Addressing the growing burden of trauma and injury in low- and middle-income countries

Dissecting inflammatory complications in critically injured patients by within-patient gene expression changes: a longitudinal clinical genomics study

BACKGROUND

Trauma is the number one killer of individuals 1-44 y of age in the United States. The prognosis and treatment of inflammatory complications in critically injured patients continue to be challenging, with a history of failed clinical trials and poorly understood biology. New approaches are therefore needed to improve our ability to diagnose and treat this clinical condition.

METHODS AND FINDINGS

We conducted a large-scale study on 168 blunt-force trauma patients over 28 d, measuring ∼400 clinical variables and longitudinally profiling leukocyte gene expression with ∼800 microarrays. Marshall MOF (multiple organ failure) clinical score trajectories were first utilized to organize the patients into five categories of increasingly poor outcomes. We then developed an analysis framework modeling early within-patient expression changes to produce a robust characterization of the genomic response to trauma. A quarter of the genome shows early expression changes associated with longer-term post-injury complications, captured by at least five dynamic co-expression modules of functionally related genes. In particular, early down-regulation of MHC-class II genes and up-regulation of p38 MAPK signaling pathway were found to strongly associate with longer-term post-injury complications, providing discrimination among patient outcomes from expression changes during the 40-80 h window post-injury.

CONCLUSIONS

The genomic characterization provided here substantially expands the scope by which the molecular response to trauma may be characterized and understood. These results may be instrumental in furthering our understanding of the disease process and identifying potential targets for therapeutic intervention. Additionally, the quantitative approach we have introduced is potentially applicable to future genomics studies of rapidly progressing clinical conditions.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00257231

Epidemiology of major incidents: an EMS study from Pakistan

Background

A major incident is defined as an event that owing to the number of casualties has the potential to overwhelm the available resources. This paper attempts to describe the incidence and epidemiology of major incidents dealt with by a government-run emergency medical service (EMS) in the Punjab province of Pakistan, a developing country in South Asia. A major incident in this EMS is defined as any incident that produces three or more patients, or any incident in which extraordinary resources are needed.

Methods

All the calls received by an EMS Rescue 1122 were studied over a 6-month period. Calls that were defined as major incidents were identified, and further details were sought from the districts regarding these incidents. Questions specifically asked were the type of incident, time of the incident, response time for the incident, the resources needed, and the number of dead and injured casualties. Retrospective data were collected from the submitted written reports.

Results

Road traffic crashes (RTCs) emerged as the leading cause of a major incident in the province of Punjab and also led to the greatest number of casualties, followed by fire incidents. The total number of casualties was 3,380, out of which 73.7% were RTC victims. There was a high rate of death on the scene (10.4%). Certain other causes of major incidents also emerged, including violence, gas explosions and drowning.

Conclusion

Road traffic crashes are the most common cause of a major incident in developing countries such as Pakistan. Injury prevention initiatives need to focus on RTCs.

Disparities in injury mortality between Uganda and the United States: comparative analysis of a neglected disease

Background

The burden of global injury-related deaths predominantly affects developing countries, which have little infrastructure to evaluate these disparities. We describe injury-related mortality patterns in Kampala, Uganda and compare them with data from the United States and San Francisco (SF), California.

Methods

We created a database in Kampala of deaths recorded by the City Mortuary, the Mulago Hospital Mortuary, and the Uganda Ministry of Health from July to December 2007. We analyzed the rate and odds ratios and compared them to data from the U.S. Centers for Disease Control and Prevention and the California Department of Public Health.

Results

In Kampala, 25% of all deaths were due to injuries (812/3303) versus 6% in SF and 7% in the United States. The odds of dying of injury in Kampala were 5.0 times higher than in SF and 4.2 times higher than in the United States. Age-standardized death rates indicate a 93% greater risk of dying from injury in Kampala than in SF. The mean age was lower in Kampala than in SF (29 vs. 44 years). The adult injury death rate (rate ratio, or RR) was higher in Kampala than in SF (2.3) or the United States (1.5). Head/neck injury was reported in 65% of injury deaths in Kampala compared to 34% in SF [odds ratio (OR) 3.7] and 28% in the US (OR 4.8).

