicles and variable cellularity and associated with dilated and think walled blood vessels. CONCLUSION: Chest wall schwannomas are rare; they mimic chest wall malignant lesions.

Improving Surgical Access in Rural Africa through a Surgical Camp Model.

Introduction. Surgical camps are preplanned activities where volunteer surgical teams congregate at specified place(s) and perform a wide range of mostly elective procedures for a limited period of time. This is usually at no cost to the patients, who belong to vulnerable (poor and hard to reach) communities. We describe a surgical camp model and its challenges as a means of improving access to surgical services. Methods. A cross-sectional descriptive study. Data from a recent Association of Surgeons of Uganda surgical camp were collected and analyzed for demographics, costs, procedure types, and rates and, in addition, challenges encountered and solutions. Personnel that participated in this exercise included specialist surgeons, surgical residents, medical officers, clinical officers, anesthetists, and theater nurses (a total of 121 staff). Results. In total, 551 procedures were performed during a four-day-long camp. Mean age was 35 years (SD 23), M : F ratio was 2 : 1. Herniorrhaphy, skin lump excision, hydrocelectomy, and thyroidectomy formed 81% of all the procedures. Average cost per procedure was $73 USD. Conclusion. Surgical camps offer increased access to surgical services to vulnerable populations. Hernias and goiters were most common. Surgical camps should become an integral part of the Health Service delivery in low-resourced environments.

Patient delay factors in women presenting with breast cancer in a low income country.

BACKGROUND: In low income countries, many patients with breast cancer present with advanced disease which is majorly attributed to late presentation and this is associated with poor survival rates. The aim of this study was to determine the magnitude of patient delay and the factors that influence, delay in seeking health care in female breast cancer patients. METHODS: A cross-sectional study was done between January and April 2014 at a tertiary breast unit. Female patients with breast cancer above the age of 18 years were interviewed. Ethical approval was obtained. RESULTS: In total 162 patients were recruited, the mean patient delay in months was 22.6 (SD = 26.4), median delay was 13 months and range was 1-127 months. 139 (89 %) patients delayed by more than 3 months after noticing symptoms of breast anomaly. Patients with no social support from spouses and family were more likely to delay (OR = 7.1, 95 % CI 2.4-21.5, p = 0.001), those who perceived the symptoms as very serious were less likely to delay (OR = 0.2, 95 % CI 0.1-0.6, p = 0.007). There was a significant association between delayed presentation and advanced stage at presentation (p = 0.006). CONCLUSION: Most women (89 %) with breast cancer delayed by more than 3 months to seek the first medical consultation after noticing symptoms. Patients who had no social support from their families were more likely to delay.

The Burden of Hand Injuries at a Tertiary Hospital in Sub-Saharan Africa.

Background. Hand injuries are common worldwide and lead to heavy financial losses in terms of treatment, job loss, and time off duty. There is paucity of data on hand injuries in sub-Saharan Africa. The aim of this study was to determine the burden and early outcomes of hand injuries at a tertiary hospital. Method. A descriptive prospective study. Eligible patients were recruited over 5 months and followed up for four weeks. Pain, nerve function, and gross functions of the hand were assessed. Results. In total 138 patients were enrolled out of 2940 trauma patients. Of these, 122 patients returned for follow-up. The majority of the patients were males (83%). Mean age was 26.7 years (SD 12.8). The commonest places of injury occurrence were the workplace (36%), home (28%), and on the road (traffic crushes) (23%). Machines (21.3%) were the commonest agent of injuries; others were knives (10%) and broken glass (10%). Sixty-three (51%) patients still had pain at one month. Conclusions. Hand injuries accounted for 4.7% of all trauma patients. Road traffic crushes and machines were the commonest causes of hand injuries. Men in their 20s were mostly involved. Sensitization for prevention strategies at the workplace may be helpful.

Prevalence of Helicobacter pylori in dyspeptic patients at a tertiary hospital in a low resource setting.

