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Demlie TA, Alemu MT, Messelu MA, Wagnew F, Mekonen EG. Incidence and predictors of mortality among traumatic brain injury patients admitted to Amhara region Comprehensive Specialized Hospitals, northwest Ethiopia, 2022. BMC Emerg Med 2023; 23:55. [PMID: 37226098 DOI: 10.1186/s12873-023-00823-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/17/2023] [Indexed: 05/26/2023] Open
Abstract
INTRODUCTION Traumatic brain injury is a substantial cause of mortality and morbidity with a higher burden in low and middle-income countries due to healthcare systems that are unable to deliver effectively the acute and long-term care the patients require. Besides its burden, there is little information on traumatic brain injury-related mortality in Ethiopia, especially in the region. Therefore, this study aimed to assess the incidence and predictors of mortality among traumatic brain injury patients admitted to comprehensive specialized hospitals in the Amhara region, northwest Ethiopia, 2022. METHODS An institution-based retrospective follow-up study was conducted among 544 traumatic brain injury patients admitted from January 1, 2021, to December 31, 2021. A simple random sampling method was used. Data were extracted using a pre-tested and structured data abstraction sheet. Data were entered, coded, and cleaned into EPi-info version 7.2.0.1 software and exported to STATA version 14.1 for analysis. The Weibull regression model was fitted to determine the association between time to death and covariates. Variables with a P-value < 0.05 were declared statistically significant. RESULTS The overall incidence of mortality among traumatic brain injury patients was 1.23 per 100 person-day observation [95% (CI: 1.0, 1.5)] with a median survival time of 106 (95% CI: 60, 121) days. Age [AHR: 1.08 (95% CI; 1.06, 1.1)], severe traumatic brain injury [AHR: 10 (95% CI; 3.55, 28.2)], moderate traumatic brain injury [AHR: 9.2 (95% CI 2.97, 29)], hypotension [AHR: 6.9 (95% CI; 2.8, 17.1)], coagulopathy [AHR: 2.55 (95% CI: 1.27, 5.1)], hyperthermia [AHR: 2.79 (95% CI; 1.4, 5.5)], and hyperglycemia [AHR: 2.28 (95% CI; 1.13, 4.6)] were positively associated with mortality while undergoing neurosurgery were negatively associated with mortality [AHR: 0.47 (95% CI; 0.27-0 0.82)]. CONCLUSION The overall incidence of mortality was found to be high. Age, severe and moderate traumatic brain injury, hypotension at admission, coagulopathy, presence of associated aspiration pneumonia, undergoing a neurosurgical procedure, episode of hyperthermia, and hyperglycemia during hospitalization were the independent predictors of time to death. Therefore, interventions to reduce mortality should focus on the prevention of primary injury and secondary brain injury.
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Affiliation(s)
- Tiruye Azene Demlie
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Mahlet Temesgen Alemu
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mengistu Abebe Messelu
- Department of Nursing, College of Medicine and Health Sciences, Debre Markos University, Debre Markos, Ethiopia
| | - Fasil Wagnew
- College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
- National Center for Epidemiology and Population Health (NCEPH), College of Health and Medicine, The Australian National University, Canberra, Australia
| | - Enyew Getaneh Mekonen
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Tegegne NG, Fentie DY, Tegegne BA, Admassie BM. Incidence and Predictors of Mortality Among Patients with Traumatic Brain Injury at University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia: A Retrospective Follow-Up Study. Patient Relat Outcome Meas 2023; 14:73-85. [PMID: 37051137 PMCID: PMC10083132 DOI: 10.2147/prom.s399603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/29/2023] [Indexed: 04/07/2023] Open
Abstract
Background Traumatic brain injury is a major list of health and socioeconomic problems especially in low- and middle-income countries which influences productive age groups. Differences in patient characteristics, socioeconomic status, intensive care unit admission thresholds, health-care systems, and the availability of varying numbers of intensive care unit (ICU) beds among hospitals had shown to be the causes for the variation on the incidence in mortality following traumatic brain injury across different continents. The aim of this study was to assess the incidence and predictors of mortality among patients with traumatic brain injury at University of Gondar Comprehensive Specialized Hospital. Methods A retrospective follow-up study was conducted based on chart review and selected patient charts admitted from January, 2017 to January, 2022. Participants in the study were chosen using a simple random sample procedure that was computer generated. Data was entered with epi-data version 4.6 and analyzed using SPSS version 26. Both bivariate and multivariate logistic regression analyses were used, and in multivariate logistic regression analysis, P-value <0.05 with 95% CI was considered statistically significant. Results The magnitude of mortality was 28.8%. Most of the injuries were caused by assault followed by road traffic accident (RTA). About 30% of the subjects presented with severe head injuries and epidural hematoma (EDH) followed by skull fracture were the most common diagnoses on admission. The independent predictors of mortality were male sex (AOR: 6.12, CI: 1.82, 20.5), severe class injury with Glasco coma scale (GCS <9) (AOR: 5.96, CI: 2.07, 17.12), intraoperative hypoxia episode (AOR: 10.5, CI: 2.6-42.1), hyperthermia (AOR: 25, CI: 5.54, 115.16), lack of pre-hospital care (AOR: 2.64 CI: 1.6-4.2), abnormal appearance on both eyes (AOR: 13.4, CI: 5.1-34.6), in-hospital hypoxia episode and having extra-cranial concomitant injury were positively associated with mortality, while on admission, systolic blood pressure (SBP) of 100-149 (AOR: 0.086, CI: 0.016-0.46) was negatively associated with mortality. Conclusion The overall mortality rate was considerably high. As a result, traumatic brain injury management should be focused on modifiable factors that increase patient mortality, such as on-admission hypotension, a lack of pre-hospital care, post-operative complications, an intraoperative hypoxia episode, and hyperthermia.