Conclusions

Urban injury-related mortality is significantly higher in Uganda than in the United States. Injury preferentially affects adults in the prime of their economically productive years. These findings serve as a call for stronger injury prevention and control policies in Uganda.

Collecting injury surveillance data in low- and middle-income countries: the Cape Town Trauma Registry pilot

Injury is a major public health issue, responsible for 5 million deaths each year, equivalent to the total mortality caused by HIV, malaria and tuberculosis combined. The World Health Organisation estimates that of the total worldwide deaths due to injury, more than 90% occur in low- and middle-income countries (LMIC). Despite the burden of injury sustained by LMIC, there are few continuing injury surveillance systems for collection and analysis of injury data. We describe a hospital-based trauma surveillance instrument for collection of a minimum data-set for calculating common injury scoring metrics including the Abbreviated Injury Scale and the Injury Severity Score. The Cape Town Trauma Registry (CTTR) is designed for injury surveillance in low-resource settings. A pilot at Groote Schuur Hospital in Cape Town was conducted for one month to demonstrate the feasibility of systematic data collection and analysis, and to explore challenges of implementing a trauma registry in a LMIC. Key characteristics of the CTTR include: ability to calculate injury severity, key minimal data elements, expansion to include quality indicators and minimal drain on human resources based on few fields. The CTTR provides a strategy to describe the distribution and consequences of injury in a high trauma volume, low-resource environment.

Epidemiology of child injuries in Uganda: challenges for health policy

Globally, 90% of road crash deaths occur in the developing world. Children in Africa bear the major part of this burden, with the highest unintentional injury rates in the world. Our study aims to better understand injury patterns among children living in Kampala, Uganda and provide evidence that injuries are significant in child health. Trauma registry records of injured children seen at Mulago Hospital in Kampala were analysed. Data were collected when patients were seen initially and included patient condition, demographics, clinical variables, cause, severity, as measured by the Kampala trauma score, and location of injury. Outcomes were captured on discharge from the casualty department and at two weeks for admitted patients. From August 2004 to August 2005, 872 injury visits for children <18 years old were recorded. The mean age was 11 years (95% CI 10.9-11.6); 68% (95% CI 65-72%) were males; 64% were treated in casualty and discharged; 35% were admitted. The most common causes were traffic crashes (34%), falls (18%) and violence (15%). Most children (87%) were mildly injured; 1% severely injured. By two weeks, 6% of the patients admitted for injuries had died and, of these morbidities, 16% had severe injuries, 63% had moderate injuries and 21% had mild injuries. We concluded that, in Kampala, children bear a large burden of injury from preventable causes. Deaths in low severity patients highlight the need for improvements in facility based care. Further studies are necessary to capture overall child injury mortality and to measure chronic morbidity owing to sequelae of injuries.

Current patterns of prehospital trauma care in Kampala, Uganda and the feasibility of a lay-first-responder training program

BACKGROUND

Uganda currently has no organized prehospital emergency system. We sought to measure the current burden of injury seen by lay people in Kampala, Uganda and to determine the feasibility of a lay first-responder training program.

METHODS

We conducted a cross-sectional survey of current prehospital care providers in Kampala: police officers, minibus taxi drivers, and Local Council officials, and collected data on types and frequencies of emergencies witnessed, barriers to aid provision, history of training, and current availability of first-aid supplies. A context-appropriate course on basic first-aid for trauma was designed and implemented. We measured changes in trainees' fund of knowledge before and after training.

RESULTS

A total of 309 lay people participated in the study, and during the previous 6 months saw 18 traumatic emergencies each; 39% saw an injury-related death. The most common injury mechanisms were road crashes, assault, and burns. In these cases, 90% of trainees provided some aid, most commonly lifting (82%) or transport (76%). Fifty-two percent of trainees had previous first-aid training, 44% had some access to equipment, and 32% had ever purchased a first-aid kit. Before training, participants answered 45% of test questions correctly (mean %) and this increased to 86% after training (p < 0.0001).

