Browsing by Author "Alaroker, Florence"

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    Characterising Childhood Blackwater Fever and Its Clinical Care at Two Tertiary Hospitals in Eastern Uganda
    (Research Square, 2021) Paasi, George; Ndila, Carolyne; Okiror, William; Namayanja, Cate; Okalebo, Benard Phelan; Abongo, Grace; Alaroker, Florence; Abeso, Julian; Kasoro, Andrew; Okello, Francis; Olupot, Peter Olupot
    In eastern Uganda, reports suggest that cases of Blackwater Fever (BWF) are on the rise. We summarise the base-line characteristics and routine care available to patients with BWF presenting at two tertiary hospitals in Eastern Uganda prior to the Phase I/II trial on use of paracetamol for acute kidney injury in children with BWF (PARIST; ISRCTN84974248). This was a retrospective descriptive study for the period January – December 2018 for children admitted with a clinical diagnosis of BWF at Mbale and Soroti Regional Referral Hospitals in Eastern Uganda. Data on sociodemographic and clinical characteristics, routine in-patient care and outcomes were abstracted using a customised study proforma and analysed using STATA. We obtained 9578 admission records during the study period, of which 1241 (13.0%) were admitted with a diagnosis of BWF. The median age was 60 months (IQR 36–90). Male: female ratio was 1.5:1. More cases of BWF 682/1241 (55.0%) were in children > 5 years compared to 559/1241 (45.0%) ≤ 5 years [95%CI (0.41–0.59); P = 0.0002]. The common symptoms included fever 1109/1241 (89.4%), vomiting 599/1241 (48.3%) and abdominal pain 494/1241 (39.8%). Conversely, the common signs recorded were clinical pallor 742/1241 (59.8%), clinical jaundice 369/1241 (29.7%), fever 332/1241 (26.7%) and prostration 231/1241 (18.6%). In addition, abdominal tenderness was documented in 120/1241 (9.7%), splenomegaly in 122/1241 (9.8%) and hepatomegaly in 86/1241 (6.9%). Case records with BWF were more in the second half of the year with a peak in the months of July and September. 510/1241 (41.1%) were treated with antimalarial drugs mainly parenteral Artesunate 501/510 (98.2%). 660/1241(53.2%) of the patients were managed with antibiotics mainly parenteral ceftriaxone 616/660 (93.3%). There were 426/1241 (34.3%) patients who received blood transfusion during admission. Clinicians used steroid treatment in 388/1241 (31.3%), mainly parenteral hydrocortisone 370/388 (95.4%).BWF accounted for 13% paediatric hospital admissions in the region. It was predominant in children > 5 years of age. It typically presents with passing dark urine, fever, abdominal pain, clinical jaundice and pallor. Locally there are no treatment guidelines for BWF. These data provide background data useful for future studies on BWF in the region.
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    Characterising Demographics, Knowledge, Practices And Clinical Care Among Patients Attending Sickle Cell Disease Clinics In Eastern Uganda
    (Wellcome Open Research, 2020) Olupot, Peter Olupot; Wabwire, Ham; Ndila, Carolyne; Adong, Ruth; Ochen, Linus; Amorut, Denis; Abongo, Grace; Okalebo, Charles B.; Akello, Sarah Rachael; Oketcho, Joy B.; Okiror, William; Asio, Sarah; Odiit, Amos; Alaroker, Florence; Nyutu, Gideon; Maitland, Kathryn; Williams, Thomas N.
    In Uganda to date, there are neither established registries nor descriptions of facility-based sickle cell disease (SCD) patient characteristics beyond the central region. Here, we summarize data on the baseline clinical characteristics and routine care available to patients at four clinics in Eastern Uganda as a prelude to a clinical trial.Between February and August 2018, we conducted a cross-sectional survey of patients attending four SCD clinics in Mbale, Soroti, Atutur and Ngora, all in Eastern Uganda, the planned sites for an upcoming clinical trial (H-PRIME: ISRCTN15724013). Data on socio-demographic characteristics, diagnostic methods, clinic schedules, the use of prophylactic and therapeutic drugs, clinical complications and patient understanding of SCD were collected using a structured questionnaire.Data were collected on 1829 patients. Their ages ranged from 0 to 64 years with a median (IQR) of 6 (3-11) years. 49.1% of participants were male. The majority (1151; 62.9%) reported a positive family history for SCD. Approximately half knew that SCD is inherited from both parents but a substantial proportion did not know how SCD is transmitted and small numbers believed that it is acquired by either transfusion or from other people. Only 118/1819 (6.5%) participants had heard about or were using hydroxyurea while 356/1794 (19.8%) reported stigmatization. Participants reported a median of three (IQR 1-4) hospital admissions during the preceding 12 months; 80.8% had been admitted at least once, while 14.2% had been admitted more than five times. Pain was the most common symptom, while 83.9% of those admitted had received at least one blood transfusion.The majority of patients attending SCD clinics in Eastern Uganda are children and few are currently being treated with hydroxyurea. The data collected through this facility-based survey will provide background data that will be useful in planning for the H-PRIME trial.