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Affiliation(s)
- Nega Getachew Tegegne
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demeke Yilkal Fentie
- Department of Anesthesia, School of medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Biresaw Ayen Tegegne
- Department of Anesthesia, School of medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Correspondence: Biresaw Ayen Tegegne, Tel +251-9-27-60-14-27, Email
| | - Belete Muluadam Admassie
- Department of Anesthesia, School of medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Allen BC, Cummer E, Sarma AK. Traumatic Brain Injury in Select Low- and Middle-Income Countries: A Narrative Review of the Literature. J Neurotrauma 2023; 40:602-619. [PMID: 36424896 DOI: 10.1089/neu.2022.0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Low- and middle-income countries (LMICs) experience the majority of traumatic brain injuries (TBIs), yet few studies have examined the epidemiology and management strategies of TBI in LMICs. The objective of this narrative review is to discuss the epidemiology of TBI within LMICs, describe the adherence to Brain Trauma Foundation (BTF) guidelines for the management of severe TBI in LMICs, and document TBI management strategies currently used in LMICs. Articles from January 1, 2009 to September 30, 2021 that included patients with TBI greater than 18 years of age in low-, low middle-, and high middle-income countries were queried in PubMed. Search results demonstrated that TBI in LMICs mostly impacts young males involved in road traffic accidents. Within LMICs there are a myriad of approaches to managing TBI with few randomized controlled trials performed within LMICs to evaluate those interventions. More studies are needed in LMICs to establish the effectiveness and appropriateness of BTF guidelines for managing TBI and to help identify methods for managing TBI that are appropriate in low-resource settings. The problem of limited pre- and post-hospital care is a bigger challenge that needs to be considered while addressing management of TBI in LMICs.
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Affiliation(s)
- Beddome C Allen
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Elaina Cummer
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Anand K Sarma
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Neurology, Division of Neurocritical Care, Atrium Health Wake Forest Baptist Hospital, Winston-Salem, North Carolina, USA
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4
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Réa-Neto Á, da Silva Júnior ED, Hassler G, Dos Santos VB, Bernardelli RS, Kozesinski-Nakatani AC, Martins-Junior MJ, Reese FB, Cosentino MB, Oliveira MC, Teive HAG. Epidemiological and clinical characteristics predictive of ICU mortality of patients with traumatic brain injury treated at a trauma referral hospital - a cohort study. BMC Neurol 2023; 23:101. [PMID: 36890473 PMCID: PMC9993710 DOI: 10.1186/s12883-023-03145-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 02/27/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) has substantial physical, psychological, social and economic impacts, with high rates of morbidity and mortality. Considering its high incidence, the aim of this study was to identify epidemiological and clinical characteristics that predict mortality in patients hospitalized for TBI in intensive care units (ICUs). METHODS A retrospective cohort study was carried out with patients over 18 years old with TBI admitted to an ICU of a Brazilian trauma referral hospital between January 2012 and August 2019. TBI was compared with other traumas in terms of clinical characteristics of ICU admission and outcome. Univariate and multivariate analyses were used to estimate the odds ratio for mortality. RESULTS Of the 4816 patients included, 1114 had TBI, with a predominance of males (85.1%). Compared with patients with other traumas, patients with TBI had a lower mean age (45.3 ± 19.1 versus 57.1 ± 24.1 years, p < 0.001), higher median APACHE II (19 versus 15, p < 0.001) and SOFA (6 versus 3, p < 0.001) scores, lower median Glasgow Coma Scale (GCS) score (10 versus 15, p < 0.001), higher median length of stay (7 days versus 4 days, p < 0.001) and higher mortality (27.6% versus 13.3%, p < 0.001). In the multivariate analysis, the predictors of mortality were older age (OR: 1.008 [1.002-1.015], p = 0.016), higher APACHE II score (OR: 1.180 [1.155-1.204], p < 0.001), lower GCS score for the first 24 h (OR: 0.730 [0.700-0.760], p < 0.001), greater number of brain injuries and presence of associated chest trauma (OR: 1.727 [1.192-2.501], p < 0.001). CONCLUSION Patients admitted to the ICU for TBI were younger and had worse prognostic scores, longer hospital stays and higher mortality than those admitted to the ICU for other traumas. The independent predictors of mortality were older age, high APACHE II score, low GCS score, number of brain injuries and association with chest trauma.
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Affiliation(s)
- Álvaro Réa-Neto
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil. .,Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, General Carneiro Street, 181, Curitiba, Paraná, 80060-900, Brazil.
| | | | - Gabriela Hassler
- Federal University of Paraná, General Carneiro Street, 181, Curitiba, Paraná, 80060-900, Brazil
| | - Valkiria Backes Dos Santos
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil
| | - Rafaella Stradiotto Bernardelli
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil.,School of Medicine and Life Sciences, Pontifical Catholic University of Paraná, Imaculada Conceição Street, 1155, Curitiba, Paraná, 80215-901, Brazil
| | - Amanda Christina Kozesinski-Nakatani
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil.,Hospital Santa Casa de Curitiba., Praça Rui Barbosa, 694, Curitiba, Paraná, 80010-030, Brazil
| | - Marcelo José Martins-Junior
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil
| | - Fernanda Baeumle Reese
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil.,Complexo Hospitalar do Trabalhador (CHT), República Argentina Street, 4406, Curitiba, Paraná, 81050-000, Brazil
| | - Mariana Bruinje Cosentino
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil.,Complexo Hospitalar do Trabalhador (CHT), República Argentina Street, 4406, Curitiba, Paraná, 81050-000, Brazil
| | - Mirella Cristine Oliveira
- Center for Studies and Research in Intensive Care Medicine (CEPETI), Monte Castelo Street, 366, Curitiba, Paraná, 82530-200, Brazil.,Complexo Hospitalar do Trabalhador (CHT), República Argentina Street, 4406, Curitiba, Paraná, 81050-000, Brazil
| | - Hélio Afonso Ghizoni Teive
- Neurology Service, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, General Carneiro Street, 181, Curitiba, Paraná, 80060-900, Brazil