CONCLUSIONS

Lay people witness many emergencies and deaths in Kampala, Uganda and provide much needed care but are ill-prepared to do so. A context-appropriate prehospital trauma care course can be developed and improve lay people's knowledge of basic trauma care. The effectiveness of such a training program needs to be evaluated prospectively.

Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy

Background

Despite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality.

Aim

To estimate the epidemiology of the injury seen in patients presenting to the government hospital in Kampala, the capital city of Uganda.

Methods

A secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005.

Results

From 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance.

Conclusions

Road traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development.

Road traffic injuries as seen in a Nigerian teaching hospital

Trauma is a major problem in both developing and developed countries. World wide road-traffic injuries (RTIs) represent 25% of all trauma deaths. Injuries cause 12% of the global disease burden and are the third commonest cause of death globally. In our own environment, trauma is also important, with RTIs being a leading cause of morbidity and mortality. There is limited data on RTIs in West African countries, and this necessitated our study. We aimed to find common causative factors and proffer solutions. This was a one year prospective study examining all cases of trauma from RTIs seen at the Accident and Emergency Department of the Ebonyi State University Teaching Hospital (EBSUTH), Abakaliki, Nigeria. Three hundred and sixty-three patients were studied. There was a male/female ratio of 3.4:1, with the modal age being 25 years. Most injuries involved motorcycles (54%). Passengers from cars and buses were also commonly affected (34.2%). Most of accidents occurred from head-on collisions (38.8%). Soft-tissue injuries and fractures accounted for 83.5% of injuries. The head and neck region was the commonest injury site (41.1%), and the most commonly fractured bones were the tibia and fibula (5.8%). Death occurred in 17 patients (4.7%), and 46 (12.7%) patients discharged themselves against medical advice. Improvements in road safety awareness, proper driver education-especially motorcycle drivers-and proper hospital care are needed in our subregion.

The global burden of unintentional injuries and an agenda for progress

According to the World Health Organization, unintentional injuries were responsible for over 3.9 million deaths and over 138 million disability-adjusted life-years in 2004, with over 90% of those occurring in low- and middle-income countries (LMIC). This paper utilizes the year 2004 World Health Organization Global Burden of Disease Study estimates to illustrate the global and regional burden of unintentional injuries and injury rates, stratified by cause, region, age, and gender. The worldwide rate of unintentional injuries is 61 per 100,000 population per year. Overall, road traffic injuries make up the largest proportion of unintentional injury deaths (33%). When standardized per 100,000 population, the death rate is nearly double in LMIC versus high-income countries (65 vs. 35 per 100,000), and the rate of disability-adjusted life-years is more than triple in LMIC (2,398 vs. 774 per 100,000). This paper calls for more action around 5 core areas that need research investments and capacity development, particularly in LMIC: 1) improving injury data collection, 2) defining the epidemiology of unintentional injuries, 3) estimating the costs of injuries, 4) understanding public perceptions about injury causation, and 5) engaging with policy makers to improve injury prevention and control.

Patterns of injury and childhood psychiatric disorder in a low-income population

This study examined cross-sectional patterns of association between childhood psychiatric disorders and non-fatal injuries. The study population consisted of 763,251 youth between the ages of five and 18 years. Having any psychiatric diagnosis increased the odds of injury by a factor of two (OR = 2.12, CI 2.08-2.16). Strong associations were found between poisoning and unipolar depression (OR = 5.45, 95% CI 5.02-5.93), bipolar mood disorders (OR = 7.00, 95% CI 6.15-7.95) and major depression (OR = 9.63; 95% CI 8.51-10.89). Medicaid data provide an important resource to examine the intersection of psychiatric diagnosis and injury on a population basis.

Injury surveillance in low-resource settings using Geospatial and Social Web technologies

Background

Extensive public health gains have benefited high-income countries in recent decades, however, citizens of low and middle-income countries (LMIC) have largely not enjoyed the same advancements. This is in part due to the fact that public health data - the foundation for public health advances - are rarely collected in many LMIC. Injury data are particularly scarce in many low-resource settings, despite the huge associated burden of morbidity and mortality. Advances in freely-accessible and easy-to-use information and communication (ICT) technology may provide the impetus for increased public health data collection in settings with limited financial and personnel resources.

