ABO and Rh Antigen Distribution Among Pregnant Women in South Western Uganda

Introduction

ABO and Rh are the major blood group systems in Transfusion Medicine, the ABO system based on two red cell antigens (A, B) while the Rh has about 50 antigens of which five are highly clinically significant (D, C, c, E, e). These vary among races and ethnic groups. Blood type phenotype incompatibility between mother and fetus may result in antigen mismatch, triggering alloimmunization, and thus causing hemolytic transfusion reaction (HTR), which results in hemolytic disease of fetus and newborn (HDFN). This study aimed to determine the frequencies of ABO and rhesus blood group antigen in the pregnant women in South Western Uganda.

Methods

A cross-sectional study was carried out on 1369 pregnant women who were recruited and provided consent to participate during their regular antenatal visits between August 2020 and July 2021. Four milliliters (4mL) of EDTA-anti-coagulated blood samples were collected and ABO and Rh-blood grouping including Rh antigen screening was done using the agglutination technology comprised of glass beads and reagent contained in a column of the Ortho Biovue ID Micro Typing System (Ortho Clinical Diagnostics, New Jersey, USA). The Rh antigen phenotypes and frequencies were then determined.

Results

There was percentage distribution of 99.8%, c 99.3%, D 94.3%, C 19.2% and E 15.9%, with Rh cDe/cDe (65.1%) being the most common phenotype followed by cDe/CDe (15%), cDe/cDE (10.8%) and cDE/cDE 0.1% least common. The ABO grouping frequency was obtained as O 49.4%, A 29.5%, B 17.0% and AB 4.1%, with D positivity at 94.3%.

Discussion

Population genetic variations result in varied expressions of red cell antigens that may have clinical complications. Knowledge of the presence of these Rh antigen distributions and phenotype frequencies during pregnancy help in rational management of the pregnancy, alloimmunization and better approach to safe blood transfusion.

The Mirasol Evaluation of Reduction in Infections Trial (MERIT): study protocol for a randomized controlled clinical trial

BACKGROUND

Transfusion-transmitted infections (TTIs) are a global health challenge. One new approach to reduce TTIs is the use of pathogen reduction technology (PRT). In vitro, Mirasol PRT reduces the infectious load in whole blood (WB) by at least 99%. However, there are limited in vivo data on the safety and efficacy of Mirasol PRT. The objective of the Mirasol Evaluation of Reduction in Infections Trial (MERIT) is to investigate whether Mirasol PRT of WB can prevent seven targeted TTIs (malaria, bacteria, human immunodeficiency virus, hepatitis B virus, hepatitis C virus, hepatitis E virus, and human herpesvirus 8).

METHODS

MERIT is a randomized, double-blinded, controlled clinical trial. Recruitment started in November 2019 and is expected to end in 2024. Consenting participants who require transfusion as medically indicated at three hospitals in Kampala, Uganda, will be randomized to receive either Mirasol-treated WB (n = 1000) or standard WB (n = 1000). TTI testing will be performed on donor units and recipients (pre-transfusion and day 2, day 7, week 4, and week 10 after transfusion). The primary endpoint is the cumulative incidence of one or more targeted TTIs from the Mirasol-treated WB vs. standard WB in a previously negative recipient for the specific TTI that is also detected in the donor unit. Log-binomial regression models will be used to estimate the relative risk reduction of a TTI by 10 weeks associated with Mirasol PRT. The clinical effectiveness of Mirasol WB compared to standard WB products in recipients will also be evaluated.

DISCUSSION

Screening infrastructure for TTIs in low-resource settings has gaps, even for major TTIs. PRT presents a fast, potentially cost-effective, and easy-to-use technology to improve blood safety. MERIT is the largest clinical trial designed to evaluate the use of Mirasol PRT for WB. In addition, this trial will provide data on TTIs in Uganda.

TRIAL REGISTRATION

Mirasol Evaluation of Reduction in Infections Trial (MERIT) NCT03737669 . Registered on 9 November 2018.

Poor Economics – Knowledge Economy and The Existing Knowledge Gaps (Higher and Academic Education) In Healthcare; How To Overcome?

