Sigmoid Volvulus and Ileosigmoid Knotting at St. Mary’s Hospital Lacor in Gulu, Uganda

Background: Sigmoid volvulus is a common cause of intestinal obstruction in developing countries where it affects relatively young people. Little is known about this condition in our country and there is yet no literature from an environment like ours (northern Uganda) where civil war has devastated the economy with most of the populace displaced into internally displaced peoples’ camp. The main objective of this study was to determine the demographics, treatment and outcome of sigmoid Volvulus cases seen at Lacor Hospital.Methods: This was both a retrospective and prospective study of patients who presented with sigmoid volvulus at St. Mary’s Hospital Lacor over a period of 61/2 years from 1st January 2002 to 31st July 2008. Medical records of patients who underwent sigmoid surgery was stratified for the following measures; demographic characteristics, presentation to hospital (emergency or elective), operative finding and operative procedure, complication, co-ominous factors and outcome. Similar data was gathered from patients who were prospectively followed up. Data was analyzed using SPSS.Results: A total of 44 patients were studied. Their age ranged from 16 to 80 years with a mean of 52.2years (SD +/- 15.98) and a mode of 60years. There was a preponderance of male (84%) with a male to female sex ratio of 5.3: 1. The disease significantly affected the older males compared with females P=0.032. Approximately 77% of the patients presented acutely and had to undergo emergency surgical intervention, the rest were subacute. About 75% of the patients were treated with primary resection and anastomosis, of which 52.2% were emergency cases. Colostomy was offered to 20.5% and sigmoidoscopic derotation to 4.5%. Overall mortality rate was 15.9% and of the patients who died, 18% had primary resection and anastomosis, while 11% were offered colostomy, (P>0.05). Most of those who died were either the older ones (median age 68years) and/or had co morbid illness such as diabetes mellitus, hypertension, intra-abdominal abscess and cancer.Conclusion: Sigmoid volvulus is relatively rare in our community. It commonly affect males particularly the old. Most of the patients presented acutely, requiring immediate resuscitation and surgical approach. In viable bowel, primary resection and anastomosis of the twisted sigmoid is feasible as it may not adversely affect outcome. Nevertheless colostomy should be considered if the bowel is gangrenous or perforated. Though the disease carries a high mortality, most of the patient who die are either older and/or have co-morbid conditions

Biliary Atresia – An Easily Missed Cause of Jaundice amongst Children in Uganda

Back ground: Biliary atresia is characterized by biliary obstruction, it has an incidence of 1:15000 and presents with jaundice, acholic stools / dark urine and hepatomegaly. This disease rapidly leads to liver cirrhosis and liver failure if untreated surgically. The main objective was to establish the epidemiology of patients presenting with biliary atresia and immediate surgical outcome. Methods: A review of a prospective data base for pediatric surgical admissions from January 2012 to December 2015 was made and examined all the entries for children admitted with biliary atresia. Results: In this study 46 patients were recruited with an age range at admission of 2 weeks to 3.5 years and a peak age of 2 months. During the four years, 14 Patients had portoenterostomy done and of these 5 died within 7 days after surgery. Thirty two (32) patients were not operated, 18 of them died and 13 were still alive by the close of 2015. Conclusion: A big number of children with biliary atresia presented late with decompensated liver functions having lost time in peripheral health facilities being managed for medical jaundice.Key words: Biliary atresia, Uganda, Jaundic

Colorectal Polyposis in a 15 Year Old Boy in Uganda - Case Report

Colorectal polyps usually present as rectal bleeding and are associated with increased risk of colorectal carcinoma. This is a 15 year old boy who presented with painless rectal bleeding for 9 years and mass protruding from the anus for 2 years after passing stool. He had history of 3 nephews with similar symptoms. On clinical assessment an impression of Adematous familial colorectal polyposis was made and biopsy was taken from the mass that revealed inflammatory polyps. He subsequently had a total colectomy and ileall pouch anal anastomosis with good outcome. In absence of endoscopic surveillance and diagnostic services diagnosis of colorectal polyposis syndromes is a challenge because clinicians rely on digital rectal assessment and examination under anesthesia.Key words: polyposis, polyps, Ugand