Methods and Results

A pilot study was conducted at a hospital in Cape Town, South Africa to assess the utility and feasibility of using free (non-licensed), and easy-to-use Social Web and GeoWeb tools for injury surveillance in low-resource settings. Data entry, geocoding, data exploration, and data visualization were successfully conducted using these technologies, including Google Spreadsheet, Mapalist, BatchGeocode, and Google Earth.

Conclusion

This study examined the potential for Social Web and GeoWeb technologies to contribute to public health data collection and analysis in low-resource settings through an injury surveillance pilot study conducted in Cape Town, South Africa. The success of this study illustrates the great potential for these technologies to be leveraged for public health surveillance in resource-constrained environments, given their ease-of-use and low-cost, and the sharing and collaboration capabilities they afford. The possibilities and potential limitations of these technologies are discussed in relation to the study, and to the field of public health in general.

Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review

BACKGROUND

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.

METHODS

The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.

RESULTS

Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.

CONCLUSIONS

Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Cost-effectiveness of replacing skeletal traction by interlocked intramedullary nailing for femoral shaft fractures in a provincial trauma hospital in Cambodia

In this article the costs and effectiveness of introducing the SIGN nailing system for femoral shaft fractures in a provincial trauma hospital in Cambodia are compared to those of Perkin's traction treatment. At an average cost per patient of $1,107 in the traction group and $888 in the nail group (p < 0.01), and with better clinical outcomes in the nail group, internal fixation is more cost-effective than conservative treatment.

Infrastructural requirements for local implementation of safety policies: the discordance between top-down and bottom-up systems of action

BACKGROUND

Safety promotion is planned and practised not only by public health organizations, but also by other welfare state agencies, private companies and non-governmental organizations. The term 'infrastructure' originally denoted the underlying resources needed for warfare, e.g. roads, industries, and an industrial workforce. Today, 'infrastructure' refers to the physical elements, organizations and people needed to run projects in different societal arenas. The aim of this study was to examine associations between infrastructure and local implementation of safety policies in injury prevention and safety promotion programs.

METHODS

Qualitative data on municipalities in Sweden designated as Safe Communities were collected from focus group interviews with municipal politicians and administrators, as well as from policy documents, and materials published on the Internet. Actor network theory was used to identify weaknesses in the present infrastructure and determine strategies that can be used to resolve these.

RESULTS

The weakness identification analysis revealed that the factual infrastructure available for effectuating national strategies varied between safety areas and approaches, basically reflecting differences between bureaucratic and network-based organizational models. At the local level, a contradiction between safety promotion and the existence of quasi-markets for local public service providers was found to predispose for a poor local infrastructure diminishing the interest in integrated inter-agency activities. The weakness resolution analysis showed that development of an adequate infrastructure for safety promotion would require adjustment of the legal framework regulating injury data exchange, and would also require rational financial models for multi-party investments in local infrastructures.

CONCLUSION

We found that the "silo" structure of government organization and assignment of resources was a barrier to collaborative action for safety at a community level. It may therefore be overly optimistic to take for granted that different approaches to injury control, such as injury prevention and safety promotion, can share infrastructure. Similarly, it may be unrealistic to presuppose that safety promotion can reach its potential in terms of injury rate reductions unless the critical infrastructure for this is in place. Such an alignment of the infrastructure to organizational processes requires more than financial investments.

Nongovernmental organizations in musculoskeletal care: Orthopaedics Overseas

Injuries are a major worldwide contributor to morbidity and mortality. The negative impact caused by such injuries is disproportionately heavy in developing countries. Such disparities are caused by a complex array of problems, including a lack of physical resources, poor infrastructure, and a shortage of trained health professionals. Overcoming such deficits in care will require the involvement of organizations that can offer broad-based solutions. These organizations must bridge the gap between private and public institutions to establish a systems-based approach to program development and institution-building. They must provide not just an adequate level of care, but a transfer of knowledge that leads to sustainable and cost-effective intervention. Orthopedics Overseas is an example of such an organization. We examine the development of Orthopedics Overseas and describe their interventions in Uganda as a case-study to show the unique position they have to affect change.