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Zimmerman A, Barcenas LK, Pesambili M, Sakita F, Mallya S, Vissoci JRN, Park L, Mmbaga BT, Bettger JP, Staton CA. Injury characteristics and their association with clinical complications among emergency care patients in Tanzania. Afr J Emerg Med 2022; 12:378-386. [PMID: 36091971 PMCID: PMC9445286 DOI: 10.1016/j.afjem.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 08/02/2022] [Accepted: 08/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background Over 5 million people annually die from injuries and millions more sustain non-fatal injuries requiring medical care. Ninety percent of injury deaths occur in low- and middle-income countries (LMICs). This study describes the characteristics, predictors and outcomes of adult acute injury patients presenting to a tertiary referral hospital in a low-income country in sub-Saharan Africa. Methods This secondary analysis uses an adult acute injury registry from Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania. We describe this patient sample in terms of socio-demographics, clinical indicators, injury patterns, treatments, and outcomes at hospital discharge. Outcomes include mortality, length of hospital stay, and functional independence. Associations between patient characteristics and patient outcomes are quantified using Cox proportional hazards models, negative binomial regression, and multivariable logistic regression. Results Of all injury patients (n=1365), 39.0% were aged 30 to 49 years and 81.5% were men. Most patients had at least a primary school education (89.6%) and were employed (89.3%). A majority of injuries were road traffic (63.2%), fall (16.8%), or assault (14.0%) related. Self-reported comorbidities included hypertension (5.8%), HIV (3.1%), and diabetes (2.3%). Performed surgeries were classified as orthopedic (32.3%), general (4.1%), neurological (3.7%), or other (59.8%). Most patients reached the hospital at least four hours after injury occurred (53.9%). Mortality was 5.3%, median length of hospital stay was 6.1 days (IQR: 3.1, 15.0), self-care dependence was 54.2%, and locomotion dependence was 41.5%. Conclusions Our study sample included primarily young men suffering road traffic crashes with delayed hospital presentations and prolonged hospital stays. Being older, male, and requiring non-orthopedic surgeries or having HIV portends a worse prognosis. Prevention and treatment focused interventions to reduce the burden of injury mortality and morbidity at KCMC are needed to lower injury rates and improve injury outcomes.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carlina, United States
| | - Loren K. Barcenas
- Duke Global Health Institute, Duke University, Durham, North Carlina, United States
| | | | | | - Simon Mallya
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carlina, United States
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States
| | - Lawrence Park
- Duke Global Health Institute, Duke University, Durham, North Carlina, United States
| | - Blandina T. Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Janet Prvu Bettger
- Duke Global Health Institute, Duke University, Durham, North Carlina, United States
| | - Catherine A. Staton
- Duke Global Health Institute, Duke University, Durham, North Carlina, United States
- Department of Emergency Medicine, Duke University Medical Center, Durham, North Carolina, United States
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Abstract
Neurocritical care (NCC) is an emerging field within critical care medicine, reflecting the widespread prevalence of neurologic injury in critically ill patients. Morbidity and mortality from neurocritical illness (NCI) have been reduced substantially in resource-rich settings (RRS), owing to the development of advanced technologies, neuro-specific units, and subspecialized medical training. Despite shouldering much of the burden of NCI worldwide, resource-limited settings (RLS) face immense hurdles when implementing guidelines generated in RRS. This review summarizes the current epidemiology, management, and outcomes of the most common NCIs in RLS and offers commentary on future directions in NCC practiced in RLS.
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Severe traumatic brain injuries secondary to motor vehicle crashes in two Namibian regions: A retrospective review. Afr J Emerg Med 2022; 12:225-230. [PMID: 35719186 PMCID: PMC9188956 DOI: 10.1016/j.afjem.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 04/18/2022] [Accepted: 04/22/2022] [Indexed: 11/22/2022] Open
Abstract
Introduction Traumatic Brain Injuries (TBIs) are a leading cause of morbidity and mortality among trauma patients globally, with motor vehicle crashes (MVCs) being a major contributor. Namibia had a World Health Organization (WHO) estimated MVC-related fatality rate of 30.4 per 100 000 population in 2016, higher than that of the African continent, while no epidemiological studies describing the distribution and determinants of TBIs exist in the country. The study aimed to describe the characteristics of adult patients (≥18 years) with severe TBI secondary to MVCs which occurred in two regions of Namibia between the years 2014-2018. Methods A retrospective descriptive observational study was conducted in adult patients who sustained severe TBIs secondary to MVCs in two Namibian regions. The inclusion criteria were patients ≥18 years with a severe (as described on the Motor Vehicle Accident Fund system) MVC-related TBI who sustained an injury in the Otjozondjupa or Khomas regions between the years 2014-2018. Results A total of 87 patients met the inclusion criteria, 65 (74.7%) from the Khomas region, and 22 (25.3%) from the Otjozondjupa region. The overall mean age of patients was 34 years (SD 11.79), most were male (n = 78. 89.7%) and 55.2% (n = 48) of all patients sustained an isolated TBI. The majority of the patients were admitted to a state healthcare facility (n = 52, 59.8%). Pedestrians were the most injured (n = 34, 52.3%) in the Khomas region while vehicle drivers were the most injured (n = 11, 50%) in the Otjozondjupa Region. A total of 34 (39.1%) patients died and 53 (60.9%) were discharged from hospital. Overall, there were no statistically significant relationships between patient outcomes and independent variables. Conclusions The study was to our knowledge the first to describe the epidemiology of TBIs in Namibia. Young individuals are the main people who sustained TBIs, which may subsequently place a socio-economic burden on the country. There is however limited research in Namibia to guide healthcare planning.
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Evaluating Post-Injury Functional Status among Patients Presenting for Emergency Care in Kigali, Rwanda. TRAUMA CARE 2022. [DOI: 10.3390/traumacare2030036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Despite high injury-related morbidity, approaches for evaluating post-injury functional status after emergency care are poorly characterized in resource-limited settings. This study evaluated the feasibility of standardized disability assessments among patients presenting with significant trauma to the Centre Hospitalier Universitaire de Kigali ED in Rwanda from January–June 2020. The functional status at 28-days post-injury was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2), the Katz Activities of Daily Living (ADL) Scale, and self-reported functional state. The primary outcome was a descriptive profile of the disability status at 28-days post-injury. The WHODAS 2.0, Katz ADL Scale and patients’ self-perceived functional status was compared using Kendall’s rank correlation coefficient. Twenty-four patients were included. The most common injury mechanism was road traffic accident (70.8%); 58.3% of patients had traumatic brain injury. The self-perception questionnaire and the Katz ADL scale were strongly correlated with the WHODAS 2.0 scale; however, self-perception was not well correlated with the ADL scale. Post-injury morbidity was high and morbidity assessment was feasible, with a strong correlation between patients’ self-perceived functional status and the WHODAS-2 scale. Structured post-injury assessments may serve to inform the development of rehabilitation services in Rwanda, although larger studies are needed to inform such initiatives.
