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Background: Gallstone disease (GSD) is the most prevalent medical condition in the pancreatobiliary system. The burden of GSD and its complications are major public health issues globally. It is a common cause of surgical intervention, contributing substantially to health care costs. Most patients are asymptomatic, however 20% become symptomatic after 10 years. Its preva- lence differs among populations and remains unknown in Uganda. Objective: To determine the prevalence and risk factors of GSD in patients undergoing abdominal ultrasonography at Mulago hospital, Uganda. Methods: This was a cross-sectional study at the Department of Radiology in Mulago hospital. Convenient sampling was used to recruit individuals having an abdominal ultrasound scan. Questionnaires were used to assess risk factors, and an abdominal exam was performed for individuals with gallstones to assess symptomatology. Results: The prevalence of GSD was 22%. Statistically significant factors associated with GSD were a history of hormonal contraceptive use OR 3.2 (1.88-5.41) and a history of previous biliary symptoms OR 2.9 (1.68-4.91). Ninety-four percent of individuals with gallstones had epigastric/right upper quadrant pain. Conclusion: The prevalence of GSD is high in Mulago hospital; use of hormonal contraceptives and a previous history of biliary symptoms were significant risk factors for GSD in this study. Majority of patients with GSD were symptomatic with epigastric pain as the cardinal symptom. We recommend a countrywide screening program using abdominal ultrasonography to determine the prevalence of GSD in the general population. There is need to study further the risk of hormonal contraceptive use and GSD. Women on these contraceptives should be informed of the potential risk, and offered alternative options where feasible. Keywords: Gallstone disease; ultrasonography; Mulago hospital; Uganda.

Introduction Mortality from trauma remains a major challenge despite recent substantial improvements in acute trauma care. In trauma care patient resuscitation to correct hypotension from volume loss still majorly relies on use of physiological parameters such as blood pressure, pulse rate, respiratory rate, urine output and oxygen saturation. In resource limited settings these methods may not be sufficient to detect occult tissue hypoxia and the accompanying metabolic derangements. Methods A prospective observational study carried out at a level I urban Trauma centre; Accident and Emergency unit. Major trauma patients were consecutively recruited into the study. Venous blood samples were drawn for analysis of serum electrolytes, serum PH and anion gap. The venous blood gas findings were correlated with patients’ clinical outcome at two weeks. Ethical approval was obtained. Results Ninety three major trauma patients were recruited, patients’ age ranged from 12 months to 50 years. Forty nine patients (53%) were acidotic (PH less than 7.32), 39 patients (42%) had low bicarbonate (bicarbonate level less than 21 mmol), 54 patients (58%) had high corrected anion gap (anion gap corrected of 16 or more). Fourteen patients (15%) developed secondary organ failure and 32 (34%) patients died. Conclusion Metabolic acidosis is common among major trauma patients, its severity may be related to delay in initiating care. Acid base derangements were predictors of mortality among major trauma patients in this resource limited setting.

Background Deep venous thrombosis (DVT) is a major cause of morbidity and mortality among postoperative patients. Its incidence has been reported to range between 16% and 38% among general surgery patients and may be as high as 60% among orthopaedic patients. The most important clinical outcome of DVT is pulmonary embolism, which causes about 10% of hospital deaths. In over 90% of patients, occurrence of DVT is silent and presents no symptoms until onset of pulmonary embolism and/or sudden death. The only effective way of guarding against this fatal condition is therefore prevention/prophylaxis. However, prophylaxis programs are usually based on the estimated prevalence of DVT in that particular community. There is currently no data concerning rates of postoperative DVT in Uganda. The purpose of the study was therefore to determine the prevalence of DVT among postoperative patients at Mulago Uganda’s National Referral Hospital. Methods A cross sectional descriptive study was conducted between March and June 2011. Eligible patients were identified and screened and patient details were collected. Clinical examinations were done on postoperative days (PODs) 1, 2, and 4 and Doppler ultrasounds were done on POD 7 and POD 21 to assess for DVT. Patients found with DVT were treated appropriately according to local treatment guidelines. Results A total of 82 patients were recruited, 4/82 (5%) had DVT. The most common risk factor was cancer. The overall mean age was 45 years (range 20–83 years). The male to female ratio was 1.6:1. Participants with more than one risk factor for DVT were 16/82 (20%). Conclusions Prevalence of DVT among major post-abdominal surgery patients was low (5%). Cancer was the most common associated factor apart from surgery.

