Comparative assessment of methicillin resistant Staphylococcus aureus diagnostic assays for use in resource-limited settings.

BACKGROUND: The rise of methicillin-resistant Staphylococcus aureus (MRSA) is a global health concern. Paucity of data on MRSA carriage prevalence and diagnostic methods in resource-limited settings hampers efforts to define the problem and plan an appropriate response. Additionally, high variability in cost and logistical characteristics of MRSA screening methods may impede infection control efforts. We compared the performance of locally-available chromogenic agar BD CHROMagar MRSA II and two PCR-based assays (Hain GenoQuick MRSA and Cepheid Xpert SA Complete) for the detection of asymptomatic MRSA carriage in nasal swabs. RESULTS: During 2015, we enrolled 500 patients from five hospital wards at a Ugandan regional referral hospital. We found 30% prevalence of methicillin-sensitive Staphylococcus aureus (MSSA) nasal carriage, and 5.4% MRSA nasal carriage prevalence. Compared to a composite reference standard defined as a positive test result on any one of the three assays, Hain GenoQuick MRSA demonstrated the highest sensitivity (96%) followed by direct plating on CHROMagar at (70%), with the lowest sensitivity observed with Xpert SA Complete (52%). Cepheid Xpert provided the most rapid results (< 1 h) but was the most expensive (US $45-50/test). Substantially more labor was required for the Hain GenoQuick MRSA compared to Xpert SA Complete or CHROMagar tests. CONCLUSION: MRSA nasal carriage prevalence rates were low, and high diagnostic sensitivity was achieved using Hain GenoQuick MRSA. Chromogenic media had significantly lower sensitivity, but may represent a viable local option given its lower cost compared to PCR-based assays.

The analgesic effects of intrathecal morphine in comparison with ultrasound-guided transversus abdominis plane block after caesarean section: a randomised controlled trial at a Ugandan regional referral hospital.

Both transversus abdominis plane block and intrathecal morphine may produce prolonged postoperative analgesia, but the respective clinical outcomes of these anaesthetic techniques in resource-limited settings are not well described. We randomly assigned patients undergoing caesarean section to receive a hyperbaric bupivacaine (10 mg) spinal anaesthetic followed by an ultrasound-guided transversus abdominis plane block, or a hyperbaric bupivacaine (10 mg) spinal anaesthetic with 100 mcg intrathecal morphine, followed by a postoperative sham block. Supplemental postoperative analgesia included self-administered oral diclofenac 50 mg and paracetamol 1 g every 8 h. Numerical pain rating scores, the need for rescue medication, side-effects and patient satisfaction were recorded at 8, 16 and 24 h. We enrolled a total of 130 patients, with 65 women in each group. The mean numerical rating score for intrathecal morphine vs. transversus abdominis plane blocks at 8 h were: at rest, 2.5 vs. 3.1 (p = 0.04); with coughing, 4.3 vs. 4.8 (p = 0.07); and with movement, 3.6 vs. 4.2 (p = 0.06). At 16 h, respective scores were: 2.9 vs. 3.1 (p = 0.40) at rest; 4.0 vs. 4.3 (p = 0.19) with coughing; and 4.8 vs. 5.0 (p = 0.33) with movement. At 24 h, the respective scores were: 2.9 vs. 2.3 (p = 0.01); 4.6 vs. 4.2 (p = 0.04) with coughing; and 3.9 vs. 3.4 (p = 0.02) with movement. The need for rescue medication and the incidence of pruritis, sedation and nausea and vomiting were similar in both groups. Patient satisfaction with pain control was similar in both groups, with the majority of patients reporting satisfaction as good or excellent. Intrathecal morphine and transversus abdominis plane block provided clinically similar outcomes for pain relief after caesarean section.

A mixed-methods evaluation of the Association of Anaesthetists of Great Britain and Ireland Uganda Fellowship Scheme.