BACKGROUND: More than half of the world's population is infected with Helicobacter pylori (H. pylori), the primary cause of chronic gastritis. Chronic gastritis is associated with peptic ulcer and in advanced stages with an increased risk of developing gastric adenocarcinoma. In many developing countries access to upper gastrointestinal (UGI) endoscopy services is limited. As a result, many UGI diseases are treated empirically. OBJECTIVE: To determine the prevalence of H. pylori in patients presenting with dyspepsia, and the mean time from onset of symptoms to performing an endoscopy examination. METHODS: A cross sectional descriptive study conducted from 5th January to 30th April 2014. Adult patients with dyspepsia who were referred for UGI endoscopy were recruited consecutively. Questionnaires were used to collect data which were analyzed using STATA software. IRB approval was obtained. RESULTS: In total, 111 participants' data were analyzed. The F:M ratio was 1:1.4, mean age 43 years (SD = 16). The prevalence of H. pylori gastritis was 36%. The minimum time to endoscopy was 3 weeks, maximum 1,248 weeks and the mean time 57 weeks. CONCLUSION: The burden of H. pylori infection in patients with dyspepsia was high. Patients had prior empirical antibiotic therapy. Access to endoscopic services is limited.

Mastalgia: prevalence at a sub-saharan african tertiary hospital.

Introduction. Mastalgia is a common breast condition among women referred to breast clinics worldwide. Whereas the prevalence is known in the Western world and Asia, the prevalence of the disease is unknown in many African countries. The aim of this study therefore was to determine the prevalence and describe factors associated with mastalgia among women attending a tertiary hospital in sub-Saharan Africa. Methods. A cross-sectional study was done in Kampala, Uganda. Mastalgia was defined as self-reported breast pain (unilateral or bilateral) for a period not less than two months. A pretested questionnaire was used to collect the data and statistical analysis was performed using SPSS version 11. Ethical approval was obtained. Results. Out of the 1048 women who presented to the breast clinic during the study period, 168 (16%) were diagnosed with mastalgia in the absence of breast cancer. Noncyclical and cyclical mastalgia were 22/168 (13%) and 5/168 (3%), respectively. The onset of noncyclical category as compared to the cyclical type of mastalgia was observed to manifest before 24 years of age (P = 0.006). Conclusion. Mastalgia was a common condition among women in this sub-Saharan African setting as is elsewhere. The early onset mastalgia in this sub-Saharan African study requires further exploration for determination of its risk factors.

Outcomes of dorsal and ventral buccal graft urethroplasty at a tertiary hospital in Uganda.

Purpose. Although the use of buccal mucosa in substitution urethroplasty has been practiced for some years, it has not been free of controversy over which surgical technique is the most appropriate to use. There is paucity of data in Sub-Saharan Africa about its success; this study presents the outcomes of dorsal and ventral buccal graft urethroplasty at a sub-Saharan tertiary hospital. Methods. This is a prospective study in which buccal mucosa was used for ventral and dorsal grafts; followup was up to two years. All patients provided informed written consent for the procedures. Results. Seventy-two patients with bulbar urethral strictures underwent buccal graft one-stage urethroplasty. Mean age was 55 years; etiology of the strictures was postinflammatory due to urethritis from sexually transmitted infections 97% (70/72) and trauma 3% (2/72). Buccal mucosa grafts were harvested from the cheek using a two-team approach. Grafts were placed on the ventral and dorsal urethral surfaces in 32 and 40 cases, respectively; the success rate was 84 and 80%, respectively. Repeated urethroplasty was successfully done among 10% (7/72) and patients reported resolution of symptoms in the follow-up period. Conclusion. There was no difference between dorsal and ventral onlay buccal graft outcomes for bulbar urethral strictures. The success rate was 80 to 84%.

Emergency Ultrasound Predicting the Need for Therapeutic Laparotomy among Blunt Abdominal Trauma Patients in a Sub-Saharan African Hospital.

Background. The trauma burden globally accounts for high levels of mortality and morbidity. Blunt abdominal trauma (BAT) contributes significantly to this burden. Patient's evaluation for BAT remains a diagnostic challenge for emergency physicians. SSORTT gives a score that can predict the need for laparotomy. The objective of this study was to assess the accuracy of SSORTT score in predicting the need for a therapeutic laparotomy after BAT. Method. A prospective observational study. Eligible patients were evaluated for shock and the presence of haemoperitoneum using a portable ultrasound machine. Further evaluation of patients following the standard of care (SOC) protocol was done. The accuracy of SSORTT score in predicting therapeutic laparotomy was compared to SOC. Results. In total, 195 patients were evaluated; M : F ratio was 6 : 1. The commonest injuries were to the head 80 (42%) and the abdomen 54 (28%). A SSORTT score of >2 appropriately identified patients that needed a therapeutic laparotomy (with sensitivity 90%, specificity 90%, PPV 53%, and NPV 98%). The overall mortality rate was 17%. Conclusion. Patients with a SSORTT score of 2 and above had a high likelihood of requiring a therapeutic laparotomy. SSORTT scoring should be adopted for routine practice in low technology settings.