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9
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Peek-Asa C, Coman MA, Zorn A, Chikhladze N, Cebanu S, Tadevosyan A, Hamann CJ. Association of traumatic brain injury severity and time to definitive care in three low-middle-income European countries. Inj Prev 2022; 28:54-60. [PMID: 33910969 PMCID: PMC11267067 DOI: 10.1136/injuryprev-2020-044049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Low-middle-income countries experience among the highest rates of traumatic brain injury in the world. Much of this burden may be preventable with faster intervention, including reducing the time to definitive care. This study examines the relationship between traumatic brain injury severity and time to definitive care in major trauma hospitals in three low-middle-income countries. METHODS A prospective traumatic brain injury registry was implemented in six trauma hospitals in Armenia, Georgia and the Republic of Moldova for 6 months in 2019. Brain injury severity was measured using the Glasgow Coma Scale (GCS) at admission. Time to definitive care was the time from injury until arrival at the hospital. Cox proportionate hazards models predicted time to care by severity, controlling for age, sex, mechanism, mode of transportation, location of injury and country. RESULTS Among 1135 patients, 749 (66.0%) were paediatric and 386 (34.0%) were adults. Falls and road traffic were the most common mechanisms. A higher proportion of adult (23.6%) than paediatric (5.4%) patients had GCS scores indicating moderate (GCS 9-11) or severe injury (GCS 0-8) (p<0.001). Less severe injury was associated with shorter times to care, while more severe injury was associated with longer times to care (HR=1.05, 95% CI 1.01 to 1.09). Age interacted with time to care, with paediatric cases receiving faster care. CONCLUSIONS Implementation of standard triage and transport protocols may reduce mortality and improve outcomes from traumatic brain injury, and trauma systems should focus on the most severe injuries.
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Affiliation(s)
- Corinne Peek-Asa
- Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, USA
| | - Madalina Adina Coman
- Public Health, Babes-Bolyai University Faculty of Political Administrative and Communication Sciences, Cluj-Napoca, Cluj, Romania
| | - Alison Zorn
- Biostatistics, University of Iowa, Iowa City, Iowa, USA
| | - Nino Chikhladze
- Public Health, Ivane Javakhishvili Tbilisi State University, Tbilisi, Georgia
| | - Serghei Cebanu
- Department of Hygiene, Moldova State University, Chisinau, Moldova (the Republic of)
| | - Artashes Tadevosyan
- Department of Public Health and Healthcare Organization, Yerevan State Medical University, Yerevan, Armenia
| | - Cara J Hamann
- Occupational and Environmental Health, University of Iowa, Iowa City, Iowa, USA
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10
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Raees M, Hooli S, von Saint André-von Arnim AO, Laeke T, Otupiri E, Fabio A, Rudd KE, Kumar R, Wilson PT, Aklilu AT, Tuyisenge L, Wang C, Tasker RC, Angus DC, Kochanek PM, Fink EL, Bacha T. An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa. Front Pediatr 2022; 10:936150. [PMID: 36061402 PMCID: PMC9428450 DOI: 10.3389/fped.2022.936150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs. METHODS We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests. RESULTS Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge. CONCLUSION Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.
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Affiliation(s)
- Madiha Raees
- Division of Critical Care Medicine, Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States
| | - Shubhada Hooli
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, United States
| | - Amélie O von Saint André-von Arnim
- Division of Pediatric Critical Care, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, United States.,Department of Global Health, University of Washington, Seattle, WA, United States
| | - Tsegazeab Laeke
- Division of Neurosurgery, Department of Surgery, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,National Institute for Health Care and Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Easmon Otupiri
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Anthony Fabio
- Epidemiology Data Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kristina E Rudd
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh, Pittsburgh, PA, United States
| | - Rashmi Kumar
- Department of Paediatrics and Child Health, University of Nairobi, Nairobi, Kenya
| | - Patrick T Wilson
- Department of Pediatrics, Columbia University Medical Center, New York, NY, United States
| | - Abenezer Tirsit Aklilu
- Division of Neurosurgery, Department of Surgery, College of Health Science, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.,National Institute for Health Care and Research (NIHR) Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Lisine Tuyisenge
- Department of Paediatrics, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Chunyan Wang
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert C Tasker
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States.,Clinical Research, Investigation, and Systems Modeling of Acute Illness Center (CRISMA), University of Pittsburgh, Pittsburgh, PA, United States
| | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Ericka L Fink
- Department of Critical Care Medicine, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, United States
| | - Tigist Bacha
- Department of Pediatrics and Child Health, St. Paul Millennium Medical College, Addis Ababa, Ethiopia
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11
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Mangat HS, Wu X, Gerber LM, Shabani HK, Lazaro A, Leidinger A, Santos MM, McClelland PH, Schenck H, Joackim P, Ngerageza JG, Schmidt F, Stieg PE, Hartl R. Severe traumatic brain injury management in Tanzania: analysis of a prospective cohort. J Neurosurg 2021; 135:1190-1202. [PMID: 33482641 PMCID: PMC8295409 DOI: 10.3171/2020.8.jns201243] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Given the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania. METHODS A neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model. RESULTS In total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model. CONCLUSIONS The 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.
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Affiliation(s)
- Halinder S. Mangat
- Department of Neurology, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Xian Wu
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Linda M. Gerber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, New York
| | - Hamisi K. Shabani
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Albert Lazaro
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Andreas Leidinger
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Maria M. Santos
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Paul H. McClelland
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | | | - Pascal Joackim
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Japhet G. Ngerageza
- Department of Neurological Surgery, Muhimbili Orthopaedic Institute, Dar-es-Salaam, Tanzania
| | - Franziska Schmidt
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Philip E. Stieg
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
| | - Roger Hartl
- Department of Neurological Surgery, Weill Cornell Brain and Spine Institute, New York
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12
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Mehmood A, Rowther AA, Kobusingye O, Ssenyonjo H, Zia N, Hyder AA. Delays in emergency department intervention for patients with traumatic brain injury in Uganda. Trauma Surg Acute Care Open 2021; 6:e000674. [PMID: 34527810 PMCID: PMC8395360 DOI: 10.1136/tsaco-2021-000674] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/20/2021] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Amber Mehmood
- College of Public Health, University of South Florida, Tampa, Florida, USA.,International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Armaan Ahmed Rowther
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Olive Kobusingye
- Trauma, Injury, & Disability Unit, Makerere University's School of Public Health, Kampala, Uganda
| | | | - Nukhba Zia
- International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Adnan A Hyder
- Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC, USA
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13
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Abio A, Bovet P, Valentin B, Bärnighausen T, Shaikh MA, Posti JP, Lowery Wilson M. Changes in Mortality Related to Traumatic Brain Injuries in the Seychelles from 1989 to 2018. Front Neurol 2021; 12:720434. [PMID: 34512529 PMCID: PMC8430237 DOI: 10.3389/fneur.2021.720434] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction: Traumatic Brain Injuries (TBIs) are a significant source of disability and mortality, which disproportionately affect low- and middle-income countries. The Republic of Seychelles is a country in the African region that has experienced rapid socio-economic development and one in which all deaths and the age distribution of the population have been enumerated for the past few decades. The aim of this study was to investigate TBI-related mortality changes in the Republic of Seychelles during 1989–2018. Methods: All TBI-related deaths were ascertained using the national Civil Registration and Vital Statistics System. Age- and sex-standardised mortality rates (per 100,000 person-years) were standardised to the age distribution of the World Health Organisation standard population. Results: The 30-year age-standardised TBI-related mortality rates were 22.6 (95% CI 19.9, 25.2) in males and 4.0 (95% CI 2.9, 5.1) in females. Road traffic collisions were the leading contributor to TBI-related mortality [10.0 (95% CI 8.2, 11.8) in males and 2.7 (95% CI 1.8, 3.6) in females, P > 0.05]. TBI-related mortality was most frequent at age 20–39 years in males (8.0) and at age 0–19 in females (1.4). Comparing 2004–2018 vs. 1989–2003, the age-standardised mortality rates changed in males/females by −20%/−11% (all cause mortality), −24%/+39.4% (TBIs) and +1%/+34.8% (road traffic injury-related TBI). Conclusion: TBI-related mortality rates were much higher in males but decreased over time. Road traffic collisions were the single greatest contributor to TBI mortality, emphasising the importance of road safety measures.
