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

Understanding the factors that influence CT utilization for mild traumatic brain injury in a low resource setting - a qualitative study using the Theoretical Domains Framework

Introduction

In low resource settings (LRS), utilization of Computed Tomography scan (CTS) for mild traumatic brain injuries (mTBIs) presents unique challenges and considerations given the limited infrastructure, financial resources, and trained personnel. The Theoretical Domains Framework (TDF) offers a comprehensive theoretical lens to explore factors influencing the decision-making to order CTS for mTBI by imaging referrers (IRs).

Objectives

The primary objective was to explore IRs' beliefs about factors influencing CT utilization in mTBIs using TDF in Uganda.Differences in the factors influencing CTS ordering behavior across specialties, levels of experience, and hospital category were also explored.

Materials and Methods

In-depth semi-structured interviews guided by TDF were conducted among purposively selected IRs from 6 tertiary public and private hospitals with functional CTS services. A thematic analysis was performed with codes and emerging themes developed based on the TDF.

Results

Eleven IRs including medical officers, non-neurosurgeon specialists and neurosurgeons aged on average 42 years (SD+/-12.3 years) participated.Identified factors within skills domain involved IRs' clinical assessment and decision-making abilities, while beliefs about capabilities and consequences encompassed their confidence in diagnostic abilities and perceptions of CTS risks and benefits. The environmental context and resources domain addressed the availability of CT scanners and financial constraints. The knowledge domain elicited IRs' understanding of clinical guidelines and evidence-based practices while social influences considered peer influence and institutional culture. For memory, attention & decision processes domain, IRs adherence to guidelines and intentions to order CT scans were cited.

Conclusion

Using TDF, IRs identified several factors believed to influence decision making to order CTS in mTBI in a LRS. The findings can inform stakeholders to develop targeted strategies and evidence-based interventions to optimize CT utilization in mTBI such as; educational programs, workflow modifications, decision support tools, and infrastructure improvements, among others.

Predictive models for occurrence of expansive intracranial hematomas and surgical evacuation outcomes in traumatic brain injury patients in Uganda: A prospective cohort study

BACKGROUND

Hematoma expansion is a common manifestation of acute intracranial hemorrhage (ICH) which is associated with poor outcomes and functional status. Objective We determined the prevalence of expansive intracranial hematomas (EIH) and assessed the predictive model for EIH occurrence and surgical evacuation outcomes in patients with traumatic brain injury (TBI) in Uganda. Methods We recruited adult patients with TBI with intracranial hematomas in a prospective cohort study. Data analysis using logistic regression to identify relevant risk factors, assess the interactions between variables, and developing a predictive model for EIH occurrence and surgical evacuation outcomes in TBI patients was performed. The predictive accuracies of these algorithms were compared using the area under the receiver operating characteristic curve (AUC). A p-values of < 0.05 at a 95% Confidence interval (CI) was considered significant. Results A total of 324 study participants with intracranial hemorrhage were followed up for 6 months after surgery. About 59.3% (192/324) had expansive intracranial hemorrhage. The study participants with expansive intracranial hemorrhage had poor quality of life at both 3 and 6-months with p < 0.010 respectively. Among the 5 machine learning algorithms, the random forest performed the best in predicting EIH in both the training cohort (AUC = 0.833) and the validation cohort (AUC = 0.734). The top five features in the random forest algorithm-based model were subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma. Other models demonstrated good discrimination with AUC for intraoperative complication (0.675) and poor discrimination for mortality (0.366) after neurosurgical evacuation in TBI patients. Conclusion Expansive intracranial hemorrhage is common among patients with traumatic brain injury in Uganda. Early identification of patients with subdural hematoma, diffuse axonal injury, systolic and diastolic blood pressure, association between depressed fracture and subdural hematoma, were crucial in predicting EIH and intraoperative complications.

Three delays model applied to pediatric injury care seeking in Northern Tanzania: A mixed methods study

Pediatric injuries are a leading cause of morbidity and mortality in low-and middle-income countries. Timely presentation to care is key for favorable outcomes. The goal of this study was to identify and examine delays that children experience between injury and receiving definitive care at a zonal referral hospital in Northern Tanzania. Between November 2020 and October 2021, we enrolled 348 pediatric trauma patients, collecting quantitative data on referral and timing information. In-depth interviews (IDIs) to explain and explore delays to care were completed with a sub-set of 30 family members. Data were analyzed according to the Three Delays Model. 81.0% (n = 290) of pediatric injury patients sought care at an intermediary facility before reaching the referral hospital. Time from injury to presentation at the referral hospital was 10.2 hours [IQR 4.8, 26.5] if patients presented first to clinics, 8.0 hours [IQR 3.9, 40.0] if patients presented first to district/regional hospitals, and 1.4 hours [IQR 0.7, 3.5] if patients presented directly to the referral hospital. In-hospital mortality was 8.2% (n = 30); 86.7% (n = 26) of these children sought care at an intermediary facility prior to reaching the referral hospital. IDIs revealed themes related to each delay. For decision to seek care (Delay 1), delays included emergency recognition, applying first aid, and anticipated challenges. For reaching definitive care (Delay 2), delays included caregiver rationale for using intermediary facilities, the complex referral system, logistical challenges, and intermediary facility delays. For receiving definitive care (Delay 3), wait time and delays due to treatment cost existed at the referral hospital. Factors throughout the healthcare system contribute to delays in receipt of definitive care for pediatric injuries. To minimize delays and improve patient outcomes, interventions are needed to improve caregiver and healthcare worker education, streamline the current trauma healthcare system, and improve quality of care in the hospital setting.

Protocol for a Multicenter, Prospective, Observational Pilot Study on the Implementation of Resource-Stratified Algorithms for the Treatment of Severe Traumatic Brain Injury Across Four Treatment Phases: Prehospital, Emergency Department, Neurosurgery, and Intensive Care Unit

BACKGROUND

Severe traumatic brain injury (sTBI) is a public health issue with great disparity among low- and middle-income countries where the implementation of evidence-based guidelines is challenging because resources are often unavailable. A consensus process including experts in the prehospital, emergency department, neurosurgery, and intensive care unit took place in Colombia to develop a set of stratified protocols called BOOTStraP, targeting resource-poor environments, but it has not been systematically implemented and tested.

OBJECTIVE

To identify the facilitators of, and barriers to, collecting data about patients with sTBI and to implement a stratified protocol across the treatment phases of prehospital, emergency department, neurosurgery, and intensive care unit in low-resource settings. We also aim to identify a possible association between adherence to these protocols and outcomes for these patients.

METHODS

A prospective, observational, before and after, pilot study will be performed in three phases as follows: before implementation, implementation, and after implementation. The BOOTStraP protocols will be implemented in three Colombian centers.

EXPECTED OUTCOMES

We expect to find numerous barriers during the implementation phase. We also expect moderate adherence to the protocols. However, we expect to find an increase in the survival rate to hospital discharge and an improvement in neurological outcomes at discharge.