Patient outcome after traumatic brain injury in high-, middle- and low-income countries: analysis of data on 8927 patients in 46 countries

BACKGROUND

Traumatic brain injury (TBI) is one of the leading causes of death and disability worldwide. The burden of TBI is greatest in low- and middle-income countries (LAMIC), yet little is known about patient outcomes in these settings.

METHODS

Complete data on 8927 patients from 46 countries from the corticosteroid randomization after significant head injury (CRASH) trial were analysed to explore whether outcomes 6 months after TBI differed between high-income countries and LAMIC.

RESULTS

Just under half of patients experienced a good recovery, one-third moderate or severe disability and one-quarter died within 6 months of their injury. Univariate analyses showed that patients in LAMIC were more likely to die following severe TBI, but were less likely to be disabled following mild and moderate TBI. These results were confirmed in multivariate analyses. Compared to patients in high-income countries, patients in LAMIC have over twice the odds of dying following severe TBI (OR 2.23, 95% CI 1.51-3.30) but half the odds of disability following mild (OR 0.41, 95% CI 0.23-0.72) and moderate TBI (OR 0.53, 95% CI 0.35-0.81). There were no differences between settings in the odds of death following either mild or moderate TBI.

CONCLUSIONS

Reduced death rates following severe TBI in patients from high-income countries may be due to differences in medical care which may result in a higher proportion of patients surviving with a disability. Socio-cultural factors may explain the lower levels of disability after mild and moderate TBI in LAMIC.

Unintentional injuries in the rural population of Twiserkan, Iran: a cross-sectional study on their incidence, characteristics and preventability

BACKGROUND

Knowledge is sparse concerning injuries affecting rural populations in low and middle-income countries in general and in Iran in particular. This study documents the incidence and characteristics of severe injuries affecting rural people in the Iranian district of Twiserkan and it investigates these people's suggestions for injury prevention and control.

METHODS

An interview-based investigation was undertaken that comprised all unintentional injuries leading to hospitalization (more than 6 hours) or death that had occurred within a twelve month period and that were identified in the files of the 62 "health houses" of the Twiserkan district. For each case, semi-structured interviews were conducted at the households of the injured people (134 injuries affecting 117 households were identified).

RESULTS

The incidence rates of fatal and non-fatal injuries were respectively 4.1 and 17.2 per 10 000 person-years and, as expected, men were more affected than women (77.6% of all injury cases). Traffic injuries (in particular among motorcyclists) were as common as home-related injuries but they were far more fatal. Among common suggestions for prevention, people mentioned that the authorities could work on the design and engineering of the infrastructure in and around the village, that the rural health workers could contribute more with local information and education and that the people themselves could consider behaving in a safer manner.

CONCLUSION

Not only domestic injuries but also those in traffic are an important cause of severe and fatal injury among rural people. Health workers may play an important role in injury surveillance and in identifying context-relevant means of prevention that they or other actors may then implement.

Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years

BACKGROUND

Of all deaths from injury, 90% occur in low- and middle-income countries, and most of the injured die before reaching a hospital. We have previously shown that a rural trauma system in Northern Iraq significantly reduced mortality in victims of mines and war injuries. In this follow-up study, we evaluated the adaptation and maturation of the system to changing injury patterns, focusing on mortality, time intervals from injury to medical help, and treatment effect on the physiologic impact of injuries.

METHODS

Approximately 6,000 first responders and 88 paramedics were trained in Northern Iraq from 1996 to 2004 and treated 2,349 victims. All patients were prospectively registered with monitoring of time intervals, interventions performed, prehospital treatment effect, and mortality.

RESULTS

Injury pattern changed markedly during the study period, with penetrating injuries decreasing from 91% to 15%. Mortality in victims of mines and war injuries (n = 919) decreased from 28.7% to 9.4% (p = 0.001), as did the time interval from injury to first medical help, from 2.4 hours to 0.6 hours (p = 0.002). The prehospital treatment effect improved significantly in the later part of the study period compared with the first years (p < 0.0005). Improvement was maintained in new injury groups. Retention of paramedics in the program was 72% after 8 years.