Urinary Continence Outcomes after Puboprostatic Ligament Preserving Open Retropubic Radical Prostatectomy at a Sub-Saharan Hospital.

Background. Open retropubic radical prostatectomy is a commonly performed procedure for clinically localized prostate cancer. The demand for high level functional outcomes after therapy is increasing especially for young age patients; in this regard refinements in the surgical technique have been made. There is limited data to show the success of some of these refinements in resource limited settings. Methods. A retrospective clinical study was performed over a 2-year period at Mengo Hospital, Urology Unit. Men with clinically localized prostate cancer and who consented to the procedure were eligible and were recruited. Consequently excluded were those that turned out to have advanced disease and those with severe comorbidities. Patients were followed up for 3 months after surgery. Data was entered using SPSS version 17 and analyzed. Results. A total of 24 men with clinically localized prostate cancer underwent open retropubic puboprostatic ligament preserving radical prostatectomy technique. Mean age was 66, range 54-75 years. Outcome. Two patients had stress incontinence and three were incontinent at 3 months. The urinary continence recovery rate was 19/24 (79%) at 3 months. Conclusion. Preservation of the puboprostatic ligament in open retropubic radical prostatectomy was associated with rapid and a high rate of return to urinary continence among men with clinically localized disease.

To drain or not to drain after thyroid surgery: a randomized controlled trial at a tertiary Hospital in East Africa.

INTRODUCTION: In many facilities, drains are routinely inserted after thyroidectomy with the aim of preventing hematoma formation and accumulation of seroma. The continued use of drains may be based more on tradition rather than proven scientific evidence. OBJECTIVE: To assess the benefit of drain use after thyroidectomy by determining; length of hospital stay, post operative pain and wound sepsis. METHODS: This was a randomized controlled trial, carried out at a tertiary national referral hospital (Mulago, Kampala). Over a 6 month period in 2011, we recruited 68 patients. Socio-demographic information and clinical parameters were recorded. Outcomes measures were evaluated. Data were double entered into epidata version 3.1.1 and analyzed using STATA version 10.0. Ethical approval was secured. RESULTS: Mean age of participants was 46 and 43.7 years in drain and no drain arm respectively. Most participants were female. Mean duration of hospital stay after thyroidectomy was significantly higher among the drain arm as compared with the no drain arm [2.41 (± 0.89) vs 1.71 (± 0.76) days (p = 0.0008)]. One patient (drain arm) had wound infection. The pain score on the postoperative day was statistically higher among in the drain arm than the no drain arm [5.71 vs 2.53 (p = 0.001)]. CONCLUSION: Not inserting a drain post operatively after thyroid surgery was associated with short hospital stay and less operative pain. Results of this study do not support routine drainage after thyroid surgery.

Difference in Risk Factors for Breast Cancer by ER Status in an Indigenous African Population.

Introduction. Breast cancer is the commonest cancer among women globally. In Uganda, it is on the rise, projected at a 4.5% annual ASR increase (age standardized incidence rate). The reasons for this steep increase are not fully established. In the recent past, gene profiling in tumor tissues suggests that breast cancers are divided into subtypes dependent on the presence or absence of oestrogen receptor, progesterone, and human epidermal growth factor receptor 2 (HER 2). These subtypes do have distinctive clinical outcomes and perhaps risk factors from past studies. There is paucity of data on hormonal receptor status and the traditionally known risk factors in sub-Saharan Africa. The purpose of this study therefore was to establish the differences between ER status and the traditionally known risk factors for breast cancer in Uganda. Methods. An observational analytical hospital, based study, carried out at Makerere University, College of Health Sciences. Formalin fixed and paraffin imbedded sections were prepared for haemotoxylin and eosin (H&E) stains and immunohistochemistry (IHC). Ethical approval was obtained. Results. A total of 113 women were recruited. Mean age was 45 years (SD14). There were no significant differences in selected risk factors (setting, age, contraceptive use, parity, breast feeding, or menarche) by ER status although ER negative tumors had significantly higher grade tumors (by a factor of two) compared to ER positive tumors. Conclusion. There were no significant differences among risk factors by ER status contrary to what several other studies suggest. The manifestation of breast cancer in Africa warrants further extensive inquiry.