DISCUSSION

This pilot study will serve as a first step to identify variables that are critical to successful implementation, to be considered for the design of a future large-scale international study to measure the effectiveness of resource-based protocols and to improve outcomes from sTBI.

Delays in emergency department intervention for patients with traumatic brain injury in Uganda

Background

In Sub-Saharan African countries, the incidence of traumatic brain injury (TBI) is estimated to be many folds higher than the global average and outcome is hugely impacted by access to healthcare services and quality of care. We conducted an analysis of the TBI registry data to determine the disparities and delays in treatment for patients presenting at a tertiary care hospital in Uganda and to identify factors predictive of delayed treatment initiation.

Methods

The study was conducted at the Mulago National Referral Hospital, Kampala. The study included all patients presenting to the emergency department (ED) with suspected or documented TBI. Early treatment was defined as first intervention within 4 hours of ED presentation-a cut-off determined using sensitivity analysis to injury severity. Descriptive statistics were generated and Pearson's χ² test was used to assess the sample distribution between treatment time categories. Univariable and multivariable logistic regression models with <0.05 level of significance were used to derive the associations between patient characteristics and early intervention for TBI.

Results

Of 3944 patients, only 4.6% (n=182) received an intervention for TBI management within 1 hour of ED presentation, whereas 17.4% of patients (n=708) received some treatment within 4 hours of presentation. 19% of those with one or more serious injuries and 18% of those with moderate to severe head injury received care within 4 hours of arrival. Factors independently associated with early treatment included young age, severe head injury, and no known pre-existing conditions, whereas older or female patients had significantly less odds of receiving early treatment.

Discussion

With the increasing number of patients with TBI, ensuring early and appropriate management must be a priority for Ugandan hospitals. Delay in initiation of treatment may impact survival and functional outcome. Gender-related and age-related disparities in care should receive attention and targeted interventions.

Level of evidence

Prognostic and epidemiological study; level II evidence.

Prenatal consultation and survival of children under five in Togo

INTRODUCTION

Child survival is low in Togo, often linked to socio-economic and other exogenous factors such as lack of antenatal consultation and Bacille Calmette-Guérin (BCG) vaccination. These different variables impacting the chances of survival of children underneath five have not been completely examined. The objective of this study is to analyse the socio-economic variables that influence the survival risk of children beneath five in Togo.

METHODS

These different variables influencing the chances of survival of the data used is from the 2017 MICS6 Overview. It speaks to an arrangement of broadly agent tests of families, children matured 0-5 years, women matured 15-49 years and men matured 15-59 years. Information on pre-birth meetings and the inoculation status of children at (BCG) were collected from this overview. The Cox corresponding risks backslide illustrate is used to evaluate the connection between pre-birth visits and child survival.

RESULTS

The risk of survival in children beneath 5 years is high as the age of the mother increases. This risk is 0.48 for the age between 19 and 24 years (AHR = 2.485, 95% CI 1.49-4.13). A child born to a woman with no education is at high risk of child survival (AHR = 2.96, 95% CI 092-9.36). Furthermore, the results show that women with twins have a high risk of 0.44 of the death of these children (AHR = 1.44, 95% CI 1.25-1.67). In addition, (BCG) vaccination has been related with an expanded recurrence in children, where it was found that 70.37% of vaccinated children were born to women who had experienced pre-birth meetings.

CONCLUSION

Basic risk variables for child survival can offer assistance in defining policy suggestions for children's wellbeing. The results recommend they have to empower policies to improve women's proficiency, the presence of a wellbeing insurance framework is suggested to decrease the burden of care, implement a procedure for access to antenatal meetings.

Long-term follow-up of neurosurgical outcomes for adult patients in Uganda with traumatic brain injury

OBJECTIVE

Traumatic brain injury (TBI) is a major cause of mortality and morbidity in Uganda and other low- and middle-income countries (LMICs). Due to the difficulty of long-term in-person follow-up, there is a paucity of literature on longitudinal outcomes of TBI in LMICs. Using a scalable phone-centered survey, this study attempted to investigate factors associated with both mortality and quality of life in Ugandan patients with TBI.

METHODS

A prospective registry of adult patients with TBI admitted to the neurosurgical ward at Mulago National Referral Hospital was assembled. Long-term follow-up was conducted between 10.4 and 30.5 months after discharge (median 18.6 months). Statistical analyses included univariable and multivariable logistic regression and Cox proportional hazards regression to elucidate factors associated with mortality and long-term recovery.

RESULTS

A total of 1274 adult patients with TBI were included, of whom 302 (23.7%) died as inpatients. Patients who died as inpatients received surgery less frequently (p < 0.001), had more severe TBI at presentation (p < 0.001), were older (p < 0.001), and were more likely to be female (p < 0.0001). Patients presenting with TBI resulting from assault were at reduced risk of inpatient death compared with those presenting with TBI caused by road traffic accidents (OR 0.362, 95% CI 0.128-0.933). Inpatient mortality and postdischarge mortality prior to follow-up were 23.7% and 9%, respectively. Of those discharged, 60.8% were reached through phone interviews. Higher Glasgow Coma Scale score at discharge (continuous HR 0.71, 95% CI 0.53-0.94) was associated with improved long-term survival. Tracheostomy (HR 4.38, 95% CI 1.05-16.7) and older age (continuous HR 1.03, 95% CI 1.009-1.05) were associated with poor long-term outcomes. More than 15% of patients continued to suffer from TBI sequelae years after the initial injury, including seizures (6.1%) and depression (10.0%). Despite more than 60% of patients seeking follow-up healthcare visits, mortality was still 9% among discharged patients, suggesting a need for improved longitudinal care to monitor recovery progress.

CONCLUSIONS

Inpatient and postdischarge mortality remain high following admission to Uganda's main tertiary hospital with the diagnosis of TBI. Furthermore, posttraumatic sequelae, including seizures and depression, continue to burden patients years after discharge. Effective scalable solutions, including phone interviews, are needed to elucidate and address factors limiting in-hospital capacity and access to follow-up healthcare.

Caregiver worry and injury hazards in the daily lives of Ugandan children

Background:

Over 95% of unintentional injury-related childhood deaths globally occur in low- and middle-income countries, such as Uganda. Risks for injury in settings like rural Uganda are vastly understudied despite differing patterns of child injury risk. The present study investigated the prevalence and type of hazards in children’s environments in rural Uganda, as well as the relationship between hazard exposure and parent attitudes and perceptions regarding unintentional injury.

Methods:

Our sample included 152 primary caregivers in Eastern Rural Uganda who had children in either 1st or 6th grade. All parents/guardians completed caregiver surveys following verbal instructions. Surveys assessed demographic information, child hazard exposure, and parent beliefs regarding child injury.

Results:

Almost all parents (98.5%) reported daily exposure for their children to at least one of the hazards assessed. Caregiver's perceived likelihood of child injury was positively related to hazard exposure (r = .21, p less than .05). This relationship remained significant when controlling for family demographics, child grade level, and child injury history (F (7, 126) = 2.25, p less than .05).