CONCLUSIONS

This low-tech prehospital emergency system designed for dealing with penetrating trauma matured by reducing time to first medical help and by improving physiologic parameters after prehospital treatment during the 8-year study period. The program adapted to changing injury patterns without compromising results.

Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients

OBJECTIVE

To develop and validate practical prognostic models for death at 14 days and for death or severe disability six months after traumatic brain injury.

DESIGN

Multivariable logistic regression to select variables that were independently associated with two patient outcomes. Two models designed: "basic" model (demographic and clinical variables only) and "CT" model (basic model plus results of computed tomography). The models were subsequently developed for high and low-middle income countries separately.

SETTING

Medical Research Council (MRC) CRASH Trial.

SUBJECTS

10,008 patients with traumatic brain injury. Models externally validated in a cohort of 8509.

RESULTS

The basic model included four predictors: age, Glasgow coma scale, pupil reactivity, and the presence of major extracranial injury. The CT model also included the presence of petechial haemorrhages, obliteration of the third ventricle or basal cisterns, subarachnoid bleeding, midline shift, and non-evacuated haematoma. In the derivation sample the models showed excellent discrimination (C statistic above 0.80). The models showed good calibration graphically. The Hosmer-Lemeshow test also indicated good calibration, except for the CT model in low-middle income countries. External validation for unfavourable outcome at six months in high income countries showed that basic and CT models had good discrimination (C statistic 0.77 for both models) but poorer calibration.

CONCLUSION

Simple prognostic models can be used to obtain valid predictions of relevant outcomes in patients with traumatic brain injury.

Emergency medicine in a developing country: experience from Kilimanjaro Christian Medical Centre, Tanzania, East Africa

Tanzania in East Africa has a population of over 36 million and is one of the poorest countries in the world. Life expectancy has declined and infant mortality rates are increasing. Four consultant specialist hospitals and 17 regional hospitals service the mainland. Kilimanjaro Christian Medical Centre is a major specialist teaching hospital with 500 beds, serving the entire north-west of the country. There is a small 'casualty' ward with three cubicles and one resuscitation room. Malaria, HIV, respiratory infections and gastroenteritis are the chief causes of death in children. Changing lifestyle and Western influences have increased diabetes and vascular disease in adults, and large numbers of trauma deaths are increasingly encountered. Kilimanjaro Christian Medical Centre 'Casualty' admission data are presented, as well as an insight into the challenges of emergency medicine in this country.

The injury severity score or the new injury severity score for predicting mortality, intensive care unit admission and length of hospital stay: experience from a university hospital in a developing country

INTRODUCTION

Limited research has been performed to compare the predictive abilities of the injury severity score (ISS) and the new ISS (NISS) in the developing world.

PATIENTS AND METHODS

From January 2001 until January 2003 all trauma patients admitted to the American University of Beirut Medical Centre were enrolled. The statistical performance of the ISS/NISS in predicting mortality, admission to the intensive care unit (ICU) and length of hospital stay (LOS dichotomised as <10 or > or =10 days) was evaluated using receiver operating characteristic and the Hosmer-Lemeshow calibration statistic.

RESULTS

A total of 891 consecutive patients were enrolled. The ISS and NISS were equivalent in predicting survival, and both performed better in patients younger than 65 years of age. However, the ISS predicted ICU admission and LOS better than the NISS. However, these predictive abilities were lower for the geriatric trauma patients aged 65 years and above compared to the other age groups.

DISCUSSION

There are conflicting results in the literature about the abilities of ISS and NISS to predict mortality. However, this is the first study to report that ISS has a superior ability in predicting both LOS and ICU admission.

CONCLUSION

The scoring of trauma severity may need to be individualised to different countries and trauma systems.