Introduction: Trauma is a major public health hazard, contributing significantly to mortality. It is the leading cause of death among adolescents and young adults worldwide. Road traffic injuries come top of the list of forms of trauma in urban areas, with more than 3000 deaths occurring daily. Most deaths (85%) occur in low and middle income countries and are a result of shock secondary to haemorrhage. There being a dearth of documented information on the short term outcome and associated factors of haemorrhagic shock in a Sub Saharan setting, a study to this effect was conducted. Methods: A prospective descriptive cohort study was conducted from October 2012 to March 2013, involving patients attending Mulago National Referral and Teaching Hospital’s Accident and Emergency Department, who had traumatic haemorrhagic shock. Patients aged 5 years and above and of both genders were included. They were managed according to the ATLS guidelines and followed-up for 24 hours. The outcomes were: the 24 hour survival or mortality of these patients; the adequacy of resuscitation of the survivors; and the distribution of factors known to affect mortality. Results: A total of 55 participants, 40 (72.7%) of them males, were recruited. The mean age was 27.2 years. There were 16 (29.1%) deaths in 24 hrs. Of the survivors, 13 (33.3%) of them were inadequately resuscitated when clinical signs alone were used to monitor resuscitation. Grade IV shock, time since injury, and the need for major surgery to control bleeding, contributed significantly to mortality. Conclusion: The 24 hour mortality due to haemorrhagic shock at Mulago Hospital is slightly lower than that reported in some studies but strategies to reduce it further need to be explored

Background Necrotizing fasciitis is an infectious process characterized by rapidly progressing necrosis of superficial fascia and subcutaneous tissue with subsequent necrosis of overlying skin. Necrotizing fasciitis is a rare but fatal infection. The worldwide incidence is at 0.4 per 100,000. Mortality is up to 80% with no intervention, and 30-50% with intervention. Delay in intervention is associated with poor outcome. The risk factors for necrotizing fasciitis are diabetes mellitus, HIV, malignancy, illicit drug use, malnutrition among others. The aim of this study was to describe the clinical presentation and early outcomes of necrotizing fasciitis amongst Ugandan patients. Methods A prospective descriptive case series study conducted at Mulago National Referral and Teaching hospital from 5th January to 30th April 2011. Patients with necrotizing fasciitis were consecutively recruited after clinical evaluation, laboratory and microbiological tests were performed. Aggressive debridement was done and broad-spectrum antibiotics administered. Patients were followed up on surgical wards. Ethical approval was obtained. Results Thirty five patients were recruited over a 4 months period. More males were affected with, M: F 3:1. The 20-40 years age group was most affected. Attainment of healthy granulation tissue took 19 days on average. Mortality rate was 14% (5/35). Limbs were the most affected body parts 20/35 (57%), the scrotum and perineum (23%). Among infants the scalp was the most affected. Co-morbidities included HIV 8/35 (17%), and DM (5%) among others. The commonest organisms were gram negative. Split skin grafting was necessary in 74% (26/35) of patients. Conclusion There were a high number of patients with necrotizing fasciitis; it was associated with low mortality but high morbidity (long hospital stay). There was a high preponderance to males and limbs were the more affected body parts.

Background Surgical site infections (SSIs) are difficult to treat and are associated with substantially longer hospital stay, higher treatment cost, morbidity and mortality, particularly when the etiological agent is multidrug-resistant (MDR). To address the limited data in Uganda on SSIs, we present the spectrum of bacteria isolated from hospitalized patients, the magnitude and impact of MDR bacterial isolates among patients with SSIs. Methods A descriptive cross sectional study was conducted from September 2011 through April 2012 involving 314 patients with SSIs in the obstetrics & gynecology, general surgery and orthopedic wards at Mulago National Hospital in Kampala, Uganda. Wound swabs were taken and processed using standard microbiological methods. Clinico-demographic characteristics of patients were obtained using structured questionnaires and patients’ files. Results Of the 314 enrolled patients with SSIs (mean age 29.7 ±13.14 years), 239 (76.1%) were female. More than half of the patients were from obstetrics and gynecology (62.1%, 195/314). Of 314 wound swabs taken, 68.8% (216/314) were culture positive aerobically, yielding 304 bacterial isolates; of which 23.7% (72/304) were Escherichia coli and 21.1% (64/304) were Staphylococcus aureus. More than three quarters of Enterobacteriaceae were found to be extended spectrum beta lactamase (ESBL) producers and 37.5% of S. aureus were Methicillin resistant S. aureus (MRSA). MDR occurred in 78.3% (238/304) of the isolates; these were more among Gram-negative bacteria (78.6%, 187/238) compared to Gram-positive bacteria (21.4%, 51/238), (p-value