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    Children’s Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial
    (Wellcome open research, 2021) Kiguli, Sarah; Olopot-Olupot, Peter; Alaroker, Florence; Engoru, Charles; Opoka, Robert O.; Tagoola, Abner; Hamaluba, Mainga; Mnjalla, Hellen; Mogaka, Christabel; Nalwanga, Damalie; Nabawanuka, Eva; Nokes, James; Nyaigoti, Charles; Woensel, Job B. M. van; Thomas, Karen; Harrison, David A.; Maitland, Kathryn
    To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies.
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    Co-Trimoxazole Or Multivitamin Multimineral Supplement For Post-Discharge Outcomes After Severe Anaemia In African Children: A Randomised Controlled Trial
    (The Lancet Global Health, 2019) Maitland, Kathryn; Olupot, Peter Olupot; Kiguli, Sarah; Chagaluka, George; Alaroker, Florence; Opoka, Robert O.; Mpoya, Ayub; Walsh, Kevin; Engoru, Charles; Nteziyaremye, Julius; Mallewa, Machpherson; Nakuya, Margaret; Kennedy, Neil; Namayanja, Cate; Kayaga, Julianne; Nabawanuka, Eva; Sennyondo, Tonny; Aromut, Denis; Kumwenda, Felistas; Musika, Cynthia Williams; Thomason, Margaret J.; Bates, Imelda; Hensbroek, Michael Boele von; Evans, Jennifer A .; Uyoga, Sophie; Williams, Thomas N.; Frost, Gary; George, Elizabeth C.; Gibb, Diana M.; Walker, A. Sarah; the TRACT trial group
    Severe anaemia is a leading cause of paediatric admission to hospital in Africa; post-discharge outcomes remain poor, with high 6-month mortality (8%) and re-admission (17%). We aimed to investigate post-discharge interventions that might improve outcomes.Within the two-stratum, open-label, multicentre, factorial randomised TRACT trial, children aged 2 months to 12 years with severe anaemia, defined as haemoglobin of less than 6 g/dL, at admission to hospital (three in Uganda, one in Malawi) were randomly assigned, using sequentially numbered envelopes linked to a second non-sequentially numbered set of allocations stratified by centre and severity, to enhanced nutritional supplementation with iron and folate-containing multivitamin multimineral supplements versus iron and folate alone at treatment doses (usual care), and to co-trimoxazole versus no co-trimoxazole. All interventions were administered orally and were given for 3 months after discharge from hospital. Separately reported randomisations investigated transfusion management. The primary outcome was 180-day mortality. All analyses were done in the intention-to-treat population; follow-up was 180 days. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN84086586, and follow-up is complete.From Sept 17, 2014, to May 15, 2017, 3983 eligible children were randomly assigned to treatment, and followed up for 180 days. 164 (4%) were lost to follow-up. 1901 (95%) of 1997 assigned multivitamin multimineral supplement, 1911 (96%) of 1986 assigned iron and folate, and 1922 (96%) of 1994 assigned co-trimoxazole started treatment. By day 180, 166 (8%) children in the multivitamin multimineral supplement group versus 169 (9%) children in the iron and folate group had died (hazard ratio [HR] 0·97, 95% CI 0·79–1·21; p=0·81) and 172 (9%) who received co-trimoxazole versus 163 (8%) who did not receive co-trimoxazole had died (HR 1·07, 95% CI 0·86–1·32; p=0·56). We found no evidence of interactions between these randomisations or with transfusion randomisations (p>0·2). By day 180, 489 (24%) children in the multivitamin multimineral supplement group versus 509 (26%) children in the iron and folate group (HR 0·95, 95% CI 0·84–1·07; p=0·40), and 500 (25%) children in the co-trimoxazole group versus 498 (25%) children in the no co-trimoxazole group (1·01, 0·89–1·15; p=0·85) had had one or more serious adverse events. Most serious adverse events were re-admissions, occurring in 692 (17%) children (175 [4%] with at least two re-admissions).Neither enhanced supplementation with multivitamin multimineral supplement versus iron and folate treatment or co-trimoxazole prophylaxis improved 6-month survival. High rates of hospital re-admission suggest that novel interventions are urgently required for severe anaemia, given the burden it places on overstretched health services in Africa.