Capacity building: A concept analysis of the term applied to research

Recent policy developments in Ireland have led to a focus on research capacity building as a means of consolidating nurse and midwifery education in the Irish academic setting. This follows similar initiatives in the United Kingdom and Australia. However, sparse literature and a lack of clarity of the term 'research capacity building' leads to some confusion. A concept analysis using Rodgers' framework was conducted. The literature examined included 'grey' literature, policy documents and indexed papers across a range of disciplines, derived from CINAHL/PubMed searches. The concept of research capacity building was deemed to imply a funded, dynamic intervention operationalized through a range of foci and levels to augment ability to achieve objectives in the research field over the long-term, with aspects of social change as an ultimate outcome. This is presented as an interim statement because of the evolutionary nature of the concept and the limitations of the exercise.

The high burden of injuries in South Africa

OBJECTIVE

To estimate the magnitude and characteristics of the injury burden in South Africa within a global context.

METHODS

The Actuarial Society of South Africa demographic and AIDS model (ASSA 2002) - calibrated to survey, census and adjusted vital registration data - was used to calculate the total number of deaths in 2000. Causes of death were determined from the National Injury Mortality Surveillance System profile. Injury death rates and years of life lost (YLL) were estimated using the Global Burden of Disease methodology. National years lived with disability (YLDs) were calculated by applying a ratio between YLLs and YLDs found in a local injury data source, the Cape Metropole Study. Mortality and disability-adjusted life years' (DALYs) rates were compared with African and global estimates.

FINDINGS

Interpersonal violence dominated the South African injury profile with age-standardized mortality rates at seven times the global rate. Injuries were the second-leading cause of loss of healthy life, accounting for 14.3% of all DALYs in South Africa in 2000. Road traffic injuries (RTIs) are the leading cause of injury in most regions of the world but South Africa has exceedingly high numbers - double the global rate.

CONCLUSION

Injuries are an important public health issue in South Africa. Social and economic determinants of violence, many a legacy of apartheid policies, must be addressed to reduce inequalities in society and build community cohesion. Multisectoral interventions to reduce traffic injuries are also needed. We highlight this heavy burden to stress the need for effective prevention programmes.

Pediatric unintentional injury: behavioral risk factors and implications for prevention

Unintentional injury is the leading cause of death for children and adolescents between the ages of 1 and 18 in the United States, accounting for more deaths than the next 20 causes of mortality combined. It is estimated that pediatric injury accounts for more than $50 billion in annual losses from medical care costs, future wages, and quality of life. Despite these numbers, much remains to be learned about the behavioral risks for pediatric unintentional injury. This article reviews behavioral risk factors for pediatric unintentional injury risk, with a particular focus on four broad areas. First, we discuss the effects of demographic risk factors, including gender, socioeconomic status, and ethnicity. Second, we present information about child-specific risk factors, including temperament, personality, psychopathology, and cognitive development. Third, we discuss the influence of parents and other primary caregivers on childhood injury risk, with a particular focus on the effects of supervision and parenting quality and style. Finally, we discuss the role of peers on child injury risk. We conclude with a discussion of the ways in which the material reviewed has been translated into injury prevention techniques, with a focus on how pediatricians might use knowledge about etiological risk to prioritize safety counseling topics. We also present thoughts on four priorities for future research: injury risk in diverse nations and cultures; developmental effects of injury; the influence of multiple risk factors together on injury risk; and translation of knowledge about risk for injury into intervention and prevention techniques.

Systems of provision and delivery of hand care, and its impact on the community

Hand injuries are important causes of impairment in the United States. They are one of the top causes for days lost from work and they impose a great economic burden on the country. In less affluent regions of the world, the impact of hand injuries on the population is even more dire, rendering the affected to life-long disability. When one considers that 85% of the world's population lives in low to middle income countries, the global deleterious effect of hand trauma becomes apparent. This paper is a review of pertinent literature available on the provision and delivery of trauma care around the world. While specific reference to hand surgery care is sparse, we will infer trauma management in these countries, synthesised from available literature, to the provision of hand surgery care. We will also examine programs around the world that are implemented at an affordable cost to the respective countries.

Regenerative medicine and the developing world

This is the first study to systematically identify and prioritize which applications of regenerative medicine are the most promising for improving health in developing countries.