Conclusions:

Our results suggest that Ugandan parents are aware of the risks of children’s exposure to hazards, but may lack the tools to address it. Development of injury prevention interventions focusing on behavioral change techniques may help reduce childhood injury and injury-related deaths in Uganda.

Development and temporal external validation of a simple risk score tool for prediction of outcomes after severe head injury based on admission characteristics from level-1 trauma centre of India using retrospectively collected data

OBJECTIVE

To develop and validate a simple risk scores chart to estimate the probability of poor outcomes in patients with severe head injury (HI).

DESIGN

Retrospective.

SETTING

Level-1, government-funded trauma centre, India.

PARTICIPANTS

Patients with severe HI admitted to the neurosurgery intensive care unit during 19 May 2010-31 December 2011 (n=946) for the model development and further, data from same centre with same inclusion criteria from 1 January 2012 to 31 July 2012 (n=284) for the external validation of the model.

OUTCOMES

In-hospital mortality and unfavourable outcome at 6 months.

RESULTS

A total of 39.5% and 70.7% had in-hospital mortality and unfavourable outcome, respectively, in the development data set. The multivariable logistic regression analysis of routinely collected admission characteristics revealed that for in-hospital mortality, age (51-60, >60 years), motor score (1, 2, 4), pupillary reactivity (none), presence of hypotension, basal cistern effaced, traumatic subarachnoid haemorrhage/intraventricular haematoma and for unfavourable outcome, age (41-50, 51-60, >60 years), motor score (1-4), pupillary reactivity (none, one), unequal limb movement, presence of hypotension were the independent predictors as its 95% confidence interval (CI) of odds ratio (OR)_did not contain one. The discriminative ability (area under the receiver operating characteristic curve (95% CI)) of the score chart for in-hospital mortality and 6 months outcome was excellent in the development data set (0.890 (0.867 to 912) and 0.894 (0.869 to 0.918), respectively), internal validation data set using bootstrap resampling method (0.889 (0.867 to 909) and 0.893 (0.867 to 0.915), respectively) and external validation data set (0.871 (0.825 to 916) and 0.887 (0.842 to 0.932), respectively). Calibration showed good agreement between observed outcome rates and predicted risks in development and external validation data set (p>0.05).

CONCLUSION

For clinical decision making, we can use of these score charts in predicting outcomes in new patients with severe HI in India and similar settings.

Trends in mortality from external causes in the Republic of Seychelles between 1989 and 2018

Data on injury-related mortality are scarce in the African region. Mortality from external causes in the Seychelles was assessed, where all deaths are medically certified and the population is regularly enumerated. The four fields for underlying causes of death recorded were reviewed in the national vital statistics register. The age-standardised mortality rates were estimated (per 100,000 person-years) from external causes in 1989–1998, 1999–2008, and 2009–2018. Mortality rates per 100,000 person-years from external causes were 4–5 times higher among males than females, and decreased among males over the three 10-year periods (127.5, 101.4, 97.1) but not among females (26.9, 23.1, 26.9). The contribution of external causes to total mortality did not change markedly over time (males 11.6%, females 4.3% in 1989–2018). Apart from external deaths from undetermined causes (males 14.6, females 2.4) and “other unintentional injuries” (males 14.1, females 8.0), the leading external causes of death in 2009–2018 were drowning (25.9), road traffic injuries (18.0) and suicide (10.4) among males; and road traffic injuries (4.6), drowning (3.4) and poisoning (2.6) among females. Mortality from broad categories of external causes did not change consistently over time but rates of road traffic injuries increased among males. External causes contributed approximately 1 in 10 deaths among males and 1 in 20 among females, with no marked change in cause-specific rates over time, except for road traffic injuries. These findings emphasise the need for programs and policies in various sectors to address this large, but mostly avoidable health burden.

A Comparison of the Predictive Value of the Glasgow Coma Scale and the Kampala Trauma Score for Mortality and Length of Hospital Stay in Head Injury Patients at a Tertiary Hospital in Uganda: A Diagnostic Prospective Study

Introduction

The prevalence rates of head injury have been shown to be as high as 25% among trauma patients with severe head injury contributing to about 31% of all trauma deaths. Triage utilizes numerical cutoff points along the scores continuum to predict the greatest number of people who would have a poor outcome, “severe” patients, when scoring below the threshold and a good outcome “non severe” patients, when scoring above the cutoff or numerical threshold. This study aimed to compare the predictive value of the Glasgow Coma Scale and the Kampala Trauma Score for mortality and length of hospital stay at a tertiary hospital in Uganda.

Methods

A diagnostic prospective study was conducted from January 12, 2018 to March 16, 2018. We recruited patients with head injury admitted to the accidents and emergency department who met the inclusion criteria for the study. Data on patient's demographic characteristics, mechanisms of injury, category of road use, and classification of injury according to the GCS and KTS at initial contact and at 24 hours were collected. The receiver operating characteristics (ROC) analysis and logistic regression analysis were used for comparison.

Results

The GCS predicted mortality and length of hospital stay with the GCS at admission with AUC of 0.9048 and 0.7972, respectively (KTS at admission time, AUC 0.8178 and 0.7243). The GCS predicted mortality and length of hospital stay with the GCS at 24 hours with AUC of 0.9567 and 0.8203, respectively (KTS at 24 hours, AUC 0.8531 and 0.7276). At admission, the GCS at a cutoff of 11 had a sensitivity of 83.23% and specificity of 82.61% while the KTS had 88.02% and 73.91%, respectively, at a cutoff of 13 for predicting mortality. At admission, the GCS at a cutoff of 13 had sensitivity of 70.48% and specificity of 66.67% while the KTS had 68.07% and 62.50%, respectively, at a cutoff of 14 for predicting length of hospital stay.

Conclusion

Comparatively, the GCS performed better than the KTS in predicting mortality and length of hospital stay. The GCS was also more accurate at labelling the head injury patients who died as severely injured as opposed to the KTS that categorized most of them as moderately injured. In general, the two scores were sensitive at detection of mortality and length of hospital stay among the study population.

Presentation of Pediatric Unintentional Injuries at Rural Hospitals in Rwanda: A Retrospective Study

Background:

Injuries are a leading cause of mortality among children globally, with children in low- and middle-income countries more likely to die if injured compared to children in high-income countries. Timely and high-quality care are essential to reduce injury-related morbidity and mortality.

Objectives:

This study describes patterns, management, and outcomes of children 0–15 years presenting with unintentional injuries at three district hospitals in rural Rwanda between January 1 and December 31, 2017.

Methods:

Using a retrospective cross-sectional study design, we assessed the demographic and clinical characteristics, care provided, and outcomes of the children using data extracted from patient medical charts. We describe the patient population using frequencies and proportions as well as median and interquartile ranges.