The 2018 United Nations Development Program (UNDP) presents clearly that the lower the human development indices (HDI), the more significant the decrement in secondary and tertiary education enrolment (higher and academic). For example, tertiary education in the very high-HDI countries shows 72% enrolment, where enrolment in the medium and low HDI parts of the world is only 24% and 8% respectively. The data illustrate the impressive paucity in education, hence knowledge production. This paucity in education is predicted to result in a weak knowledge economy of available and accessible knowledge. This root cause analysis discloses a significant area of attention to narrow and bridge the existing knowledge gap. Education in these countries has been focused almost exclusively on vocational education of technical skills with limited theoretical attention (knowledge) and rudimentary attention to topics such as governance, human capacity investment, and appropriate application. Education needs the proper  environment and climate at primary, secondary and tertiary education levels, resulting in an effective knowledge economy and contributing to advancing progress and improvement of quality. The healthcare system for example needs to be available and accessible to all. This environment can only be created and developed when countries establish national structures, institutional environment, and a competent leadership and management cadre. This depends on the existence of a well-educated and motivated cadre of ‘intelligentsia’, competent and responsible policymakers and governors, and creating an inviting and inspiring education climate, irrespective of the level of knowledge to be acquired.The paper provides a global situation analysis of qualified and quantified key elements of the knowledge economy, and  analysis of the impact of differentials between knowledge economies of the various human development groups on national healthcare structures and patient safety as a final outcome. Additionally, it alludes to methods on how to improve on the identified gaps.

Transfusion Challenges in Patients with Hematological Malignancies in Sub-Saharan Africa: A Prospective Observational Study from the Uganda Cancer Institute

Blood transfusion is fundamental in managing hematologic malignancies. We sought to evaluate the need and availability of blood products for patients with hematological malignancies at Uganda Cancer Institute. We prospectively studied the demand and supply of blood for patients with thrombocytopenia (platelet count ≤50 × 10⁹/L), anemia (hemoglobin ≤10 g/dL), and bleeding (WHO grade ≥2). We used Poisson generalized estimating equation regression models for longitudinal binary outcomes. Among 91 patients, the median age was 26 years (IQR, 11–47). Thrombocytopenia occurred on ≥1 day in 58% of patients and on 49% of hospital days. Platelets were transfused to 39% of patients. The mean number of platelet units requested per day was 16.2 (range 0–30); 5.1 (range 0–15) were received. Anemia occurred on ≥1 day in 90% of patients; on 78% of days; and 68% received at least one blood transfusion. The mean number of blood units requested was 36.3 (range 8–57) units per day; 14 (range 0–30) were received. Bleeding occurred on ≥1 day in 19% of patients on 8% of hospital days. Thrombocytopenia and anemia were common, but product availability was substantially below that requested. We recommend increased blood collection and adherence to strict transfusion triggers as strategies to improve blood availability.

Survey to Assess Knowledge and Reported Practices Regarding Blood Transfusion Among Cancer Physicians in Uganda

Purpose

Optimal decision making regarding blood transfusion for patients with cancer requires appropriate knowledge of transfusion medicine among physicians. We assessed blood transfusion knowledge, attitudes, and reported practices among physicians working at Uganda Cancer Institute (UCI).

Materials and Methods

A cross-sectional self-administered survey of UCI physicians on their knowledge, attitudes, and practices regarding blood transfusion was conducted from June to September 2014. In consultation with transfusion medicine experts, 30 questions were developed, including 10 questions for each of the following three domains: knowledge, attitudes, and practices. For the knowledge domain, we created a knowledge score equal to the number of questions correctly answered out of 10.

Results

Of 31 physicians approached, 90% participated. The mean knowledge score was 5.3 (median, 5.5), and 32% correctly answered at least seven of 10 questions. Almost all (96%) understood the importance of proper patient identification before transfusion and indicated identification error as the most common cause of fatal transfusion reactions. More than 60% of physicians acknowledged they lacked knowledge and needed training in transfusion medicine. Most physicians reported sometimes changing their mind about whether to provide a patient with a transfusion on the basis of opinion of colleagues and sometimes administering unnecessary transfusions because of influence from others.

Conclusion

Although UCI physicians have some basic knowledge in transfusion, most reported gaps in their knowledge, and all expressed a need for additional education in the basics of blood transfusion. Transfusion training and evidence-based guidelines are needed to reduce inappropriate transfusions and improve patient care. Greater understanding of peer influence in transfusion decision making is required.

Degloving injuries with versus without underlying fracture in a sub-Saharan African tertiary hospital: a prospective observational study

Background

Degloving injuries are surgical conditions in which an extensive portion of skin and subcutaneous tissue is detached from the underlying fasciae, muscles, or bone surface. Frequently, there is an association of fracture underlying the degloved area. We aimed to compare the short-term outcomes of degloving injuries with and without underlying fracture.