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Affiliation(s)
- Anne Abio
- Injury Epidemiology and Prevention Research Group, Turku Brain Injury Centre, Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland.,Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Pascal Bovet
- University Center for Primary Care and Public Health (Unisanté), Lausanne, Switzerland.,Ministry of Health, Victoria, Seychelles
| | | | - Till Bärnighausen
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
| | - Masood Ali Shaikh
- Injury Epidemiology and Prevention Research Group, Turku Brain Injury Centre, Division of Clinical Neurosciences, Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi P Posti
- Department of Neurosurgery and Turku Brain Injury Centre, Neurocentre, Turku University Hospital and University of Turku, Turku, Finland
| | - Michael Lowery Wilson
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
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14
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Incidence and predictors of mortality among patients with head injury admitted to Hawassa University Comprehensive Specialized Hospital, Southern Ethiopia: A retrospective follow-up study. PLoS One 2021; 16:e0254245. [PMID: 34411116 PMCID: PMC8376017 DOI: 10.1371/journal.pone.0254245] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/22/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Head injury is the leading cause of morbidity and mortality throughout the world, especially in resource-limited countries including Ethiopia. However, little is known about the mortality rate and its predictors among these patients in Ethiopia. Thus, the study aims to assess the incidence rate of mortality and its predictors among patients with head injury admitted at Hawassa University Comprehensive Specialized Hospital. Methods Institutional based retrospective follow-up study was conducted among 1220 randomly selected head injury patients admitted from July 2017 to July 2019. Bivariable and multivariable Cox regression models were fitted to identify the predictors of mortality. Proportionality assumption was tested by a global test based on the Schoenfeld residuals test. Results The incidence of the mortality rate was 2.26 (95%CI: 1.9–2.6) per 100-person day observation. The independent predictors of time to death were age above 65 years (AHR:3.49, 95%CI:1.63, 7.48), severe TBI (AHR: 8.8, 95%CI:5.13, 15.0), moderate TBI (AHR:3, 95%CI:1.73,5.31), hypotension (AHR:1.72, 95%CI: 1.11,2.66), hypoxia (AHR:1.92, 95%CI: 1.33,2.76), hyperthermia (AHR:1.8, 95%CI: 1.23,2.63) and hypoglycemic (AHR:1.94, 95%CI: 1.34, 2.81) positively associated with mortality, while underwent neurosurgery was negatively associated with mortality (AHR: 0.25, 95% CI: 0.11,0.53). Conclusion The incidence of mortality rate among head injury patients was high. Older age, moderate and severe TBI, hypotension and hypoxia at admission, neurosurgical procedure, and the episode of hyperthermia and hypoglycemia during hospitalization were the independent predictors of mortality among head injury patients. Therefore, intervention to reduce earlier deaths should focus on the prevention of secondary brain insults.
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15
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Marqués CG, Moretti K, Amanullah S, Uwamahoro C, Ndebwanimana V, Garbern S, Naganathan S, Martin K, Niyomiza J, Gjesvik A, Nkeshimana M, Levine AC, Aluisio AR. Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda. Afr J Emerg Med 2021; 11:152-157. [PMID: 33680737 PMCID: PMC7910191 DOI: 10.1016/j.afjem.2020.09.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 07/26/2020] [Accepted: 09/21/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K). METHODS Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). RESULTS From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids. CONCLUSIONS Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.
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Affiliation(s)
- Catalina González Marqués
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Katelyn Moretti
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Siraj Amanullah
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Chantal Uwamahoro
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Vincent Ndebwanimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Stephanie Garbern
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Sonya Naganathan
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Kyle Martin
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Joseph Niyomiza
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Annie Gjesvik
- Department of Epidemiology and Pediatrics Brown University School of Public Health, Providence, USA
| | - Menelas Nkeshimana
- Department of Anaesthesia, Emergency Medicine and Critical Care, College of Medicine & Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Accident and Emergency, University Teaching Hospital of Kigali, Rwanda
| | - Adam C. Levine
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
| | - Adam R. Aluisio
- Department of Emergency Medicine, Brown University Warren Alpert Medical School, Providence, USA
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16
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Odland ML, Whitaker J, Nepogodiev D, Aling' CA, Bagahirwa I, Dushime T, Erlangga D, Mpirimbanyi C, Muneza S, Nkeshimana M, Nyundo M, Umuhoza C, Uwitonze E, Steans J, Rushton A, Belli A, Byiringiro JC, Bekele A, Davies J. Identifying, Prioritizing and Visually Mapping Barriers to Injury Care in Rwanda: A Multi-disciplinary Stakeholder Exercise. World J Surg 2021; 44:2903-2918. [PMID: 32440950 PMCID: PMC7385009 DOI: 10.1007/s00268-020-05571-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background Whilst injuries are a major cause of disability and death worldwide, a large proportion of people in low- and middle-income countries lack timely access to injury care. Barriers to accessing care from the point of injury to return to function have not been delineated. Methods A two-day workshop was held in Kigali, Rwanda in May 2019 with representation from health providers, academia, and government. A four delays model (delays to seeking, reaching, receiving, and remaining in care) was applied to injury care. Participants identified barriers at each delay and graded, through consensus, their relative importance. Following an iterative voting process, the four highest priority barriers were identified. Based on workshop findings and a scoping review, a map was created to visually represent injury care access as a complex health-system problem.