Mammographic breast density patterns among a group of women in sub Saharan Africa.

INTRODUCTION: Mammographic breast density is a measure of parenchymal breast patterns on film and in part a marker of cumulative exposure to oestrogen. The risk of breast cancer for women with increased density is up to six fold more than in women with less dense tissues. The pattern of mammographic breast density among Ugandan women is not known. OBJECTIVE: To establish these as a contribution to baseline data. METHODS: A cross sectional descriptive study that enrolled women presenting for mammography at the national referral hospital radiology department. Breast densities were scored using the BI-RADS categories. IRB approval was obtained. RESULTS: Of the 190 women enrolled, 178 were scored, of those scored 10 (5.3%) had extremely dense breasts (grade IV) and 39 (20.5%) had heteregenous ones (grade III). The rest 129 (67.9%) had scattered fibroglandular or fat densities (Grades I & II). Most of the women were young 45.8 ± 12.5 years The majority had normal or benign mammographic findings and all were non pregnant. CONCLUSION: Mammographic densities in this Ugandan population appear to be of low grade. The pattern established here is markedly different from findings in other studies that indicated much higher proportions for high dense tissues in other races. Mammographic interpretation of films could therefore be easier.

Reference values for serum levels of folic acid and vitamin B12 in a young adult Ugandan population.

INTRODUCTION: Reference values may vary significantly among populations and cultures for which dietary intakes may be different. Each laboratory is expected to investigate the transferability of the expected values to its own patient population and if necessary determine its own reference ranges. This study sought to establish Folic acid and Vitamin B(12) reference values for young Ugandan adults, which reference values could be used as baseline information for future research, especially related to their role in breast cancer prevention. METHODS: A cross sectional study in which 200 undergraduate student volunteers were enrolled. The minimum sample size was 126 using the Open Epi version 2. Relevant demographics and physical examination parameters were taken as well as blood samples for laboratory tests. Prior ethical approval was granted. RESULTS: The levels of folic acid were 4.17 - 20 ng/ml and remained constant over the age cohorts. The vitamin B(12) range was 117-1158 pg/ml. Both ranges were comparable to ranges seen in other populations. CONCLUSION: In as much as the dietary intake for this study population is presumed different from populations in the western countries, the ranges for these two vitamins were similar.

Selenium deficiency a factor in endemic goiter persistence in sub-Saharan Africa.

BACKGROUND: Goiter is still common in Uganda, despite the present iodized salt coverage of at least 95%. Where there is endemic goiter after adequate iodine supplementation, selenium deficiency could be a factor for the continued occurrence of goiter. The objectives of the present study, therefore, were to determine the serum selenium levels among goitrous patients and nongoitrous controls and to determine the association between goiter and selenium levels among these patients. METHODS: The investigation was designed as a case control study in which 92 subjects were enrolled, 46 cases and 46 controls of similar age and sex distribution. Subjects were interviewed and examined. Blood samples were taken and selenium concentrations were determined by electrothermal atomic absorption spectrometry. RESULTS: The overall mean serum selenium levels were 77.25 µg/l (SD 16.78) for the goiter patients and 95.50 µg/l (24.47) for the nongoiter controls. The difference between goitrous and nongoitrous populations was statistically significant (p=0.0001). Selenium levels above 102.8 µg/l had a statistically significant protective effect against goiter with adjusted odds ratio 0.3 (0.13-0.69); p=0.005. Other factors, such as age, main food constituent, and use of iodized salt, had no association with goiter. CONCLUSIONS: There were significant differences between selenium levels among goitrous patients and nongoitrous controls. High selenium levels seem to have a protective effect against goiter. Selenium supplementation as a preventive strategy is worth further exploration.

Rethinking breast cancer screening strategies in resource-limited settings.