The Association of Anaesthetists of Great Britain and Ireland and the then Uganda Society of Anaesthesia established the Uganda Fellowship Scheme in 2006, to provide scholarships to encourage doctors to train in anaesthesia in Uganda. We conducted an evaluation of this programme using online questionnaires and face-to-face semi-structured interviews with trainees who received scholarships, as well as with senior surgeons and anaesthetists. Focus group discussions were held to assess changes in attitudes towards anaesthesia over the last 10 years. Interviews were recorded, transcribed and analysed using the constant comparative method. A total of 54 Ugandan doctors have received anaesthesia scholarships since 2006 (median funding per trainee (IQR [range]) £5520 (£5520-£6750 [£765-£9000]). There has been a four-fold increase in the number of physician anaesthetists in Uganda during this time. All those who received funding remain in the region. The speciality of anaesthesia is undergoing a dramatic transformation led by this group of motivated young anaesthetists. There is increased access to intensive care, and this has allowed surgical specialities to develop. There is greater understanding and visibility of anaesthesia, and the quality of education in anaesthesia throughout the country has improved. The Uganda Fellowship Scheme provided a relatively small financial incentive to encourage doctors to train as anaesthetists. Evaluation of the project shows a wide-ranging impact that extends beyond the initial goal of simply improving human resource capacity. Financial incentives combined with strong 'north-south' links between professional organisations can play an important role in tackling the shortage of anaesthesia providers in a low-income country and in improving access to safe surgery and anaesthesia.

The Quality and Utility of Surgical and Anesthetic Data at a Ugandan Regional Referral Hospital.

BACKGROUND: There are little primary data available on the delivery or quality of surgical treatment in rural sub-Saharan African hospitals. To initiate a quality improvement system, we characterized the existing data capture at a Ugandan Regional Referral Hospital. METHODS: We examined the surgical ward admission (January 2008-December/2011) and operating theater logbooks (January 2010-July 2011) at Mbarara Regional Referral Hospital. RESULTS: There were 6346 admissions recorded over three years. The mean patient age was 31.4 ± 22.3 years; 29.8 % (n = 1888) of admissions were children. Leading causes of admission were general surgical problems (n = 3050, 48.1 %), trauma (n = 2041, 32.2 %), oncology (n = 718, 11.3 %) and congenital condition (n = 193, 3.0 %). Laparotomy (n = 468, 35.3 %), incision and drainage (n = 188, 14.2 %) and hernia repair (n = 90, 6.8 %) were the most common surgical procedures. Of 1325 operative patients, 994 (75 %) had an ASA I-II score. Of patients undergoing 810 procedures booked as non-elective, 583 (72 %) had an ASA "E" rating. Records of 41.3 % (n-403/975) of patients age 5 years or older undergoing non-obstetric operations were missing from the ward logbook. Missing patients were younger (25 [13,40] versus 30 [18,46] years, p = 0.002) and had higher ASA scores (ASA III-V 29.0 % versus 18.9 %, p < 0.001) than patients recorded in the logbbook; there was no diffence in gender (male 62.8 % versus 67.0 %, p = 0.20). CONCLUSIONS: The hospital records system measures surgical care, but improved data capture is needed to determine outcomes with sufficient accuracy to guide and record expansion of surgical capacity.

Implementation of the WHO Surgical Safety Checklist and surgical swab and instrument counts at a regional referral hospital in Uganda - a quality improvement project.

The World Health Organization (WHO) Surgical Safety Checklist is a cost-effective tool that has been shown to improve patient safety. We explored the applicability and effectiveness of quality improvement methodology to implement the WHO checklist and surgical counts at Mbarara Regional Referral Hospital in Uganda between October 2012 and September 2013. Compliance rates were evaluated prospectively and monthly structured feedback sessions were held. Checklist and surgical count compliance rates increased from a baseline median (IQR [range]) of 29.5% (0-63.5 [0-67.0]) to 85.0% (82.8-87.5 [79.0-93.0]) and from 25.5% (0-52.5 [0-60.0]) to 83.0% (80.8-85.5 [69.0-89.0]), respectively. The mean all-or-none completion rate of the checklist was 69.3% (SD 7.7, 95% CI [64.8-73.9]). Use of the checklist was associated with performance of surgical counts (p value < 0.001; r(2) = 0.91). Pareto analysis showed that understaffing, malfunctioning and lack of equipment were the main challenges. A carefully designed quality improvement project, including stepwise incremental change and standardisation of practice, can be an effective way of improving clinical practice in low-income settings.

Synchronous distance anesthesia education by Internet videoconference between Uganda and the United States.

STUDY OBJECTIVE: We evaluated the effectiveness of anesthesia education delivered via Internet videoconferencing between the Massachusetts General Hospital, Boston, MA, and Mbarara Regional Referral Hospital, Uganda. DESIGN: This is a prospective educational study. SETTING: The setting is the education in 2 hospitals in Uganda and the United States. SUBJECTS: The subjects are anesthesia residents. INTERVENTIONS: The interventions are anesthesia education lectures delivered in person and via Internet videoconferencing. MEASUREMENTS: The average pre-lecture and post-lecture scores of the local, remote, and combined audiences were compared. MAIN RESULTS: Post-lecture test scores improved over pre-lecture scores: local audience, 59% ± 22% to 81% ± 16%, P = .0002, g = 1.144; remote audience, 51% ± 19% to 81% ± 8%, P < .0001, g = 2.058; and combined scores, 56% ± 14% to 82% ± 8%, P < .0001, g = 2.069). CONCLUSIONS: Transfer of anesthetic knowledge occurs via small group lectures delivered both in person and remotely via synchronous Internet videoconferencing. This technique may be useful to expand educational capacity and international cooperation between academic institutions, a particular priority in the growing field of global health.