Methods

A prospective cohort study was conducted. We recruited patients with degloving injuries, and followed them up for 30 days to assess the outcomes. We collected data on socio-demography, cause and mechanism of injury, presence of underlying fracture, presence of shock at admission, injury severity score, location and size of degloving injuries, their management, and short-term outcomes. There were two comparison groups of degloving injuries based on the presence or absence of underlying fracture. We analyzed the differences between the two groups by using Fisher exact test for categorical variables and Student’s t test for continuous variables; p values < 0.05 were considered to be significant. Risk ratio was calculated for the short-term outcomes.

Results

There were 1.56% (n = 51) of degloving injuries among 3279 admitted trauma patients during the study period of 5 months; 1% (n = 33) with and 0.56% (n = 18) without underlying fracture. For the overall degloving injuries, male-female ratio was 2 and mean age was 28.8 years; they were caused by road traffic crashes in 84%, and resulted in shock at admission in 29%. In the group with underlying fracture, lower limbs were frequently affected in 45% (p = 0.0018); serial debridement and excision of the avulsed flap were the most performed surgical procedures in 22% (p = 0.0373) and 14% (p = 0.0425), respectively; this same group had 3.9 times increased risk of developing poor outcomes (mainly infections) after 30 days and longer hospital stay (26.52 ± 31.31 days, p = 0.0472).

Conclusion

Degloving injuries with underlying fracture are frequent in the lower limbs, and have increased risk of poor short-term outcomes and longer hospital stay. We recommend an early plastic surgery review at admission of patients with degloving injuries with underlying fracture to improve the flap viability and reduce the infection risk.

Electronic supplementary material

The online version of this article (10.1186/s13018-017-0706-9) contains supplementary material, which is available to authorized users.

Seeking health care from a general hospital in Uganda following a fracture or a dislocation

Introduction

Selecting a treatment approach and a facility to get treated from, poses a challenge in musculoskeletal injuries in Africa. The study aimed at determining demographic and injury characteristics of patients with musculoskeletal injuries and how these impact the time and reason for presenting to a general hospital in Uganda.

Methods

An observational study was carried out at Entebbe general hospital on patients presenting with musculoskeletal injuries between 1 November 2014 and 28 February 2015. The patient demographics, injury characteristics, duration of injury to presentation for treatment and reason for seeking treatment from this hospital were noted.

Results

A total of 101 patients were recruited. Of these, 95 had fractures while six had dislocations. Patients took an average of 96 h before presenting for care, females taking significantly longer than males (191.2 and 58.6 h respectively, p = 0.005). The fractured segment of bone significantly influenced the patients’ choice for care at this hospital (p = 0.02).

Discussion

Entebbe General Hospital serves a young and unemployed population for musculoskeletal injuries. These patients present late for care, especially females. Patients base their choice for care from this hospital on the character of the injury.

The role of Ugandan District Hospital orthopedic units in the care of vulnerable road users: a cross-sectional study

BACKGROUND

Musculoskeletal injuries are a common cause of morbidity after road traffic injury (RTI) in motorizing countries. District hospitals provide front-line orthopedic care in Uganda and other sub-Saharan African nations. Improving care at the district hospital level is an important component of the World Health Organization's strategy for surgical and trauma systems strengthening, but the data necessary to inform RTI safety and care initiatives has previously been insufficient at the district hospital level. The objective of this study was to provide data on the patient population and patterns of musculoskeletal injury caused by RTI at Ugandan district hospitals.

METHODS

In this cross-sectional study, all patients with musculoskeletal injuries identified on x-ray presenting to three Ugandan district hospitals from October 2013 to January 2014 were interviewed and examined to obtain data on patient demographics and injury context by road user category. This manuscript is a sub-group analysis of RTI victims from a broader dataset of all musculoskeletal injuries.

RESULTS

Vulnerable road users comprised 92 % of musculoskeletal RTI patients, with 49 % (95 % CI 41-57 %) pedestrians, 41 % (95 % CI 33-49 %) motorcyclists, and 2 % (95 % CI 0-4 %) cyclists. Commonly injured subgroups included student pedestrians (33 % (95 % CI 22-44 %) of pedestrians) and motorcyclists with less than a post-secondary education (74 % (95 % CI 63-85 %) of motorcyclists). The morning hours were the most common time of injury for all RTI patients (37 %%; 95 % CI 30-44 %) and motorcyclists (46 %; 95 % CI 34-58 %), while pedestrians were most commonly injured in the evening (32 %; 95 % CI 21-43 %).