Noncommunicable diseases and injuries in Latin America and the Caribbean: time for action

The region is in a privileged position to quickly translate investment in health research into practice, argue Perel and colleagues.

The burden of injury in Brazil, 2003

CONTEXT AND OBJECTIVE

Since 1980, injuries have been the second biggest cause of death among the Brazilian population. This study aimed to analyze national data on fatal injuries and nonfatal injury hospitalization in Brazil, for 2003.

DESIGN AND SETTING

This was a population-based descriptive study, Brazil, 2003.

METHODS

Data from 126,520 fatal injuries and 733,712 nonfatal injuries seen at public hospitals were analyzed. The data were stratified by sex, age, intent and injury mechanism. Raw and age- and sex-specific rates were calculated per 100,000 individuals.

RESULTS

The raw injury mortality rate was 71.5/100,000 (122.6/100,000 for male and 22.0/100,000 for female). For fatal injuries, the proportions of unintentional and intentional injuries were equal (44.3% and 46.9%, respectively). Homicides were the leading cause, 40.3% overall (28.8/100,000), followed by transport-related deaths, 26.2% overall (17.0/100,000). For nonfatal injuries, the rate was 414.8/100,000 and unintentional injuries were predominant (88.9%). Overall, the leading cause was unintentional falls, accounting for 42.6% of victims treated in public hospitals (176.8/100,000). Transport-related injuries were second: 15.0% overall; 62.0/100,000. Fractures comprised 46.7% of principal diagnoses at hospitals. The injury types in the fatal and nonfatal datasets varied according to sex and age. The highest rates were found among young males and elderly people.

CONCLUSIONS

Injury prevention activities need to be developed. To prevent deaths, homicide has to be addressed. Among hospitalized cases, falls are the most important problem. Traffic-related injuries play an important role in morbidity and mortality.

The regional differences in prevalence, medical expenditures and risk factors for injury in Taiwanese teenagers

Background

Injury is the leading cause of death in teenagers worldwide. In Taiwan, people in mountainous areas have a 4 to 8 years shorter life span than the general population. Injury among teenagers is likely a major cause. The objective of this study was to investigate the regional differences in the prevalence, the risk factors, and the medical expenditures for injury among Taiwanese teenagers.

Method

An equal probability national sample was used. In addition, representative samples from mountainous areas and offshore islands were used. Only those who aged between 12 and 21 years, and signed the consent form permitting us to link their National Health Insurance (NHI) claim data were included in the analysis. Injury-related visits and expenditures in outpatient services were extracted from the NHI data. Logistic regression was used to examine the factors associated with injury. For those who had injury related outpatient visits, mixed model was used to examine the factors associated with medical expenditures accounting for multiple visits by the same individual.

Results

The prevalence of nonfatal injury was around 30% of teenagers in Taiwan. It was 10% higher in mountainous areas. Factors associated with injury were those who lived in mountainous areas (adjusted odds ratio [OR]: 1.7; 95%; confidence interval [CI]: 1.3–2.3), males (OR: 1.3; 95%; CI: 1.1–1.6), older teens (18–21 years old), and those with risk behavior were positively associated with injury. These factors were also associated with the number of injury-related outpatient visits. However, teenagers in mountainous areas did not spend more on medical care than those who lived in metropolitan Taiwan.

Conclusion

Around 30% of the teenagers were injured in a year, not including the dead. Each of the injured spent at least 851.4NTD (~27USD) for outpatient visits. The scope of the problem was not trivial. Hazardous environments and high-risk behaviors were the universal causes. In remote areas, lack of medical resources was another possibility. Empowering local people to design prevention programs according to their needs is recommended.

Research agendas in global emergency medicine

As the global culture moves forward into the 21st century with increasing interaction of populations through direct contact and electronic interchange, those citizens of our planet who have not benefited from the material gains that have been realized in the "mature economy" countries will increasingly seek equity on all levels, beginning with the most fundamental aspect of health care. There is a need to develop a capacity for treatment of urgent and emergent health conditions globally, a need that will only increase with advancing global economic development.