Results Initially, 42 barriers were identified by the 34 participants. 19 barriers across all four delays were assigned high priority; highest-priority barriers were “Training and retention of specialist staff”, “Health education/awareness of injury severity”, “Geographical coverage of referral trauma centres”, and “Lack of protocol for bypass to referral centres”. The literature review identified evidence relating to 14 of 19 high-priority barriers. Most barriers were mapped to more than one of the four delays, visually represented in a complex health-system map.
Conclusion Overcoming barriers to ensure access to quality injury care requires a multifaceted approach which considers the whole patient journey from injury to rehabilitation. Our results can guide researchers and policymakers planning future interventions.
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Affiliation(s)
- Maria Lisa Odland
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - John Whitaker
- Faculty of Life Sciences and Medicine, King's Centre for Global Health and Health Partnerships, King's College London, Room 2.13, Global Health Offices, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK. .,Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham, UK.
| | - Dmitri Nepogodiev
- National Institute for Health Research, Global Health Research Unit on Global Surgery, Institute of Translational Medicine, University of Birmingham, Birmingham, UK
| | | | | | | | - Darius Erlangga
- Warwick Medical School, Population Evidence and Technologies, University of Warwick, Coventry, UK
| | | | | | | | - Martin Nyundo
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Christian Umuhoza
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda
| | | | - Jill Steans
- Department of Political Science and International Studies, School of Government and Society, University of Birmingham, Birmingham, UK
| | - Alison Rushton
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Antonio Belli
- College of Medicine and Dental Sciences, NIHR Surgical Reconstruction and Microbiology Research Centre, University of Birmingham, Birmingham, UK
| | - Jean Claude Byiringiro
- University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda.,University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Abebe Bekele
- University of Global Health Equity, Kigali, Rwanda
| | - Justine Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Life Sciences and Medicine, King's Centre for Global Health and Health Partnerships, King's College London, Room 2.13, Global Health Offices, Weston Education Centre, Cutcombe Road, London, SE5 9RJ, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, Gauteng, South Africa
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17
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Gamble M, Luggya TS, Mabweijano J, Nabulime J, Mowafi H. Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury. Afr J Emerg Med 2020; 10:181-187. [PMID: 33299746 PMCID: PMC7700954 DOI: 10.1016/j.afjem.2020.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality. Methods A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded. Results Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6). Conclusion Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.
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18
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Zimmerman A, Fox S, Griffin R, Nelp T, Thomaz EBAF, Mvungi M, Mmbaga BT, Sakita F, Gerardo CJ, Vissoci JRN, Staton CA. An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country. PLoS One 2020; 15:e0240528. [PMID: 33045030 PMCID: PMC7549769 DOI: 10.1371/journal.pone.0240528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/29/2020] [Indexed: 11/12/2022] Open
Abstract
Background Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting. Methods We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes. Results Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery. Conclusions Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.
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Affiliation(s)
- Armand Zimmerman
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Samara Fox
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Randi Griffin
- Department of Evolutionary Anthropology, Duke University, Durham, North Carolina, United States of America
| | - Taylor Nelp
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | | | - Mark Mvungi
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Blandina T Mmbaga
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Clinical Research Institute, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Francis Sakita
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania.,Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Charles J Gerardo
- Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Joao Ricardo Nickenig Vissoci
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Catherine A Staton
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America.,Division of Emergency Medicine, Department of Surgery, Duke University Medical Center, Durham, North Carolina, United States of America
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19
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Blast-Induced Traumatic Brain Injuries: Experience from the Deadliest Double Suicide Bombing Attack in Iraq. World Neurosurg 2020; 145:e192-e201. [PMID: 33045452 DOI: 10.1016/j.wneu.2020.09.167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Blast-induced traumatic brain injuries (bTBIs) are increasingly frequent in civilian settings. We present the first study of individuals with bTBI in Iraq. The study focuses on one of the deadliest suicide car bomb attacks in Iraq and uses it to show the devastating nature of bTBIs. METHODS This study was conducted at the Neurosurgery Teaching Hospital in Baghdad, Iraq. A retrospective chart analysis of patients with bTBI admitted to the Neurosurgery Teaching Hospital was performed. Measured parameters included patients' demographics, initial presentation, injury patterns, hospital course, surgical management, and outcomes. RESULTS A total of 75 patients with bTBI were included in this study, 19 of whom died in the emergency room. The remaining 56 patients were admitted to the hospital. Of those patients, 68.6% (n = 39) underwent surgery, and 30.4% were managed conservatively. A modified, tailored triaging system was implemented. All surgery was guided by the principles of damage control neurosurgery. In addition, 76.9% and 46.2% of patients underwent corticectomy and decompressive craniectomy, respectively. Dural venous sinus repair was performed in 17.9% of patients, and 30.7% of the operations entailed additional steps to control major (arterial) cerebrovascular bleeding. The net bTBI-related complication rate was 76%. The total mortality was 48%. Of survivors, 10.7% (n = 8) were discharged with a severe disability. Overall, good outcomes were achieved in 41.3% of the patients. CONCLUSIONS This study sheds light on the devastating nature of bTBIs. Neurosurgeons worldwide need to be mindful of the unique triaging, diagnostic, and management requirements of these injuries.