The incidence of breast cancer in sub-Saharan nations is increasing. There is a worsening scarcity of Human Resource for Health in Uganda in particular and Sub Saharan Africa in general. Resources available for health care are predominantly spent on infectious disease care such as (HIV/AIDS, Tuberculosis and Malaria). These factors and more make the future of breast cancer care including screening in Sub Saharan African grim.Although mass breast cancer screening by mammography has been proved to be efficacious in the developed nations of the world, this has not been replicated in the developing nations because mass screening is not yet possible for the reasons stated. This paper proposes an alternative to mammography mass screening.Breast health programs for the most part are adhoc or non-existent in Uganda. The challenge of mass screening is not only limited to less readily available mammogram machines and trained human resources but also to the fact that the targeted population is of relatively young women in their 30s, implying that screening should commence earlier than it is practiced in nations where breast cancer peaks among women in their 50s. Mammography is not efficacious in young women with dense breast tissue. Ultra sound scans are not only up to 10 fold more available than mammography machines but are half the cost per examination.Although using ultra sound Scan for screening for non-palpable lumps is not up to par with standard breast cancer care mammography. It may be better than nothing, may be beneficial in aiding early cancer diagnosis. This concept is akin to the 'task shifting' advocated by WHO. It is worth investigating use of ultra sound scan for mass screening for breast cancer in resource-limited environments. This is not in any way lowering standards of oncologic diagnosis but filling the otherwise unattended to gap, the unmet need.

Knowledge and Practice of Breast Self Examination among Female Students in a Sub-Saharan African University

Background: Breast cancer is the most common cancer among women in many parts of Africa. Facilities for screening and early detection are extremely limited yet early diagnosis improves survival. This study explored the practice of Breast Self Examination among female university students as a means of screening and early detection in a low resources environment.Subjects and Methods: A cross sectional descriptive study at a Sub Saharan university. A call for volunteers to the study was made; a pretested standardised questionnaire was used for data collection. The process was limited to an interview and a physical examination. IRB approval was granted before the study began.Results: A total of 320 participants volunteered; 314 were recruited. The majority were aged between 21 and 25. The range was between 19 to 31 years. There was a high awareness of Breast Self Examination (BSE) of 81.5; 30had ever performed a BSE; 14performed it regularly; 8knew the correct monthly timing; the technique was accurately demonstrated by 1of participants. 4.8 were found to have breast lumps.Conclusion: There is a likelihood of most young women in the country practicing BSE inadequately. There is a need for widespread BSE campaigns emphasizing the correct technique and a need to evaluate BSE efficacy. The prevalence of breast lumps among young women attending this university was comparable to other community prevalence studies in this age group

Thyroid Dysfunction among Young Adults in Uganda

Background: Most studies on thyroid dysfunction have been on patients refereed for treatment; little is known about the prevalence in the general populations. The importance of knowing such prevalence data lies in that fact that subclinical thyroid dysfunction is an important risk on development of heart disease; osteoporosis; hypercholesterolemia and mental illness. This study set out to determine thyroid dysfunction prevalence in a health young adult population. Methods: A cross sectional study carried out at the College of Health Sciences; Makerere University enrolled 100 Undergraduate medical students by invitations through notices and announcements. Informed consent was sought after approval from research ethics committee. Results: Of the 100 students enrolled and the samples drawn; 83 tests for TSH and 82 tests for FT4 were successfully run. Three results were abnormal making a prevalence of 3.6for thyroid dysfunction; a high TSH (5.71) with a normal fT4 (19.2); a normal TSH (1.67) with a high fT4 (22.31) and one with a low TSH (0.03). The mean age of participants was 23 years; there were slightly more males 1.3:1.Conclusion: The prevalence of thyroid dysfunction in this cohort was low but falls in the range found elsewhere. These findings could inform the criteria of screening asymptomatic otherwise young health adults

Cancer of the breast: 5-year survival in a tertiary hospital in Uganda.

The objective was to investigate survival of breast cancer patients at Mulago Hospital. A retrospective study of the medical records of 297 breast cancer patients referred to the combined breast clinic housed in the radiotherapy department between 1996 and 2000 was done. The female/male ratio was 24 : 1. The age range was 22-85 years, with a median of 45 years and peak age group of 30-39 years. Twenty-three percent had early disease (stages 0-IIb) and 26% had metastatic disease. Poorly differentiated was the most common pathological grade (58%) followed by moderately differentiated (33%) and well-differentiated (9%) tumours. The commonest pathological type encountered was 'not otherwise specified' (76%). Of all patients, 75% had surgery, 76% had radiotherapy, 60% had hormonotherapy and 29% had chemotherapy. Thirty-six (12%) patients received all the four treatment modalities. The 5-year survival probabilities (Kaplan-Meier) for early disease were 74 and 39% for advanced disease (P=0.001). The overall 5-year survival was 56%, which is lower than the rates in the South African blacks (64%) and North American whites (82-88%).