CONCLUSIONS

By demonstrating commonly injured demographic groups and high frequency times of day for injury, this surveillance study of musculoskeletal RTI suggests targeted avenues for future road safety research in the districts of Uganda. Compared with previous studies from the capital of Uganda, these results suggest that Ugandan district hospitals care for a disproportionate share of vulnerable road users, a discrepancy which may pertain to other sub-Saharan African nations, as well. Strengthening district hospital orthopedic care should be considered a priority of strategies aimed at improving outcomes for these vulnerable groups.

A pilot orthopedic trauma registry in Ugandan district hospitals

BACKGROUND

Musculoskeletal injuries are a major public health problem in low-income countries like Uganda. Patterns of musculoskeletal injuries presenting to district hospitals are unknown. Our pilot orthopedic trauma registry establishes a framework for broader district hospital injury surveillance.

MATERIALS AND METHODS

We interviewed and examined patients presenting to Mityana, Entebbe, and Nakaseke hospitals with musculoskeletal injuries from October 2013 to January 2014. We compared patient and Demographic and Health Survey population demographics and determined predictors of delayed presentation for care.

RESULTS

Men, adults, and individuals with postsecondary education were more common among patients than in the Demographic and Health Survey population. Common causes included road traffic injuries (48.5%) and falls (25.1%). Closed, simple fractures comprised 70% of injuries. Compared to the self-employed, subsistence farmers (odds ratio [OR] = 2.99, 95% confidence interval [CI] = 1.15-7.91), motorcycle taxi drivers (OR = 10.50, 95% CI = 1.92-64.57), and preschool children (OR = 4.24, 95% CI = 1.05-17.39) were significantly more likely to be delayed to care after adjustment for covariates. Subsistence farmers were more likely than other occupations to seek care from traditional bonesetters (23% versus 7%, P = 0.001). All patients who visited bonesetters were delayed to hospital care.

CONCLUSIONS

Policies for trauma systems strengthening must address the needs of underserved groups and involve all stakeholders, including bonesetters. Research should address reasons for delayed care among subsistence farmers, motorcycle taxi drivers, and preschool children. Injury surveillance at district hospitals facilitates evidence-based resource allocation and should continue in the form of an Ugandan national trauma registry.

Transfusion Medicine in Sub-Saharan Africa: Conference Summary

In November 2014, a 3-day conference devoted to transfusion medicine in sub-Saharan Africa was held in Kampala, Uganda. Faculty from academic institutions in Uganda provided a broad overview of issues pertinent to transfusion medicine in Africa. The conference consisted of lectures, demonstrations, and discussions followed by 5 small group workshops held at the Uganda Blood Transfusion Service Laboratories, the Ugandan Cancer Institute, and the Mulago National Referral Hospital. Highlighted topics included the challenges posed by increasing clinical demands for blood, the need for better patient identification at the time of transfusion, inadequate application of the antiglobulin reagent during pretransfusion testing, concern regarding proper recognition and evaluation of transfusion reactions, the expanded role for nurse leadership as a means to improve patient outcomes, and the need for an epidemiologic map of blood usage in Africa. Specialty areas of focus included the potential for broader application of transcranial Doppler and hydroxyurea therapy in sickle cell disease, African-specific guidelines for transfusion support of cancer patients, the challenges of transfusion support in trauma, and the importance of African-centered clinical research in pediatric and obstetric transfusion medicine. The course concluded by summarizing the benefits derived from an organized quality program that extended from the donor to the recipient. As an educational tool, the slide-audio presentation of the lectures will be made freely available at the International Society of Blood Transfusion Academy Web site: http://www.isbtweb.org/academy/.

Blood utilization at a national referral hospital in sub-Saharan Africa

BACKGROUND

A safe and adequate supply of blood is critical to improving health care systems in sub-Saharan Africa, where little is known about the current use of blood. The aim of this study was to comprehensively describe the use of blood at a tertiary care hospital to inform future efforts to strengthen blood programs in resource-limited settings.

STUDY DESIGN AND METHODS

Data were collected from blood bank documentation for all units issued at Mulago Hospital Complex in Kampala, Uganda, from mid-January to mid-April 2014.

RESULTS

A total of 6330 units (69% whole blood, 32% red blood cells, 6% platelets, 2% plasma) were issued over the 3-month study period to 3662 unique patients. Transfusion recipients were 58% female and median age was 27 years (interquartile range [IQR], 14-41). Median pretransfusion hemoglobin was 5.6 g/dL (IQR, 4.0-7.2 g/dL, n = 1090). Strikingly, cancer was the top indication for transfusion (33.5%), followed by pregnancy-related complications (12.4%) and sickle cell disease (6.9%).

CONCLUSION

This study provides a comprehensive picture of blood use at a national referral hospital in sub-Saharan Africa. Noncommunicable diseases, particularly oncologic conditions, represent a large proportion of demand for transfusion services.