Findings:

Of the 449 injured children who sought care at the three rural district hospitals, 66.2% (n = 297) were boys. The main causes of injury were falls (n = 261, 58.1%), burns (n = 101, 22.5%), and road traffic injuries (n = 67, 14.9%). Burns were the most common injury among children aged 0–5 years while falls were the leading injury type among the 5–15 years age group. Vital signs were inconsistently completed ranging between 23.8–89.1% of vital sign items. Of the injured children, 37.0% (n = 166) received surgery at the district hospital, general practitioners performed 80.9% (n = 114) of surgeries, 87.4% (n = 145) of operated patients received no anesthesia, and 69.3% (n = 311) were admitted to the district hospital, while 2.7% (n = 12) were transferred to tertiary facilities for higher-level care.

Conclusions:

The presentation of child injuries—namely falls, burns, and road traffic accidents—is similar to what has been reported in other sub-Saharan African countries. However, more needs to be done to improve the completion and documentation of vital signs and increase availability of surgical specialists. Finally, targeted strategies to prevent burns and motorcycle-related injuries are recommended prevention interventions for this rural population.

Injury patterns of patients presenting to a non-governmental hospital in Western Uganda

Introduction

Injury is a leading cause of morbidity and mortality globally and disproportionately affects low-income countries. While most injury data comes from tertiary care centers in urban settings, the purpose of this study was to describe the characteristics and severity of injury in rural Uganda and the associated treatment patterns and delays in care.

Methods

This is a retrospective cohort study of a trauma registry that was implemented at Masindi-Kitara Medical Center (MKMC), a rural hospital in Western Uganda. Demographic information, injury characteristics, modified Kampala Trauma Scores (M-KTS), and treatment modalities over a 12 month period were retrospectively collected from paper-based registry forms completed for all injury patients presenting to MKMC.

Results

A total of 350 patients were entered into the trauma registry. Most patients were male (71.2%) with a median age of 26.5 years. Motorcycle crashes were the most prevalent mechanism of injury (42.3%) with the majority being unhelmeted (83.3%). Soft tissue injury was the most common diagnosis (44.9%). Patients were frequently treated in the outpatient department and then discharged (54.8%). Patients requiring admission or transfer (M-KTS = 11.57 or 11.67) tended to have a lower M-KTS than discharged patients (M-KTS = 12.75). Analgesics (74.6%) and antibiotics (52.9%) were the most common treatments administered. For those patients requiring admission (29.4%), only one in-hospital death was documented. Thirty-nine percent of patients reported a delay in seeking care, most frequently due to lack of transportation (31.5%) with a median time of delay of 11 h.

Conclusion

Road traffic injuries were the leading cause of injury in Masindi, with a high proportion of injuries associated with unhelmeted motorcycle crashes. Future opportunities to prevent injury and improve care may be seen through improved prehospital care, enforcement of helmet laws, increased access to neurosurgical services, and enactment of hospital quality improvement measures.

Geospatial Analysis of Trauma Burden and Surgical Care Capacity in Teso Sub-region of Eastern Uganda

INTRODUCTION

Over 90% of injury-related deaths occur in low- and middle-income countries. Relating spatial distribution of injury burden and trauma care capacity is crucial for effective resource allocation. Our study assesses trauma burden and emergency and essential surgical care (EESC) quality in Teso Sub-region Eastern Uganda through a spatial analysis of trauma burden in relation to surgical capacity at the district level.

METHODS

In this study, we surveyed trauma patients presenting at Soroti Regional Referral Hospital (SRRH) and assessed EESC capacity of district hospitals. We used geospatial techniques to relate trauma burden and capacity and characterized delay using the three-delay framework.

RESULTS

We surveyed 131 trauma patients presenting to SRRH for trauma-related injuries from June 1 to July 15, 2017. Almost all trauma incidents (n = 129, 98.4%) occurred within a 2-h ideal drive time to SRRH. From time of injury to receiving care, median time totaled to approximately 9.25 h. District hospital exhibited decreased EESC capacity (personnel, infrastructure, procedures, equipment, and supplies (PIPES) score range 2.2-5.5, mean 4.2) compared to SRRH (PIPES score 8.1).

CONCLUSION

Trauma patients face delays in each step of the care-seeking process from deciding to seek care, arriving at care site, and receiving treatment. Synergistic effects of a poor prehospital care, EESC deficiencies on district and regional levels, cost of seeking care contribute to delays that likely result in increased morbidity and mortality. Improved resource allocation, training at the district level, and strengthening system-level organization of emergency medical services could avert preventable death and disability.

Mortality and Complication Rates in Adult Trauma Patients Receiving Tranexamic Acid: A Single-center Experience in the Post-CRASH-2 Era

OBJECTIVES

The CRASH-2 trial demonstrated that tranexamic acid (TXA) in adults with significant traumatic hemorrhage safely reduces mortality. Given that the CRASH-2 trial did not include U.S. sites, our objective was to evaluate patient characteristics, TXA dosing strategies, and the incidence of mortality and adverse events in adult trauma patients receiving TXA at a U.S. Level I trauma center in the post-CRASH-2 era.

METHODS

We conducted a retrospective study that included patients aged 18 years or older who received TXA after an acute injury from July 2014 to June 2017. We excluded patients who received TXA orally, patients who received TXA for elective surgical procedures or nontrauma indications, patients who received it 8 hours or longer after the time of injury, and patients with cardiac arrest at time of emergency department arrival. Trained abstractors collected data from the trauma registry and hospital electronic medical records. Our primary outcome measures were in-hospital death and acute thromboembolic events within 28 days from injury.

RESULTS

We included 273 patients with a mean (±SD) age of 43.8 (±18.7)  years. The mean (±SD) time of administration of TXA from time of injury was 1.55 (±1.2)  hours with 229 patients (83.9%) receiving TXA within 3 hours. The overall mortality within 28 days from injury was 12.8% (95% confidence interval [CI] = 8.9% to 16.7%), which was similar compared to that in the CRASH-2 trial (14.5%, 95% CI = 13.9% to 15.2%). The incidence of acute thromboembolic events was 6.6% (95% CI = 3.7% to 9.5%), which was higher than that in the CRASH-2 trial (2.0%, 95% CI = 1.73% to 2.27%). Patients in our cohort also received surgery (64.8% vs. 47.9%) and blood transfusions (74.0% vs. 50.4%) more frequently than those in the CRASH-2 cohort.

CONCLUSIONS

Adult trauma patients receiving TXA had similar incidences of death but higher incidences of thromboembolic events compared to the CRASH-2 trial. Variation in patient characteristics, injury severity, TXA dosing, and surgery and transfusion rates could explain these observed differences. Further research is necessary to provide additional insight into the incidence and risk factors of thromboembolic events in TXA use.

Determinants of emergency department disposition of patients with traumatic brain injury in Uganda: results from a registry

Background

Traumatic brain injuries (TBIs) are a common cause of emergency department (ED) visits and hospital admissions in Kampala, Uganda. The objective of this study was to assess determinants of ED discharge disposition based on patient demographic and injury characteristics. Four ED outcomes were considered: discharge home, hospital admission, death, and others.