The burden of bacterial antimicrobial resistance in the WHO European region in 2019: a cross-country systematic analysis

Background Antimicrobial resistance (AMR) represents one of the most crucial threats to public health and modern health care. Previous studies have identified challenges with estimating the magnitude of the problem and its downstream effect on human health and mortality. To our knowledge, this study presents the most comprehensive set of regional and country-level estimates of AMR burden in the WHO European region to date. Methods We estimated deaths and disability-adjusted life-years attributable to and associated with AMR for 23 bacterial pathogens and 88 pathogen–drug combinations for the WHO European region and its countries in 2019. Our methodological approach consisted of five broad components: the number of deaths in which infection had a role, the proportion of infectious deaths attributable to a given infectious syndrome, the proportion of infectious syndrome deaths attributable to a given pathogen, the percentage of a given pathogen resistant to an antimicrobial drug of interest, and the excess risk of mortality (or duration of an infection) associated with this resistance. These components were then used to estimate the disease burden by using two counterfactual scenarios: deaths attributable to AMR (considering an alternative scenario where infections with resistant pathogens are replaced with susceptible ones) and deaths associated with AMR (considering an alternative scenario where drug-resistant infections would not occur at all). Data were solicited from a wide array of international stakeholders; these included research hospitals, surveillance networks, and infection databases maintained by private laboratories and medical technology companies. We generated 95% uncertainty intervals (UIs) for final estimates as the 25th and 975th ordered values across 1000 posterior draws, and models were cross-validated for out-of-sample predictive validity. Findings We estimated 541 000 deaths (95% UI 370 000–763 000) associated with bacterial AMR and 133 000 deaths (90 100–188 000) attributable to bacterial AMR in the whole WHO European region in 2019. The largest fatal burden of AMR in the region came from bloodstream infections, with 195 000 deaths (104 000–333 000) associated with resistance, followed by intra-abdominal infections (127 000 deaths [81 900–185 000]) and respiratory infections (120 000 deaths [94 500–154 000]). Seven leading pathogens were responsible for about 457 000 deaths associated with resistance in 53 countries of this region; these pathogens were, in descending order of mortality, Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterococcus faecium, Streptococcus pneumoniae, and Acinetobacter baumannii. Methicillin-resistant S aureus was shown to be the leading pathogen–drug combination in 27 countries for deaths attributable to AMR, while aminopenicillin-resistant E coli predominated in 47 countries for deaths associated with AMR. Interpretation The high levels of resistance for several important bacterial pathogens and pathogen–drug combinations, together with the high mortality rates associated with these pathogens, show that AMR is a serious threat to public health in the WHO European region. Our regional and cross-country analyses open the door for strategies that can be tailored to leading pathogen–drug combinations and the available resources in a specific location. These results underscore that the most effective way to tackle AMR in this region will require targeted efforts and investments in conjunction with continuous outcome-based research endeavours. Funding Bill & Melinda Gates Foundation, Wellcome Trust, and Department of Health and Social Care using UK aid funding managed by the Fleming Fund.Coauthors affiliated with this organisation provided feedback on the initial maps and drafts of this manuscript. MA acknowledges partial support by the Romanian National Authority for Scientific Research and Innovation, under the UEFISCDI PN-III-P4-ID-PCCF-2016-0084 research grant. VBG and VKG acknowledge funding support from the National Health and Medical Research Council Australia. CH is partially supported by a grant from the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084, and by a grant from the Romanian Ministry of Research Innovation and Digitalization, MCID, project number ID-585-CTR-42-PFE-2021. SH was supported by the operational programme Research, Development and Education, Postdoc2MUNI (CZ.02.2.69/0.0/0.0/18_053/0016952). GL was supported by national funds through the Fundação para a Ciência e Tecnologia (FCT) under the Scientific Employment Stimulus–Individual Call (CEECIND/01768/2021). AGM was supported by the National Institute for Health and Care Research (NIHR) Manchester Biomedical Research Centre and by an NIHR Clinical Lectureship in Respiratory Medicine. AP is partially supported by a grant of the Romanian National Authority for Scientific Research and Innovation, CNDS-UEFISCDI, project number PN-III-P4-ID-PCCF-2016-0084. JP was supported by FCT through the Scientific Employment Stimulus–Individual Call (CEECIND/00394/2017 and UID/DTP/04138/2019). AS acknowledges support from Health Data Research UK. LRS was supported by project CENTRO-04-3559-FSE-000162, Fundo Social Europeu. SBZ acknowledges receiving a scholarship from the Australian Government Research Training Program in support of his academic career.publishedVersio