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    Whole blood versus red cell concentrates for children with severe anaemia: a secondary analysis of the Transfusion and Treatment of African Children (TRACT) trial
    (The Lancet Global Health, 2022) George, Elizabeth C.; Uyoga, Sophie; M’baya, Bridon; Kyeyune Byabazair, Dorothy; Kiguli, Sarah; Olupot-Olupot, Peter; Opoka, Robert O.; Chagaluka, George; Alaroker, Florence; Williams, Thomas N.; Bates, Imelda; Mbanya, Dora; Gibb, Diana M.; Walker, A. Sarah; Maitland, Kathryn
    The TRACT trial established the timing of transfusion in children with uncomplicated anaemia (haemoglobin 4–6 g/dL) and the optimal volume (20 vs 30 mL/kg whole blood or 10 vs 15 mL/kg red cell concentrates) for transfusion in children admitted to hospital with severe anaemia (haemoglobin <6 g/dL) on day 28 mortality (primary endpoint). Because data on the safety of blood components are scarce, we conducted a secondary analysis to examine the safety and efficacy of different pack types (whole blood vs red cell concentrates) on clinical outcomes. Methods This study is a secondary analysis of the TRACT trial data restricted to those who received an immediate transfusion (using whole blood or red cell concentrates). TRACT was an open-label, multicentre, factorial, randomised trial conducted in three hospitals in Uganda (Soroti, Mbale, and Mulago) and one hospital in Malawi (Blantyre). The trial enrolled children aged between 2 months and 12 years admitted to hospital with severe anaemia (haemoglobin <6 g/dL). The pack type used (supplied by blood banks) was based only on availability at the time. The outcomes were haemoglobin recovery at 8 h and 180 days, requirement for retransfusion, length of hospital stay, changes in heart and respiratory rates until day 180, and the main clinical endpoints (mortality until day 28 and day 180, and readmission until day 180), measured using multivariate regression models. Findings Between Sept 17, 2014, and May 15, 2017, 3199 children with severe anaemia were enrolled into the TRACT trial. 3188 children were considered in our secondary analysis. The median age was 37 months (IQR 18–64). Whole blood was the first pack provided for 1632 (41%) of 3992 transfusions. Haemoglobin recovery at 8 h was significantly lower in those who received packed cells or settled cells than those who received whole blood, with a mean of 1·4 g/dL (95% CI –1·6 to –1·1) in children who received 30 mL/kg and –1·3 g/dL (–1·5 to –1·0) in those who received 20 mL/kg packed cells versus whole blood, and –1·5 g/dL (–1·7 to –1·3) in those who received 30 mL/kg and –1·0 g/dL (–1·2 to –0·9) in those who received 20 mL/kg settled cells versus whole blood (overall p<0·0001). Compared to whole blood, children who received blood as packed or settled cells in their first transfusion had higher odds of receiving a second transfusion (odds ratio 2·32 [95% CI 1·30 to 4·12] for packed cells and 2·97 [2·18 to 4·05] for settled cells; p<0·001) and longer hospital stays (hazard ratio 0·94 [95% CI 0·81 to 1·10] for packed cells and 0·86 [0·79 to 0·94] for settled cells; p=0·0024). There was no association between the type of blood supplied for the first transfusion and mortality at 28 days or 180 days, or readmission to hospital for any cause. 823 (26%) of 3188 children presented with severe tachycardia and 2077 (65%) with tachypnoea, but these complications resolved over time. No child developed features of confirmed cardiopulmonary overload. Interpretation Our study suggests that the use of packed or settled cells rather than whole blood leads to additional transfusions, increasing the use of a scarce resource in most of sub-Saharan Africa. These findings have substantial cost implications for blood transfusion and health services. Nevertheless, a clinical trial comparing whole blood transfusion with red cell concentrates might be needed to inform policy makers.