Methods

This prospective study was conducted at Mulago National Referral Hospital, Kampala, Uganda, from May 2016 to July 2017. Patients of all age groups presenting with TBI were included. Patient demographics, external causes of injury, TBI characteristics, and disposition from EDs were noted. Injury severity was estimated using the Glasgow Coma Scale (GCS), Kampala Trauma Score (KTS), and the Revised Trauma Score (RTS). A multinomial logistic regression model was used to estimate conditional ORs of hospital admission, death, and other dispositions compared with the reference category “discharged home”.

Results

A total of 3944 patients were included in the study with a male versus female ratio of 5.5:1 and a mean age of 28.5 years (SD=14.2). Patients had closed head injuries in 62.9% of cases. The leading causes of TBIs were road traffic crashes (58.8%) and intentional injuries (28.7%). There was no significant difference between the four discharge categories with respect to age, sex, mode of arrival, cause of TBI, place of injury, type of head injury, transport time, and RTS (p>0.05). There were statistically significant differences between the four discharge categories for a number of serious injuries, GCS on arrival, change in GCS, and KTS. In a multinomial logistic regression model, change in GCS, area of residence, number of serious injuries, and KTS were significant predictors of ED disposition.

Discussion

This study provides evidence that ED disposition of patients with TBI is differentially affected by injury characteristics and is largely dependent on injury severity and change in GCS during ED stay.

Level of evidence

Level II.

Temporal Delays Along the Neurosurgical Care Continuum for Traumatic Brain Injury Patients at a Tertiary Care Hospital in Kampala, Uganda

BACKGROUND

Significant care continuum delays between acute traumatic brain injury (TBI) and definitive surgery are associated with poor outcomes. Use of the "3 delays" model to evaluate TBI outcomes in low- and middle-income countries has not been performed.

OBJECTIVE

To describe the care continuum, using the 3 delays framework, and its association with TBI patient outcomes in Kampala, Uganda.

METHODS

Prospective data were collected for 563 TBI patients presenting to a tertiary hospital in Kampala from 1 June to 30 November 2016. Four time intervals were constructed along 5 time points: injury, hospital arrival, neurosurgical evaluation, computed tomography (CT) results, and definitive surgery. Time interval differences among mild, moderate, and severe TBI and their association with mortality were analyzed.

RESULTS

Significant care continuum differences were observed for interval 3 (neurosurgical evaluation to CT result) and 4 (CT result to surgery) between severe TBI patients (7 h for interval 3 and 24 h for interval 4) and mild TBI patients (19 h for interval 3 and 96 h for interval 4). These postarrival delays were associated with mortality for mild (P = .05) and moderate TBI (P = .03) patients. Significant hospital arrival delays for moderate TBI patients were associated with mortality (P = .04).

CONCLUSION

Delays for mild and moderate TBI patients were associated with mortality, suggesting that quality improvement interventions could target current triage practices. Future research should aim to understand the contributors to delays along the care continuum, opportunities for more effective resource allocation, and the need to improve prehospital logistical referral systems.

A qualitative study exploring nurses' attitudes, confidence, and perceived barriers to implementing a traumatic brain injury nursing chart in Uganda

Introduction

In Africa, traumatic brain injuries frequently result from road traffic injuries and assaults. Despite limited resources and the high costs of life-saving neurosurgical interventions, secondary brain injury prevention has the potential for improving outcomes. However, nurses and other medical personnel infrequently monitor vital signs, blood sugar, and pulse oximetry and only sporadically re-assess neurological status.

Methods

In one-on-one, semi-structured interviews, 27 nurses from Mulago Hospital’s emergency centre, a tertiary care trauma hospital in Kampala, Uganda, provided feedback regarding a traumatic brain injury-focused education session and use of a nursing chart for detecting secondary brain injury. The interviews explored the nurses’ confidence and perceived barriers to long-term chart implementation and traumatic brain injury care, as well as their ideas for improving this intervention. Interviews were audio recorded, transcribed, and coded using ATLAS.ti: Qualitative Data Analysis and Research Software (Cleverbridge, Inc., Chicago, USA) and Microsoft Word and Excel (Microsoft Office, Redmond, USA) for thematic content analysis.

Results

Key findings identified in the interviews included the nurses’ attitudes toward the chart and their feelings of increased confidence in assessing and caring for these patients. The main barriers to continuous implementation included inadequate staffing and resources.

Conclusion

Nurses were receptive to the education session and nursing chart, and felt that it increased their confidence and improved their ability to care for traumatic brain injured patients. However, lack of supplies, overwhelming numbers of patients, and inadequate staffing interfered with consistent monitoring of patients. The nurses offered various suggestions for improving traumatic brain injury care that should be further investigated. More research is needed to assess the applicability of a standardised traumatic brain injury nursing education and chart in a broader context.

Traumatic brain injury in Uganda: exploring the use of a hospital based registry for measuring burden and outcomes

Objective

Lack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the TBI burden. This paper describes a scientific approach for hospital based systematic data collection in a low-income country. The registry is based on the evaluation framework for injury surveillance systems which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) review of the identified variables based on adopted specific, measurable, assignable, realistic, and time-related criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system.

Results

The electronic hospital-based TBI registry is designed through a collaborative approach to capture comprehensive, yet context specific, information on each TBI case, from the time of injury until death or discharge from the hospital. It includes patients’ demographics, pre-hospital and hospital assessment and care, TBI causes, injury severity, and patient outcomes. The registry in Uganda will open the opportunity to replicate the process in other similar context and contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3419-1) contains supplementary material, which is available to authorized users.

A prospective neurosurgical registry evaluating the clinical care of traumatic brain injury patients presenting to Mulago National Referral Hospital in Uganda

Background

Traumatic Brain Injury (TBI) is disproportionally concentrated in low- and middle-income countries (LMICs), with the odds of dying from TBI in Uganda more than 4 times higher than in high income countries (HICs). The objectives of this study are to describe the processes of care and determine risk factors predictive of poor outcomes for TBI patients presenting to Mulago National Referral Hospital (MNRH), Kampala, Uganda.

Methods

We used a prospective neurosurgical registry based on Research Electronic Data Capture (REDCap) to systematically collect variables spanning 8 categories. Univariate and multivariate analysis were conducted to determine significant predictors of mortality.

Results

563 TBI patients were enrolled from 1 June– 30 November 2016. 102 patients (18%) received surgery, 29 patients (5.1%) intended for surgery failed to receive it, and 251 patients (45%) received non-operative management. Overall mortality was 9.6%, which ranged from 4.7% for mild and moderate TBI to 55% for severe TBI patients with GCS 3–5. Within each TBI severity category, mortality differed by management pathway. Variables predictive of mortality were TBI severity, more than one intracranial bleed, failure to receive surgery, high dependency unit admission, ventilator support outside of surgery, and hospital arrival delayed by more than 4 hours.