Mapping development and health effects of cooking with solid fuels in low-income and middle-income countries, 2000–18: a geospatial modelling study

Background More than 3 billion people do not have access to clean energy and primarily use solid fuels to cook. Use of solid fuels generates household air pollution, which was associated with more than 2 million deaths in 2019. Although local patterns in cooking vary systematically, subnational trends in use of solid fuels have yet to be comprehensively analysed. We estimated the prevalence of solid-fuel use with high spatial resolution to explore subnational inequalities, assess local progress, and assess the effects on health in low-income and middle-income countries (LMICs) without universal access to clean fuels. Methods We did a geospatial modelling study to map the prevalence of solid-fuel use for cooking at a 5 km × 5 km resolution in 98 LMICs based on 2·1 million household observations of the primary cooking fuel used from 663 population-based household surveys over the years 2000 to 2018. We use observed temporal patterns to forecast household air pollution in 2030 and to assess the probability of attaining the Sustainable Development Goal (SDG) target indicator for clean cooking. We aligned our estimates of household air pollution to geospatial estimates of ambient air pollution to establish the risk transition occurring in LMICs. Finally, we quantified the effect of residual primary solid-fuel use for cooking on child health by doing a counterfactual risk assessment to estimate the proportion of deaths from lower respiratory tract infections in children younger than 5 years that could be associated with household air pollution. Findings Although primary reliance on solid-fuel use for cooking has declined globally, it remains widespread. 593 million people live in districts where the prevalence of solid-fuel use for cooking exceeds 95%. 66% of people in LMICs live in districts that are not on track to meet the SDG target for universal access to clean energy by 2030. Household air pollution continues to be a major contributor to particulate exposure in LMICs, and rising ambient air pollution is undermining potential gains from reductions in the prevalence of solid-fuel use for cooking in many countries. We estimated that, in 2018, 205 000 (95% uncertainty interval 147 000–257 000) children younger than 5 years died from lower respiratory tract infections that could be attributed to household air pollution. Interpretation Efforts to accelerate the adoption of clean cooking fuels need to be substantially increased and recalibrated to account for subnational inequalities, because there are substantial opportunities to improve air quality and avert child mortality associated with household air pollution.This study was funded by the Bill & Melinda Gates Foundation. L G Abreu acknowledges support from Coordenação de Aperfeiçoamento de Pessoal de Nível Superior—Brasil (Capes; finance Code 001), Conselho Nacional de Desenvolvimento Científico e Tecnológico, and Fundação de Amparo à Pesquisa do Estado de Minas Gerais. D A Bennett