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Rosenberg A, Mukeshimana L, Uwamahoro A, Dworkin M, Nsengimana V, Kankindi E, Niyonsaba M, Uwitonze JM, Kabagema I, Dushime T, Jayaraman S. The Initial Prehospital Management of Traumatic Brain Injuries in Kigali, Rwanda. Prehosp Disaster Med 2020; 35:533-537. [PMID: 32600486 PMCID: PMC10536786 DOI: 10.1017/s1049023x20000813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Traumatic brain injuries (TBIs) are an important cause of mortality and disability around the world. Early intervention and stabilization are necessary to obtain optimal outcomes, yet little is written on the topic in low- and middle-income countries (LMICs). The aim is to provide a descriptive analysis of patients with TBI treated by Service d'Aide Medicale Urgente (SAMU), the prehospital ambulance service in Kigali, Rwanda. HYPOTHESIS/PROBLEM What is the incidence and nature of TBI seen on the ambulance in Kigali, Rwanda? METHODS A retrospective descriptive analysis was performed using SAMU records captured on an electronic database from December 2012 through May 2016. Variables included demographic information, injury characteristics, and interventional data. RESULTS Patients with TBIs accounted for 18.0% (n = 2,012) of all SAMU cases. The incidence of TBIs in Kigali was 234 crashes per 100,000 people. The mean age was 30.5 (SD = 11.5) years and 81.5% (n = 1,615) were men. The most common mechanisms were road traffic incidents (RTIs; 78.5%, n = 1,535), assault (10.7%, n=216), and falls (7.8%, n=156). Most patients experienced mild TBI (Glasgow Coma Score [GCS] ≥ 13; 83.5%, n = 1,625). The most common interventions were provision of pain medications (71.0%, n = 1,429), placement of a cervical collar (53.6%, n = 1,079), and administration of intravenous fluids (48.7%, n = 979). In total, TBIs were involved in 67.0% of all mortalities seen by SAMU. CONCLUSION Currently, TBIs represent a large burden of disease managed in the prehospital setting of Kigali, Rwanda. These injuries are most often caused by RTIs and were observed in 67% of mortalities seen by SAMU. Rwanda has implemented several initiatives to reduce the incidence of TBIs with a specific emphasis on road safety. Further efforts are needed to better prevent these injuries. Countries seeking to develop prehospital care capacity should train providers to manage patients with TBIs.
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Affiliation(s)
- Ashley Rosenberg
- Division of Acute Care Surgery, Department of Surgery Virginia Commonwealth University School of Medicine, Richmond, Virginia USA
| | | | | | - Myles Dworkin
- Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania USA
| | - Vizir Nsengimana
- Department of Emergency Medicine, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Eugenie Kankindi
- Service d’Aide Medicale Urgente- Rwanda Ministry of Health, Kigali, Rwanda
| | | | | | - Ignace Kabagema
- Service d’Aide Medicale Urgente- Rwanda Ministry of Health, Kigali, Rwanda
| | - Theophile Dushime
- Service d’Aide Medicale Urgente- Rwanda Ministry of Health, Kigali, Rwanda
| | - Sudha Jayaraman
- Division of Acute Care Surgery, Department of Surgery Virginia Commonwealth University School of Medicine, Richmond, Virginia USA
- Program for Global Surgery, Department of Surgery Virginia Commonwealth University, VCU Health, Richmond, Virginia USA
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Mattson P, Nteziryayo E, Aluisio AR, Henry M, Rosenberg N, Mutabazi ZA, Nyinawankusi JD, Byiringiro JC, Levine AC, Karim N. Musculoskeletal Injuries and Outcomes Pre- and Post- Emergency Medicine Training Program. West J Emerg Med 2019; 20:857-864. [PMID: 31738712 PMCID: PMC6860388 DOI: 10.5811/westjem.2019.7.41448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 07/31/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Musculoskeletal injuries (MSI) comprise a large portion of the trauma burden in low- and middle-income countries (LMIC). Rwanda recently launched its first emergency medicine training program (EMTP) at the University Teaching Hospital-Kigali (UTH-K), which may help to treat such injuries; yet no current epidemiological data is available on MSI in Rwanda. Methods We conducted this pre-post study during two data collection periods at the UTH-K from November 2012 to July 2016. Data collection for MSI is limited and thus is specific to fractures. We included all patients with open, closed, or mixed fractures, hereafter referred to as MSI. Gathered information included demographics and outcomes including death, traumatic complications, and length of hospital stay, before and after the implementation of the EMTP. Results We collected data from 3609 patients. Of those records, 691 patients were treated for fractures, and 674 of them had sufficient EMTP data measured for inclusion in the analysis of results (279 from pre-EMTP and 375 from post-EMTP). Patient demographics demonstrate that a majority of MSI cases are male (71.6% male vs 28.4% female) and young (64.3% below 35 years of age). Among mechanisms of injury, major causes included road traffic accidents (48.1%), falls (34.2%), and assault (6.0%). There was also an observed association between EMTP and trends of the three primary outcomes: a reduction of death in the emergency department (ED) from those with MSI by 89.9%, from 2.51% to 0.25% (p = 0.0077); a reduction in traumatic complications for MSI patients by 71.7%, from 3.58% to 1.01% (p = 0.0211); and a reduction in duration of stay in the ED among those with MSI by 52.7% or 2.81 days on average, from 5.33 to 2.52 days (p = 0.0437). Conclusion This study reveals the current epidemiology of MSI morbidity and mortality for a major Rwandan teaching hospital and the potential impacts of EM training implementation among those with MSI. Residency training programs such as EMTP appear capable of reducing mortality, complications, and ED length of stay among those with MSI caused by fractures. Such findings underscore the efficacy and importance of investments in educating the next generation of health professionals to combat prevalent MSI within their communities.
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Affiliation(s)
- Peter Mattson
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | | | - Adam R Aluisio
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Michael Henry
- Columbia University Vagelos College of Physicians and Surgeons, New York, New York
| | - Noah Rosenberg
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | | | | | | | - Adam C Levine
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
| | - Naz Karim
- Warren Alpert Medical School, Department of Emergency Medicine, Providence, Rhode Island
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22
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Niu F, Sharma A, Feng L, Ozkizilcik A, Muresanu DF, Lafuente JV, Tian ZR, Nozari A, Sharma HS. Nanowired delivery of DL-3-n-butylphthalide induces superior neuroprotection in concussive head injury. PROGRESS IN BRAIN RESEARCH 2019; 245:89-118. [DOI: 10.1016/bs.pbr.2019.03.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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23
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Cancedda C, Cotton P, Shema J, Rulisa S, Riviello R, Adams LV, Farmer PE, Kagwiza JN, Kyamanywa P, Mukamana D, Mumena C, Tumusiime DK, Mukashyaka L, Ndenga E, Twagirumugabe T, Mukara KB, Dusabejambo V, Walker TD, Nkusi E, Bazzett-Matabele L, Butera A, Rugwizangoga B, Kabayiza JC, Kanyandekwe S, Kalisa L, Ntirenganya F, Dixson J, Rogo T, McCall N, Corden M, Wong R, Mukeshimana M, Gatarayiha A, Ntagungira EK, Yaman A, Musabeyezu J, Sliney A, Nuthulaganti T, Kernan M, Okwi P, Rhatigan J, Barrow J, Wilson K, Levine AC, Reece R, Koster M, Moresky RT, O’Flaherty JE, Palumbo PE, Ginwalla R, Binanay CA, Thielman N, Relf M, Wright R, Hill M, Chyun D, Klar RT, McCreary LL, Hughes TL, Moen M, Meeks V, Barrows B, Durieux ME, McClain CD, Bunts A, Calland FJ, Hedt-Gauthier B, Milner D, Raviola G, Smith SE, Tuteja M, Magriples U, Rastegar A, Arnold L, Magaziner I, Binagwaho A. Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda. Int J Health Policy Manag 2018; 7:1024-1039. [PMID: 30624876 PMCID: PMC6326644 DOI: 10.15171/ijhpm.2018.61] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/19/2018] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda. METHODS The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors. RESULTS In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions. CONCLUSION The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.