Conclusions

The overall mortality rate of 9.6% in Uganda for TBI is high, and likely underestimates the true TBI mortality. Furthermore, the wide-ranging mortality (3–82%), high ICU fatality, and negative impact of care delays suggest shortcomings with the current triaging practices. Lack of surgical intervention when needed was highly predictive of mortality in TBI patients. Further research into the determinants of surgical interventions, quality of step-up care, and prolonged care delays are needed to better understand the complex interplay of variables that affect patient outcome. These insights guide the development of future interventions and resource allocation to improve patient outcomes.

Disparity in access and outcomes for emergency neonatal surgery: intestinal atresia in Kampala, Uganda

BACKGROUND/AIM

Intestinal atresia is one of the leading causes of neonatal intestinal obstruction (NIO). The purpose of this study was to analyze the presentation and outcome of IA and compare with those from both similar and high-income country settings.

PATIENTS AND METHODS

A retrospective review of prospectively collected data from patient charts and pediatric surgical database for 2012-2015 was performed. Epidemiological data and patient characteristics were analyzed and outcomes were compared with those reported in other LMICs and high-income countries (HICs). Unmet need was calculated along with economic valuation or economic burden of surgical disease.

RESULTS

Of 98 patients, 42.9% were male. 35 patients had duodenal atresia (DA), 60 had jejunio-ileal atresia (JIA), and 3 had colonic atresia. The mean age at presentation was 7.14 days for DA and 6.7 days for JIA. Average weight for DA and JIA was 2.2 and 2.12 kg, respectively. All patients with DA and colonic atresia underwent surgery, and 88.3% of patients with JIA had surgery. Overall mortality was 43% with the majority of deaths attributable to aspiration, anastomotic leak, and sepsis. 3304 DALYs were calculated as met compared to 25,577 DALYs' unmet.

CONCLUSION

Patients with IA in Uganda present late in the clinical course with high morbidity and mortality attributable to a combination of late presentation, poor nutrition status, surgical complications, and likely underreporting of associated anomalies rather than surgical morbidity alone.

LEVEL OF EVIDENCE

Level IV, Case series with no comparison group.

Demographic profile and pattern of fatal injuries in Nairobi, Kenya, January-June 2014

Background

Violence and Injuries are a significant global public health concern characterized by marked regional variation in incidence. Approximately five million people die from injuries each year, accounting 9% of all deaths worldwide. In Kenya, injuries are increasingly becoming a cause of hospital admissions and mortality where they account for 10% of all the deaths. The objective of this study was to determine the magnitude, demographic profile and pattern of fatal injuries in Nairobi.

Methods

Retrospective review of death certificates from the Department of Civil Registration was done for deaths caused by injuries that occurred in Nairobi during the period, January to June 2014. Data was collected using a standardized form. Data entry, cleaning and analysis was done using Epi info version 7.0.

Results

A total of 11,443 records were reviewed. From this data, deaths resulting from injuries were 1,208 accounting for 10.6% of all recorded deaths. Majority of the deaths resulting from injuries occurred in persons aged 25 to 44 years (48.1%). Males accounted for 85% of all the injuries. The leading cause of injury was assault by blunt force at 30.5%, followed by road traffic injuries at 25.9% and fire arm injuries at 15%. Pre-hospital deaths accounted for 51.4% of all the deaths. Nineteen percent of the deaths resulting from injuries had autopsies performed on them.

Conclusion

Our study found that injuries are an important cause of fatality in Nairobi, accounting for one in ten deaths. There is need for multisectoral collaboration as some of the preventive measures that target the most prevalent injuries such as assault and road traffic injuries lie outside the health sector. There exists information gaps on the death certificates hence there is need to adequately capacity build both clinicians and death certifiers. There is also a need to revise the death certificates and to improve the pre-hospital care system for the injured persons.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3958-0) contains supplementary material, which is available to authorized users.

Epidemiology of injuries and outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in Kigali, Rwanda

Introduction

Injury accounts for 9.6% of the global mortality burden, disproportionately affecting those living in low- and middle-income countries. In an effort to improve trauma care in Rwanda, the Ministry of Health developed a prehospital service, Service d’Aide Médicale Urgente (SAMU), and established an emergency medicine training program. However, little is known about patients receiving prehospital and emergency trauma care or their outcomes. The objective was to develop a linked prehospital–hospital database to evaluate patient characteristics, mechanisms of injury, prehospital and hospital resource use, and outcomes among injured patients receiving acute care in Kigali, Rwanda.

Methods

A retrospective cohort study was conducted at University Teaching Hospital – Kigali, the primary trauma centre in Rwanda. Data was included on all injured patients transported by SAMU from December 2012 to February 2015. SAMU’s prehospital database was linked to hospital records and data were collected using standardised protocols by trained abstractors. Demographic information, injury characteristics, acute care, hospital course and outcomes were included.

Results

1668 patients were transported for traumatic injury during the study period. The majority (77.7%) of patients were male. The median age was 30 years. Motor vehicle collisions accounted for 75.0% of encounters of which 61.4% involved motorcycles. 48.8% of patients sustained injuries in two or more anatomical regions. 40.1% of patients were admitted to the hospital and 78.1% required surgery. The overall mortality rate was 5.5% with nearly half of hospital deaths occurring in the emergency centre.

Conclusion

A linked prehospital and hospital database provided critical epidemiological information describing trauma patients in a low-resource setting. Blunt trauma from motor vehicle collisions involving young males constituted the majority of traumatic injury. Among this cohort, hospital resource utilisation was high as was mortality. This data can help guide the implementation of interventions to improve trauma care in the Rwandan setting.

Rwanda's Model Prehospital Emergency Care Service: A Two-year Review of Patient Demographics and Injury Patterns in Kigali

Introduction Injury is responsible for nearly five million annual deaths worldwide, and nearly 90% of these deaths occur in low- and middle-income countries (LMICs). Reliable clinical data detailing the epidemiology of injury are necessary for improved care delivery, but they are lacking in these regions.

METHODS

A retrospective review of the Service d'Aide Medicale Urgente (SAMU; Kigali, Rwanda) prehospital database for patients with traumatic injury-related conditions from December 2012 through November 2014 was conducted. Chi-squared analysis, binomial probability test, and student's t-test were used, where appropriate, to describe patient demographics, injury patterns, and temporal and geographic trends of injuries.

RESULTS

In the two-year period, 3,357 patients were managed by SAMU for traumatic injuries. Males were 76.5% of the study population, and the median age of all injured patients was 29 years (IQR=23-35). The most common causes of injury were road traffic crashes (RTCs; 73.4%), stabbings/cuts (11.1%), and falls (9.4%), and the most common anatomic regions injured were the head (55.7%), lower (45.0%) extremities, and upper (27.0%) extremities. Almost one-fourth of injured patients suffered a fracture (24.9%). The most common mechanism of injury for adults was motorcycle-related RTCs (61.4%), whereas children were more commonly injured as pedestrians (59.8%). Centrally located sectors within Kigali represented common areas for RTCs.