acknowledges support from the Oxford National Institute for Health Research (NIHR) Biomedical Research Centre (BRC). The views expressed are those of the author and not necessarily those of the NHS, the NIHR, or the UK Department of Health and Social Care. Z A Bhutta acknowledges support from the Institute for Global Health & Development at the Aga Khan University. F Carvalho acknowledges UID/MULTI/04378/2019 and UID/QUI/50006/2019 support with funding from FCT/MCTES through national funds. J-W De Neve is supported by the Alexander von Humboldt Foundation. S Dey acknowledges the support from the Centre of Excellence for Research on Clean Air, IIT Delhi. M Ausloos and C Herteliu are partly supported by a grant of the Romanian National Authority for Scientific Research and Innovation (project number PN-III-P4-ID-PCCF-2016-0084). C Herteliu is partly supported by a grant of the Romanian National Authority for Scientific Research and Innovation (project number PN-III-P2-2.1-SOL-2020-2-0351), the Romanian Ministry of Research Innovation and Digitalization (project number ID-585-CTR-42-PFE-2021), and the Romanian Ministry of Labour and Social Justice (30/PSCD/2018). M Jakovljevic acknowledges partial support through Grant OI 175 014 of the Ministry of Science Education and Technological Development of the Republic of Serbia. J S John acknowledges support from the Kunshan Government and China Center for Disease Control and Prevention. W Mendoza is a program analyst in population and development at the United Nations Population Fund country office in Peru, an institution that does not necessarily endorse this study. M N Khan acknowledges the support of Jatiya Kabi Kazi Nazrul Islam University, Bangladesh. K Krishan is supported by UGC Centre of Advanced Study (CAS II), awarded to the Department of Anthropology, Panjab University, Chandigarh, India. M Kumar acknowledges support (FIC/NIH funded K43 TW010716-04 study). B Lacey acknowledges support from UK Biobank, the NIHR Oxford Biomedical Research Centre, and the British Heart Foundation Oxford Centre of Research Excellence. B R Nascimento acknowledges support in part by CNPq (Bolsa de produtividade em pesquisa, 312382/2019-7), by the Edwards Lifesciences Foundation (Every Heartbeat Matters Program 2020) and by FAPEMIG (grant APQ-000627-20). A M Samy acknowledges the support from the Egyptian Fulbright Mission Program. M M Santric-Milicevic acknowledges the support of the Ministry of Education, Science and Technological Development of Serbia (contract 175087). A Sheikh acknowledges the support of Health Data Research UK. I N Soyiri acknowledges support from the University of Hull internal QR Global Challenges Research Fund. S B Zaman acknowledges receiving a scholarship from the Australian Government research training program in support of his academic career. Y Zhang was supported by Science and Technology Research Project of Hubei Provincial Department of Education (grant Q20201104) and Outstanding Young and Middle Aged Technology Innovation Team Project of Hubei Provincial Department of Education (grant T2020003).publishedVersio