Bottlenecks of blood processing in Uganda

AIM

To identify where and why delays occur in Uganda blood banks.

BACKGROUND

The timely provision and supply of safe and efficacious blood components to hospitals depends on sound systems in the processing blood banks. Poorly managed systems lead to apparent blood shortages in hospitals and increase discard rates due to expiry before dispatch.

MATERIALS AND METHODS

We reviewed records of 4126 units of whole blood delivered by the mobile collection teams to a major regional blood bank, in the period 1 March 2009 to 30 June 2009, to ascertain the time intervals between the critical steps in the blood processing chain. This was followed by interviews with staff in two blood banks to establish the causes of process delays.

RESULTS

The average duration between blood collection and final labelling (release from quarantine for final storage) was 15·4 (SD 10·8) days. In timeline, the step between matrix generation and grouping was (median duration 8 days) the longest, whereas grouping to labelling was the shortest (median duration 2 days). Blood expiry had the highest discard rate (0·17%) among the non-transfusion transmissible infection marker causes. A minimally facilitated small staff contributed to the process flaws.

CONCLUSION

A considerable amount of blood does not reach hospitals because of process delays between collection and ultimate dispatch. This is caused by a thin staff working with inadequate materials, out-of-date methods and in an overcrowded environment. Provision of adequate staff and improved financial allocations to the Uganda Blood Transfusion Services will mitigate this situation.

Surgical blood order equation in femoral fracture surgery

AIM

This study aimed at establishing the clinical utility of the surgical blood order equation (SBOE) in patients undergoing femoral fracture surgery.

BACKGROUND

A blood ordering schedule defines the perioperative blood use in elective surgery. It lists the number of units of blood required for each procedure preoperatively.

MATERIALS AND METHODS

A case-control study was performed among homogeneous groups of patients (n = 62 each) undergoing open reduction and internal fixation of femoral fractures. Correct prediction of blood use in the group of patients using the SBOE was compared to the group whose blood orders were made without any guideline.

RESULTS

The surgical blood ordering equation was exactly correct in ordering blood for 46 (74·2%) of 62 patients (cases). The current unaided blood ordering method was exactly correct in ordering blood for 27 (43·5%) of 62 patients (controls). Use of the SBOE resulted in a significantly lower crossmatch-to-transfusion ratio compared to that of the current ordering system (1·5 vs 2·3) and saved the hospital transfusion laboratory 465 US$ of crossmatch and inventory management costs in this cohort of patients.

CONCLUSION

The SBOE is a more accurate and cost-saving tool in predicting blood use. It should replace the current unaided method of ordering for perioperative blood in femoral fracture surgery at Mulago Hospital. However, its introduction to other hospitals should be preceded by more rigorous research to strengthen its external validity.

Blood loss and contributing factors in femoral fracture surgery

BACKGROUND

Substantial blood losses frequently accompany orthopedic procedures.

METHODS

We prospectively noted peri-operative hemoglobin changes in 93 patients undergoing surgery for femoral fracture with an aim of establishing blood loss and related factors.

RESULTS

The mean total blood loss assessed 72 hours after the surgical procedure was 3.31 (SD 1.56) units of whole blood. A multiple regression analysis revealed diathermy use and a simple fracture pattern as significant factors in reducing blood loss (p<0.01).

CONCLUSIONS

Open intramedullary fixation of femur fractures leads to considerable peri-operative blood loss. This is can be reduced by use of diathermy during surgery.

Bedside practice of blood transfusion in a large teaching hospital in Uganda: An observational study

Background:

Adverse transfusion reactions can cause morbidity and death to patients who receive a blood transfusion. Blood transfusion practice in Mulago Hospital, Kampala, Uganda is analyzed to see if and when these practices play a role in the morbidity and mortality of patients.

Materials and Methods:

An observational study on three wards of Mulago Hospital. Physicians, paramedics, nurses, medical students and nurse students were observed using two questionnaires. For comparison, a limited observational study was performed in the University Medical Centre Groningen (UMCG) in Groningen, The Netherlands.

Results:

In Mulago Hospital guidelines for blood transfusion practice were not easily available. Medical staff members work on individual professional levels. Students perform poorly due to inconsistency in their supervision. Documentation of blood transfusion in patient files is scarce. There is no immediate bedside observation, so transfusion reactions and obstructions in the blood transfusion flow are not observed.

Conclusion:

The poor blood transfusion practice is likely to play a role in the morbidity and mortality of patients who receive a blood transfusion. There is a need for a blood transfusion policy and current practical guidelines.