CONCLUSIONS

These data support the call for focused injury prevention strategies, some of which already are underway in Rwanda. Further research on care processes and clinical outcomes for injured patients may help identify avenues for improved care delivery. Enumah S , Scott JW , Maine R , Uwitonze E , Nyinawankusi JD , Riviello R , Byiringiro JC , Kabagema I , Jayaraman S . Rwanda's model prehospital emergency care service: a two-year review of patient demographics and injury patterns in Kigali. Prehosp Disaster Med. 2016;31(6):614-620.

Vital Statistics: Estimating Injury Mortality in Kigali, Rwanda

BACKGROUND

Globally, injury deaths largely occur in low- and middle-income countries. No estimates of injury associated mortality exist in Rwanda. This study aimed to describe the patterns of injury-related deaths in Kigali, Rwanda using existing data sources.

METHODS

We created a database of all deaths reported by the main institutions providing emergency care in Kigali—four major hospitals, two divisions of the Rwanda National Police, and the National Emergency Medical Service--during 12 months (Jan–Dec 2012) and analyzed it for demographics, diagnoses, mechanism and type of injury, causes of death, and all-cause and cause-specific mortality rates.

RESULTS

There were 2682 deaths, 57% in men, 67% in adults >18 year, and 16% in children <5 year. All-cause mortality rate was 236/100,000; 35% (927) were due to probable surgical causes. Injury-related deaths occurred in 22% (593/2682). The most common injury mechanism was road traffic crash (cause-specific mortality rate of 20/100,000). Nearly half of all injury deaths occurred in the prehospital setting (47%, n = 276) and 49% of injury deaths at the university hospital occurred within 24 h of arrival. Being injured increased the odds of dying in the prehospital setting by 2.7 times (p < 0.0001).

CONCLUSIONS

Injuries account for 22% of deaths in Kigali with road traffic crashes being the most common cause.Injury deaths occurred largely in the prehospital setting and within the first 24 h of hospital arrival suggesting the need for investment in emergency infrastructure. Accurate documentation of the cause of death would help policy makers make data-driven resource allocation decisions.

Patterns of surgical presentation at an African regional referral hospital: surveillance as a step towards improving access to care

PURPOSE

Surgical disease is being increasingly recognized as a significant health burden in Africa. Efforts have been made to describe surgical disease and capacity at the district hospital level. Little is known about patterns seen at regional hospitals supporting the district hospital network.

METHODS

This retrospective study was conducted at Uganda's Soroti Regional Referral Hospital, serving eight districts. Data were collected from July 2010 to March 2012 using operative and inpatient records as available. Univariate and bivariate analyses were performed to explore patterns of procedures performed and in-patient diagnoses.

RESULTS

There were 8511 procedures recorded in the operative log between July 2010 and June 2011, averaging 709 per month. Caesarian sections (41 %), dilation and evacuations (28 %), and laparotomies (19 %) were most frequent. Referrals to Soroti averaged 260 per month, while transfers out averaged 5 patients per month. Inpatient records documented 2949 surgically related diagnoses between July 2010 and May 2011. In patients >4 years old, 21 % of mortality was due to surgical disease, 29 % of which was trauma-related. Women comprised 80 % of violent injury. Common hospital record elements, such as demographic data, important clinical information, and operative notes were absent from these data sources.

CONCLUSIONS

The World Health Assembly recently recognized strengthening of first referral hospitals as a crucial element to achieving universal health coverage. Inconsistencies in recordkeeping despite the large volume of surgical disease suggest that sustainable surveillance systems and capacity building at the referral hospital level are potential building blocks to improving access to surgical care.

Multimodality monitoring consensus statement: monitoring in emerging economies

The burden of disease and so the need for care is often greater at hospitals in emerging economies. This is compounded by frequent restrictions in the delivery of good quality clinical care due to resource limitations. However, there is substantial heterogeneity in this economically defined group, such that advanced brain monitoring is routinely practiced at certain centers that have an interest in neurocritical care. It also must be recognized that significant heterogeneity in the delivery of neurocritical care exists even within individual high-income countries (HICs), determined by costs and level of interest. Direct comparisons of data between HICs and the group of low- and middle-income countries (LAMICs) are made difficult by differences in patient demographics, selection for ICU admission, therapies administered, and outcome assessment. Evidence suggests that potential benefits of multimodality monitoring depend on an appropriate environment and clinical expertise. There is no evidence to suggest that patients in LAMICs where such resources exist should be treated any differently to patients from HICs. The potential for outcome benefits in LAMICs is arguably greater in absolute terms because of the large burden of disease; however, the relative cost/benefit ratio of such monitoring in this setting must be viewed in context of the overall priorities in delivering health care at individual institutions.

Burden of injuries avertable by a basic surgical package in low- and middle-income regions: a systematic analysis from the Global Burden of Disease 2010 Study

Background

Injuries accounted for 11 % of the global burden of disease in 2010. This study aimed to quantify the burden of injury in low- and middle-income countries (LMICs) that could be averted if basic surgical services were made available and accessible to the entire population.

Methods

We examined all causes of injury from the Global Burden of Disease 2010 Study. We split the disability-adjusted life years (DALYs) for these conditions between surgically “avertable” and “nonavertable” burdens. For estimating the avertable fatal burden, we applied the lowest fatality rates among the 21 epidemiologic regions to each LMIC region, assuming that the differences in death rates between each region and the lowest rates reflect the gap in surgical care. We adjusted for fatal cases that occur prior to reaching hospitals as they are not surgically avertable. Similarly, we applied the lowest nonfatal burden per case to each LMIC region.

Results

Overall, 21 % of the injury burden in LMICs was potentially avertable by basic surgical care (52.3 million DALYs). The avertable proportion was greater for deaths than for nonfatal burden (23 vs. 20 %), suggesting that surgical services for injuries more effectively save lives than ameliorate disability. Sub-Saharan Africa had the largest proportion of potentially avertable burden (25 %). South Asia had the highest total avertable DALYs (17.4 million). Road injury comprised the largest total avertable burden in LMICs (16.1 million DALYs).

Conclusions

Basic surgical care has the potential to play a major role in reducing the injury-related burden in LMICs.

Electronic supplementary material

The online version of this article (doi:10.1007/s00268-014-2685-x) contains supplementary material, which is available to authorized users.

Mortality related to acute illness and injury in rural Uganda: task shifting to improve outcomes

BACKGROUND

Due to the dual critical shortages of acute care and healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients.

METHODS

Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department's quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit.

FINDINGS

Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases <18 years old) was 6.5% overall and 6.8% for under-fives.

INTERPRETATION

This study describes the outcomes of emergency patients treated by midlevel providers in a resource-limited setting. Our fatality rates are lower than previously published regional rates. These findings suggest this model of task-shifting can be successfully applied to acute care in order to address the shortage of emergency care services in similar settings as part of an integrated approach to health systems strengthening.