Report from the third international consensus meeting to harmonise core outcome measures for atopic eczema/dermatitis clinical trials (HOME).

This report provides a summary of the third meeting of the Harmonising Outcome Measures for Eczema (HOME) initiative held in San Diego, CA, U.S.A., 6-7 April 2013 (HOME III). The meeting addressed the four domains that had previously been agreed should be measured in every eczema clinical trial: clinical signs, patient-reported symptoms, long-term control and quality of life. Formal presentations and nominal group techniques were used at this working meeting, attended by 56 voting participants (31 of whom were dermatologists). Significant progress was made on the domain of clinical signs. Without reference to any named scales, it was agreed that the intensity and extent of erythema, excoriation, oedema/papulation and lichenification should be included in the core outcome measure for the scale to have content validity. The group then discussed a systematic review of all scales measuring the clinical signs of eczema and their measurement properties, followed by a consensus vote on which scale to recommend for inclusion in the core outcome set. Research into the remaining three domains was presented, followed by discussions. The symptoms group and quality of life groups need to systematically identify all available tools and rate the quality of the tools. A definition of long-term control is needed before progress can be made towards recommending a core outcome measure

The Burden of Skin and Subcutaneous Diseases in the United States From 1990 to 2017

IMPORTANCE Skin and subcutaneous diseases affect the health of millions of individuals in the US. Data are needed that highlight the geographic trends and variations of skin disease burden across the country to guide health care decision-making. OBJECTIVE To characterize trends and variations in the burden of skin and subcutaneous tissue diseases across the US from 1990 to 2017. DESIGN, SETTING, AND PARTICIPANTS For this cohort study, data were obtained from the Global Burden of Disease (GBD), a study with an online database that incorporates current and previous epidemiological studies of disease burden, and from GBD 2017, which includes more than 90 000 data sources such as systematic reviews, surveys, population-based disease registries, hospital inpatient and outpatient data, cohort studies, and autopsy data. The GBD separated skin conditions into 15 subcategories according to incidence, prevalence, adequacy of data, and standardized disease definitions. GBD 2017 also estimated the burden from melanoma of the skin and keratinocyte carcinoma. Data analysis for the present study was conducted from September 9, 2019, to March 31, 2020. MAIN OUTCOMES AND MEASURES Primary study outcomes included age-standardized disability-adjusted life-years (DALYs), incidence, and prevalence. The data were stratified by US states with the highest and lowest age-standardized DALY rate per 100 000 people, incidence, and prevalence of each skin condition. The percentage change in DALY rates in each state was calculated from 1990 to 2017. RESULTS Overall, age-standardized DALY rates for skin and subcutaneous diseases increased from 1990 (821.6; 95% uncertainty interval [UI], 570.3-1124.9) to 2017 (884.2; 95% UI, 614.0-1207.9) in all 50 states and the District of Columbia. The degree of increase varied according to geographic location, with the largest percentage change of 0.12% (95% UI, 0.09%-0.15%) in New York and the smallest percentage change of 0.04% (95% UI, 0.02%-0.07%) in Colorado, 0.04% (95% UI, 0.01%-0.06%) in Nevada, 0.04% (95% UI, 0.02%-0.07%) in New Mexico, and 0.04% (95% UI, 0.02%-0.07%) in Utah. The age-standardized DALY rate, incidence, and prevalence of specific skin conditions differed among the states. New York had the highest age-standardized DALY rate for skin and subcutaneous disease in 2017 (1097.0 [95% UI, 764.9-1496.1]), whereas Wyoming had the lowest age-standardized DALY rate (672.9 [95% UI, 465.6-922.3]). In all 50 states and the District of Columbia, women had higher age-standardized DALY rates for overall skin and subcutaneous diseases than men (women: 971.20 [95% UI, 676.76-1334.59] vs men: 799.23 [95% UI, 559.62-1091.50]). However, men had higher DALY rates than women for malignant melanoma (men: 80.82 [95% UI, 51.68-123.18] vs women: 42.74 [95% UI, 34.05-70.66]) and keratinocyte carcinomas (men: 37.56 [95% UI, 29.35-49.52] vs women: 14.42 [95% UI, 10.01-20.66]). CONCLUSIONS AND RELEVANCE Data from the GBD suggest that the burden of skin and subcutaneous disease was large and that DALY rate trends varied across the US; the age-standardized DALY rate for keratinocyte carcinoma appeared greater in men. These findings can be used by states to target interventions and meet the needs of their population

Global, regional, and national burden of chronic kidney disease, 1990–2017 : a systematic analysis for the Global Burden of Disease Study 2017