Background The prevalence of Methicillin resistant Staphylococcus aureus (MRSA) is progressively increasing globally with significant regional variation. Understanding the Staphylococcus aureus lineages is crucial in controlling nosocomial infections. Recent studies on S. aureus in Uganda have revealed an escalating burden of MRSA. However, the S. aureus genotypes circulating among patients are not known. Here, we report S. aureus lineages circulating in patients with surgical site infections (SSI) at Mulago National hospital, Kampala, Uganda. Methods A cross-sectional study involving 314 patients with SSI at Mulago National Hospital was conducted from September 2011 to April 2012. Pus swabs from the patients’ SSI were processed using standard microbiological procedures. Methicillin sensitive Staphylococcus aureus (MSSA) and MRSA were identified using phenotypic tests and confirmed by PCR-detection of the nuc and mecA genes, respectively. SCCmec genotypes were determined among MRSA isolates using multiplex PCR. Furthermore, to determine lineages, spa sequence based-genotyping was performed on all S. aureus isolates. Results Of the 314 patients with SSI, S. aureus accounted for 20.4% (64/314), of which 37.5% (24/64) were MRSA. The predominant SCCmec types were type V (33.3%, 8/24) and type I (16.7%, 4/24). The predominant spa lineages were t645 (17.2%, 11/64) and t4353 (15.6%, 10/64), and these were found to be clonally circulating in all the surgical wards. On the other hand, lineages t064, t355, and t4609 were confined to the obstetrics and gynecology wards. A new spa type (t10277) was identified from MSSA isolate. On multivariate logistic regression analysis, cancer and inducible clindamycin resistance remained as independent predictors of MRSA-SSI. Conclusion SCCmec types I and V are the most prevalent MRSA mecA types from the patients’ SSI. The predominant spa lineages (t645 and t4353) are clonally circulating in all the surgical wards, calling for strengthening of infection control practices at Mulago National Hospital.

Introduction Colorectal cancer (CRC) was thought to be uncommon in black Sub Saharan Africa. High fibre diet, low incidences of adenomas and low social economic class are postulated to give protection against CRC. The past two decades have, seen a significant increase in incidence of a unique early onset, non-polypoid type of tumor affecting principally the rural population of generally low socio-economy status and whose diet differ significantly from that of similar patients from the developed countries. There are some similarities between Uganda tumors and MSI-H CRC found principally in Black Americans. Is the Uganda tumor therefore a unique form of CRC with some similarities to CRC found mainly among black Americans? Aim To provide basic epidemiologic, pathological and clinical data on CRC in Uganda and identify characteristics of this tumor which differ from those of similar patients from the developed countries. Methods The data presented is from a large data-base of colorectal cancer patients established at Mulago hospital in Jan. 2003. This data-base is being continuously upgraded by the research team in our colorectal Unit. Presently the database consists of 448 fully documented CRC cases. Results Of 448 clinically diagnosed CRC, 386 had confirmed histological diagnosis. CRC constituted 3.8% of all malignancies and 19.8% of all GIT malignancies. Incidence has doubled from 1.7% in 1983 and is higher than 2.5% average for the entire African continent. Mean age was 52.4yrs and M : F=1.2 :1. 68% of patients were rural peasants feeding on Bananas, Maize, Millet, Cassava, Yams, Vegetables and Tropical fruits with very low meat consumption and over 60% did not smoke or consume alcohol. Mean duration of symptoms was 9.4 months. 62.2% of tumors were rectal and 78% occurred on the left side. 70.6% of staged patients had Duke's C and D tumors. Only 12 tumors were found in co-existence with colonic adenomas, five of which were confirmed to have arisen from pre-existing adenomas and no synchronous tumors were diagnosed. Tumor resection was carried out in 38.3% of patients while 28% of patients declined surgery. Only 42% of patients were followed-up for mean duration of 8.6 months. Conclusion CRC in Uganda, is unique early-onset, non-polypoid form of CRC occurring mainly in young rural peasants, of low socio-economic status, eating unprocessed high-fibre, high-carbohydrate, low-protein and fat, traditional diet rich in vegetables and tropical fruits and is distinct from that found in patients from developed countries, who are generally 2 to 3 decades older, are mainly affluent and of generally high socio-economic status and whose diet is rich in processed animal fats and proteins and low in vegetable fibres. Whereas majority of tumors from the developed countries do arise from pre-existing adenomatous polyps, the Uganda tumors do not arise from such polyps. Uganda tumors therefore appear to be a unique form of CRC.

Background Trauma is the leading cause of death in the developed world. Accurate assessment of severity of injuries is critical in informing treatment choices. Current models of assessing severity of injury are not without limitations. The objective of this study therefore was to determine the diagnostic accuracy of serum lactate assays in assessing injury severity and prediction of early outcomes among trauma patients. Methods This was a cross-sectional analytical study. Consecutive series of all eligible patients had a single venous blood sample drawn for lactate assay analysis (index test) and a concurrent Kampala Trauma Score (KTS) II value determination (reference test). Admitted patients were followed up to assess early outcomes (length of hospital stay and mortality). Results Out of the 502 trauma patients recruited, 108 (22%) were severely injured, 394 (78%) had non-severe injuries, and 183 were admitted. There was a significant difference between median (interquartile range (IQR)) lactate levels among the severely injured (4.3 (2.6, 6.6)) and the non-severely injured (2.4 (1.6, 3.5), p