Head injury--a neglected public health problem: a four-month prospective study at Jimma University Specialized Hospital, Ethiopia

Background

Trauma, especially head trauma, is an expanding major public health problem and the leading cause of death of the young and productive part of the world's population. Research is mainly done in high-income countries where only a small proportion of the worldwide fatalities occur. The intention of this study was to analyze head injury in a setting where most patients in low- and middle-income countries receive treatment, a referral hospital with general but no neurosurgical service like Jimma University Specialized Hospital. The study aims to provide surgeons, hospital managers and health planners working in similar set-ups with baseline information for further investigation and prevention programs intending to reduce the burden of head injury.

Methods

All head injury patients presented to Jimma University Specialized Hospital between March and June 2010 were included in this prospective research. Epidemiological, clinical and management data were collected for the study.

Results

Out of 52 patients, 47 were males. The median age was 20.0 years (SD=13.3). Fights (n=20, 38.5%) and road traffic accidents (n=19, 36.5%) were the most common causes of head injury. Half of the patients sustained mild and 36.5% sustained severe head injury. The initial GCS had a significant correlation with the outcome. The mortality rate was 21.2%. Of all patients 76.9% were managed conservatively.

Conclusion

Prevention of road traffic accidents and improvement of conservative care were identified as major methods to reduce the burden of head injury in a set-up similar to Jimma. Further studies on head injury patients in low-income countries should be done.

Acid-base disorders as predictors of early outcomes in major trauma in a resource limited setting: An observational prospective study

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.

Head injury--a neglected public health problem: a four-month prospective study at Jimma University Specialized Hospital, Ethiopia

BACKGROUND

Trauma, especially head trauma, is an expanding major public health problem and the leading cause of death of the young and productive part of the world's population. Research is mainly done in high-income countries where only a small proportion of the worldwide fatalities occur. The intention of this study was to analyze head injury in a setting where most patients in low- and middle-income countries receive treatment, a referral hospital with general but no neurosurgical service like Jimma University Specialized Hospital. The study aims to provide surgeons, hospital managers and health planners working in similar set-ups with baseline information for further investigation and prevention programs intending to reduce the burden of head injury.

METHODS

All head injury patients presented to Jimma University Specialized Hospital between March and June 2010 were included in this prospective research. Epidemiological, clinical and management data were collected for the study.

RESULTS

Out of 52 patients, 47 were males. The median age was 20.0 years (SD=13.3). Fights (n=20, 38.5%) and road traffic accidents (n=19, 36.5%) were the most common causes of head injury. Half of the patients sustained mild and 36.5% sustained severe head injury. The initial GCS had a significant correlation with the outcome. The mortality rate was 21.2%. Of all patients 76.9% were managed conservatively.

CONCLUSION

Prevention of road traffic accidents and improvement of conservative care were identified as major methods to reduce the burden of head injury in a set-up similar to Jimma. Further studies on head injury patients in low-income countries should be done.

Acute traumatic coagulopathy among major trauma patients in an urban tertiary hospital in sub Saharan Africa

BACKGROUND

Mortality from trauma remains a major public health issue as it is the leading cause of death in persons aged 5 to 44 years. Uncontrolled hemorrhage and coagulopathy is responsible for over 50% of all trauma related deaths within the first 48 hrs of admission. Coagulation profiles are not routinely done among trauma patients in resource limited settings and there is a paucity of data on acute traumatic coagulopathy (ATC) in sub Saharan Africa. The study was conducted to evaluate the prothrombin time and partial thromboplastin time (PT/PTT) as predictors of mortality and morbidity among major trauma patients.

METHODS

A prospective cohort study was carried out, in which major trauma patients admitted in A&E department between December 2011 to April 2012 were recruited. Five (5) mls of venous blood was drawn from a convenient vein within 10 minutes of the patient's arrival at A&E for analysis of PT/PTT. Patients were stratified into two groups by the presence/absence of coagulopathy then followed up for a 2 week period for morbidity and mortality.

RESULTS

A total of 182 major trauma patients were recruited; 149 (81.9%) were males, the mean age was 29.5 years (SD 9.8). Prevalence of coagulopathy was 54% (98/182). The mean ISS for the ATC group was 36.9 and the non ATC group was 26.9 (p=0.001). Patients with ATC stayed longer in hospital 11.24 days than non ATC patients 8 days (p=0.001). ATC was strongly associated with ARI (p= 0.003). Mortality was more in the ATC group 29 deaths compared to 9 deaths in the non ATC group. PTT was a strong independent predictor of mortality.

CONCLUSION

A significant proportion of major trauma patients were coagulopathic. Initial coagulation profile is useful in predicting outcomes for major trauma patients.

Global emergency medicine: a review of the literature from 2011

OBJECTIVES

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of published and unpublished articles relevant to global emergency medicine (EM) to identify, review, and disseminate the most important research in this field to a wide audience of academics and practitioners.

METHODS

This year, 7,924 articles written in seven languages were identified by our search. These articles were divided up among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the grey literature. A total of 206 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of their overall quality and importance.

RESULTS

Of the 206 articles that met our predetermined inclusion criteria, 24 articles received scores of 17 or higher and were selected for formal summary and critique. Interrater reliability for our scoring system was good with an interclass correlation coefficient of 0.628 (95% confidence interval = 0.51 to 0.72).

CONCLUSIONS

Compared to previous reviews, there was a significant increase in the number of articles that were devoted to emergency care in resource-limited settings, with fewer articles related to disaster and humanitarian response. The majority of articles that met our selection criteria were reviews that examined the efficacy of particular treatment regimens for diseases that are primarily seen in low- and middle-income countries.

National intensive care unit bed capacity and ICU patient characteristics in a low income country

Background

Primary health care delivery in the developing world faces many challenges. Priority setting favours HIV, TB and malaria interventions. Little is known about the challenges faced in this setting with regard to critical care medicine. The aim of this study was to analyse and categorise the diagnosis and outcomes of 1,774 patients admitted to a hospital intensive care unit (ICU) in a low-income country over a 7-year period. We also assessed the country’s ICU bed capacity and described the challenges faced in dealing with critically ill patients in this setting.

Findings

A retrospective audit was conducted in a general ICU in a university hospital in Uganda. Demographic data, admission diagnosis, and ICU length of stay were recorded for the 1,774 patients who presented to the ICU in the period January 2003 to December 2009. Their mean age was 35.5 years. Males accounted for 56.5% of the study population; 92.8% were indigenous, and 42.9% were referrals from upcountry units. The average mortality rate over the study period was 40.1% (n = 715). The highest mortality rate (44%) was recorded in 2004 and the lowest (33.2%) in 2005. Children accounted for 11.6% of admissions (40.1% mortality). Sepsis, ARDS, traumatic brain injuries and HIV related conditions were the most frequent admission diagnoses. A telephonic survey determined that there are 33 adult ICU beds in the whole country.

Conclusions

Mortality was 40.1%, with sepsis, head injury, acute lung injury and HIV/AIDS the most common admission diagnoses. The country has a very low ICU bed capacity. Prioritising infectious diseases poses a challenge to ensuring that critical care is an essential part of the health care package in Uganda.

Surgery in global health delivery

Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.