Background Health system planning requires careful assessment of chronic kidney disease (CKD) epidemiology, but data for morbidity and mortality of this disease are scarce or non-existent in many countries. We estimated the global, regional, and national burden of CKD, as well as the burden of cardiovascular disease and gout attributable to impaired kidney function, for the Global Burden of Diseases, Injuries, and Risk Factors Study 2017. We use the term CKD to refer to the morbidity and mortality that can be directly attributed to all stages of CKD, and we use the term impaired kidney function to refer to the additional risk of CKD from cardiovascular disease and gout. Methods The main data sources we used were published literature, vital registration systems, end-stage kidney disease registries, and household surveys. Estimates of CKD burden were produced using a Cause of Death Ensemble model and a Bayesian meta-regression analytical tool, and included incidence, prevalence, years lived with disability, mortality, years of life lost, and disability-adjusted life-years (DALYs). A comparative risk assessment approach was used to estimate the proportion of cardiovascular diseases and gout burden attributable to impaired kidney function. Findings Globally, in 2017, 1·2 million (95% uncertainty interval [UI] 1·2 to 1·3) people died from CKD. The global all-age mortality rate from CKD increased 41·5% (95% UI 35·2 to 46·5) between 1990 and 2017, although there was no significant change in the age-standardised mortality rate (2·8%, −1·5 to 6·3). In 2017, 697·5 million (95% UI 649·2 to 752·0) cases of all-stage CKD were recorded, for a global prevalence of 9·1% (8·5 to 9·8). The global all-age prevalence of CKD increased 29·3% (95% UI 26·4 to 32·6) since 1990, whereas the age-standardised prevalence remained stable (1·2%, −1·1 to 3·5). CKD resulted in 35·8 million (95% UI 33·7 to 38·0) DALYs in 2017, with diabetic nephropathy accounting for almost a third of DALYs. Most of the burden of CKD was concentrated in the three lowest quintiles of Socio-demographic Index (SDI). In several regions, particularly Oceania, sub-Saharan Africa, and Latin America, the burden of CKD was much higher than expected for the level of development, whereas the disease burden in western, eastern, and central sub-Saharan Africa, east Asia, south Asia, central and eastern Europe, Australasia, and western Europe was lower than expected. 1·4 million (95% UI 1·2 to 1·6) cardiovascular disease-related deaths and 25·3 million (22·2 to 28·9) cardiovascular disease DALYs were attributable to impaired kidney function. Interpretation Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease. CKD is largely preventable and treatable and deserves greater attention in global health policy decision making, particularly in locations with low and middle SDI

Molecular epidemiology, drug susceptibility and economic aspects of tuberculosis in mubende district, Uganda

<div><p>Background</p><p>Tuberculosis (TB) remains a global public health problem whose effects have major impact in developing countries like Uganda. This study aimed at investigating genotypic characteristics and drug resistance profiles of <i>Mycobacterium tuberculosis</i> isolated from suspected TB patients. Furthermore, risk factors and economic burdens that could affect the current control strategies were studied.</p><p>Methods</p><p>TB suspected patients were examined in a cross-sectional study at the Mubende regional referral hospital between February and July 2011. A questionnaire was administered to each patient to obtain information associated with TB prevalence. Isolates of <i>M. tuberculosis</i> recovered during sampling were examined for drug resistance to first line anti-TB drugs using the BACTEC-MGIT960^TMsystem. All isolates were further characterized using deletion analysis, spoligotyping and MIRU-VNTR analysis. Data were analyzed using different software; MIRU-VNTR <i>plus</i>, SITVITWEB, BioNumerics and multivariable regression models.</p><p>Results</p><p><i>M. tuberculosis</i> was isolated from 74 out of 344 patients, 48 of these were co-infected with HIV. Results from the questionnaire showed that previously treated TB, co-infection with HIV, cigarette smoking, and overcrowding were risk factors associated with TB, while high medical related transport bills were identified as an economic burden. Out of the 67 isolates that gave interpretable results, 23 different spoligopatterns were detected, nine of which were novel patterns. T2 with the sub types Uganda-I and Uganda-II was the most predominant lineage detected. Antibiotic resistance was detected in 19% and multidrug resistance was detected in 3% of the isolates.</p><p>Conclusion</p><p>The study detected <i>M. tuberculosis</i> from 21% of examined TB patients, 62% of whom were also HIV positive. There is a heterogeneous pool of genotypes that circulate in this area, with the T2 lineage being the most predominant. High medical related transport bills and drug resistance could undermine the usefulness of the current TB strategic interventions.</p></div