Evaluation of a large-scale donation of Lifebox pulse oximeters to non-physician anaesthetists in Uganda.

Pulse oximetry is widely accepted as essential monitoring for safe anaesthesia, yet is frequently unavailable in resource-limited settings. The Lifebox pulse oximeter, and associated management training programme, was delivered to 79 non-physician anaesthetists attending the 2011 Uganda Society of Anaesthesia Annual Conference. Using a standardised assessment, recipients were tested for their knowledge of oximetry use and hypoxia management before, immediately following and 3-5 months after the training. Before the course, the median (IQR [range]) test score for the anaesthetists was 36 (34-39 [26-44]) out of a maximum of 50 points. Immediately following the course, the test score increased to 41 (38-43 [25-47]); p < 0.0001 and at the follow-up visit at 3-5 months it was 41 (39-44 [33-49]); p = 0.001 compared with immediate post-training test scores, and 75/79 (95%) oximeters were in routine clinical use. This method of introduction resulted in a high rate of uptake of oximeters into clinical practice and a demonstrable retention of knowledge in a resource-limited setting.

Paediatric Surgery and Anaesthesia in South-Western Uganda: a Cross-Sectional Survey

Objective To study paediatric surgery rates in south-western Uganda; compare them to rates in England; and determine if existing surgical facilities and workforce meet World Health Organization (WHO) standards. Methods To obtain information on surgical facilities and workforce; we conducted a cross-sectional survey of all hospitals performing major surgery in 14 districts of south-western Uganda in 2007.2008. Using theatre logbook data; we determined the surgical rates; types of surgery performed and in-theatre surgical outcomes. Findings Of 72 hospitals surveyed; 29 were performing major surgery. None met WHO standards for essential surgery. There were 0.7 accredited surgeons per 100 000 population and no paediatric surgeons. Most anaesthetists were not physicians (accredited anaesthetist per 100 000 population: 1.1).The annual surgical rate for children aged . 14 years was 180 operations per 100 000 population; most were emergency procedures. The annual surgical rate for patients of all ages was 652 operations per 100 000 population; with a median of 422 per operating theatre (range: 60.3497) and of 226 per surgeon (range: 60.1748). Mission or nongovernmental organization (NGO) hospitals; which had 44of the hospital beds in the region; performed 3039 (55) of the paediatric operations. Externally funded surgeons performed 80of the 140 cleft lip and palate operations. Four in-theatre deaths occurred in children . 14 years old (in-theatre mortality: 7.7 deaths per 10 000 operations). Conclusion Access to all surgery; including paediatric surgery; is poor in south-western Uganda and investment in basic health-care facilities and surgical workforce and training is urgently needed. Mission and NGO hospitals make a valuable contribution to elective surgery; and externally funded surgeons make an important contribution to specialist surgery. In-theatre mortality was lower than reported for similar settings

Pioneer human open heart surgery using cardiopulmonary by pass in Uganda.

INTRODUCTION: For the first time in Uganda in April 2007,two open-heart surgeries were done using cardiopulmonary by pass. A multidisciplinary team of largely indigenous Ugandans professionals working in Uganda formed the pioneering team. CONTEXT: Access in cardiac surgery in the developing countries is very limited. The challenges that impede access to adequate and appropriate health care including open-heart surgery are in the least complex and daunting. PATIENT SELECTION: Two 13 and 17 year old males with Secundum Atrial Septal defects were chosen from a long waiting list. The criteria used included no or minimal co morbidity states, patient fitness and available ICU ventilation facilities. PREPARATION: Took an eleven months period, including formulation and adoption of peri and intra operation protocols, training of staff, sourcing of usable and mobilizing the financing. OUTCOMES: The procedure for the two patients was successfully performed. The immediate and short-term postoperative periods were uneventful. At the twelve months review point both patients were leading a normal life. In the months that followed 19 other open-heart procedures were done including two mitral valves replacements. CONCLUSION: This program has greatly enhanced the level of care for the critically ill at this facility. Its sustenance and replication in other centres in the country is essential. Government and development partners' support is critical. The educational value of this program ought to be exploited by health professions students in the country.