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Affiliation(s)
- Corrado Cancedda
- Center for Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Phil Cotton
- Office of the Vice-Chancellor, University of Rwanda, Kigali, Rwanda
| | - Joseph Shema
- Rwanda Human Resources for Health Program Team, Ministry of Health, Kigali, Rwanda
| | - Stephen Rulisa
- Office of the Dean, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Robert Riviello
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Lisa V. Adams
- Center for Health Equity, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Paul E. Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jeanne N. Kagwiza
- Office of the Principal, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Patrick Kyamanywa
- Department of Surgery, Faculty of Clinical Medicine and Dentistry, Kampala International University - Western Campus, Ishaka, Uganda
| | - Donatilla Mukamana
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Chrispinus Mumena
- Office of the Dean and Department of Oral and Maxillofacial Surgery, Oral Pathology and Oral Medicine, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - David K. Tumusiime
- School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Lydie Mukashyaka
- Rwanda Human Resources for Health Program Team, Ministry of Health, Kigali, Rwanda
| | - Esperance Ndenga
- Rwanda Human Resources for Health Program Team, Ministry of Health, Kigali, Rwanda
| | - Theogene Twagirumugabe
- Department of Anesthesiology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Kaitesi B. Mukara
- Department of Ear, Nose, and Throat, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Vincent Dusabejambo
- Department of Internal Medicine, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Timothy D. Walker
- Department of Internal Medicine, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
- Department of General Medicine, Calvary Mater Hospital, Newcastle, NSW, Australia
| | - Emmy Nkusi
- Department of Neurosurgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Lisa Bazzett-Matabele
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Alex Butera
- Department of Orthopedic Surgery, Rwanda Military Hospital, Kigali, Rwanda
| | - Belson Rugwizangoga
- Department of Pathology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Kabayiza
- Department of Pediatrics, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Simon Kanyandekwe
- Department of Mental Health, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Louise Kalisa
- Department of Radiology, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Faustin Ntirenganya
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Tanya Rogo
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
- Department of Pediatrics, BronxCare Health System, Bronx, NY, USA
| | - Natalie McCall
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Mark Corden
- Division of Hospital Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Rex Wong
- Global Health Leadership Institute, Yale School of Public Health, New Haven, CT, USA
| | - Madeleine Mukeshimana
- School of Nursing and Midwifery, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Agnes Gatarayiha
- Office of the Dean and Department of Oral and Maxillofacial Surgery, Oral Pathology and Oral Medicine, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Preventive and Community Dentistry, School of Dentistry, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Egide Kayonga Ntagungira
- School of Health Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Attila Yaman
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Anne Sliney
- Clinton Health Access Initiative, Boston, MA, USA
| | | | | | - Peter Okwi
- Clinton Health Access Initiative, Kigali, Rwanda
| | - Joseph Rhatigan
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Division of Global Health Equity, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jane Barrow
- Office of Global and Community Health, Harvard School of Dental Medicine, Boston, MA, USA
- Department of Oral Health Policy and Epidemiology, Harvard School of Dental Medicine, Boston, MA, USA
| | - Kim Wilson
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA
| | - Adam C. Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rebecca Reece
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael Koster
- Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Rachel T. Moresky
- sidHARTe Program, Heilbrunn Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York City, NY, USA
- Department of Emergency Medicine, Columbia University College of Physicians and Surgeons, New York City, NY, USA
| | - Jennifer E. O’Flaherty
- Department of Anesthesiology, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Paul E. Palumbo
- Department of Medicine, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Rashna Ginwalla
- Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Surgery, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | | | - Nathan Thielman
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
- Duke University Medical Center, Durham, NC, USA
| | - Michael Relf
- Duke Global Health Institute, Durham, NC, USA
- Duke University School of Nursing, Durham, NC, USA
| | - Rodney Wright
- Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine, New York City, NY, USA
- Obstetrics & Gynecology and Women’s Health, Montefiore Medical Center, New York City, NY, USA
| | - Mary Hill
- Division of Nursing, Howard University College of Nursing and Allied Health Sciences, Washington, DC, USA
| | - Deborah Chyun
- University of Connecticut School of Nursing, Storrs, CT, USA
| | - Robin T. Klar
- New York University Rory Meyers College of Nursing, New York City, NY, USA
| | - Linda L. McCreary
- University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Tonda L. Hughes
- Columbia University School of Nursing, New York City, NY, USA
| | - Marik Moen
- Department of Family & Community Health, University of Maryland School of Nursing, Baltimore, MD, USA
- Global Education and Mentorship, Office of Global Health, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Valli Meeks
- Department of Oncology & Diagnostic Sciences, University of Maryland School of Dentistry, Baltimore, MD, USA
| | - Beth Barrows
- Office of Global Health, University of Maryland School of Nursing, Baltimore, MD, USA
- Partnerships, Professional Education, and Practice, University of Maryland School of Nursing, Baltimore, MD, USA
| | - Marcel E. Durieux
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Craig D. McClain
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
| | - Amy Bunts
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Forrest J. Calland
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Bethany Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Danny Milner
- Center for Global Health, American Society for Clinical Pathology, Chicago, IL, USA
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Giuseppe Raviola
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Boston Children’s Hospital, Boston, MA, USA
| | - Stacy E. Smith
- Department of Radiology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Meenu Tuteja
- Global Health and Research Programs, Biomedical Research Institute, Brigham and Women’s Hospital, Boston MA, USA
| | - Urania Magriples
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT, USA
| | - Asghar Rastegar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Linda Arnold
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | | | - Agnes Binagwaho
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Institute for Health Policy and Clinical Practice, Dartmouth College, Hanover, NH, USA
- Office of the Vice-Chancellor, University of Global Health Equity, Kigali, Rwanda
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