Prehospital transport of patients with spinal cord injury in Nigeria

The Epidemiology of Spinal Neurosurgery in Nigeria: A Systematic Review and Patient-Level Analysis

OBJECTIVE

Spinal pathologies are prevalent in Nigeria, though epidemiological data remains sparse. This systematic review used pooled patient-level data from across the country to generate a standardized epidemiological reference.

METHODS

Four research databases and gray literature sources were searched. Risk of bias assessment was conducted using Risk of Bias in Non-Randomised Studies - of Interventions and Cochrane's risk of bias tool. We descriptively analyzed all article metrics and statistically analyzed relevant data variables via paired t-test and χ2 independence tests (α = 0.05).

RESULTS

One hundred twenty-seven articles, comprising a patient cohort of 8425 patients, were analyzed. Most were retrospective cohort studies (46.5%) and case reports/series (31.5%), with an overall moderate-high risk of bias. Most studies were published in the last 20 years. Most patients were male (∼2.5 males per female), with an average age of 43.2 years (±16.4). Clinical diagnoses spanned the breadth of spinal neurosurgery. Approximately 45.0% of patients had complete spinal impairment. Pain (41.7%) was the most reported presenting feature. X-ray (45.1%) was the most common investigation used. Intervertebral disc herniation (18.9%) was the most prevalent imaging finding on MRI. Most patients were managed nonoperatively (57.8%), with a favorable outcome in 27.4% of patients. Posttreatment complications included pressure sores, infection, and motor deficits.

CONCLUSIONS

This systematic review and pooled analysis provide an epidemiological overview of spinal neurosurgery in Nigeria over the last 60 years and serves as a useful reference to direct future global research in this arena.

Epidemiological Burden of Neurotrauma in Nigeria: A Systematic Review and Pooled Analysis of 45,763 Patients

OBJECTIVE

Neurotrauma is a significant cause of morbidity and mortality in Nigeria. We conducted this systematic review to generate nationally generalizable reference data for the country.

METHODS

Four research databases and gray literature sources were electronically searched. Risk of bias was assessed using the Risk of Bias in Non-Randomized Studies of Interventions and Cochrane's risk of bias tools. Descriptive analysis, narrative synthesis, and statistical analysis (via paired t-tests and χ2 independence tests) were performed on relevant article metrics (α = 0.05).

RESULTS

We identified a cohort of 45,763 patients from 254 articles. The overall risk of bias was moderate to high. Most articles employed retrospective cohort study designs (37.4%) and were published during the last 2 decades (81.89%). The cohort's average age was 32.5 years (standard deviation, 20.2) with a gender split of ∼3 males per female. Almost 90% of subjects were diagnosed with traumatic brain injury, with road traffic accidents (68.6%) being the greatest cause. Altered consciousness (48.4%) was the most commonly reported clinical feature. Computed tomography (53.5%) was the most commonly used imaging modality, with skull (25.7%) and vertebral fracture (14.1%) being the most common radiological findings for traumatic brain injury and traumatic spinal injury, respectively. Two-thirds of patients were treated nonoperatively. Outcomes were favorable in 63.7% of traumatic brain injury patients, but in only 20.9% of traumatic spinal injury patients. Pressure sores, infection, and motor deficits were the most commonly reported complications in the latter.

CONCLUSIONS

This systematic review and pooled analysis demonstrate the significant burden of neurotrauma across Nigeria.

Evaluating a digital hybrid training-of-trainers (TOT) approach for lay first responder trauma education in urban Nigeria during the COVID-19 pandemic

INTRODUCTION

Road traffic injuries (RTIs) are the largest contributor to the global burden of injury, and in 2016 were among the five leading causes of global disability-adjusted life years (DALYs). In regions with limited emergency medical services (EMS), training lay first responders (LFRs) has been shown to increase availability of prehospital care for RTIs, but sustainable mechanisms to scale these programs remain unstudied.

METHODS

Using a training of trainers (TOT) model, a 5.5-h LFR training program was launched in Lagos, Nigeria. The course was taught in a hybrid fashion with primary didactics using videoconferencing software and practical breakout sessions in-person concurrently. Thirty TOTs proceeded to train 350 transportation providers as LFRs over one month. A 23-question, pre- and post-assessment was administered digitally to assess knowledge acquisition. Participants responded to a five-point Likert survey assessing instruction quality and post-course confidence.

RESULTS

TOTs scored a median of 56.5 % (IQR:43.5 %,71.7 %) and 91.3 % (IQR:88.0 %,95.7 %) on the pre- and post-assessments, respectively, with bleeding control scores increasing most (+69.4 %). LFR course trainees scored a median of 34.8 % (IQR: 26.0 %, 43.5 %) and 73.9 % (IQR: 65.2 %, 82.6 %) on the pre- and post-assessments respectively, with airway and breathing increasing the most (+48.6 %). All score increases were statistically significant with p < 0.001. All 30 TOT trainers instructed at least one training session after their initial session. LFR participants' rated confidence in first aid skills went from 3/5 (IQR 3, 4) pre-course to 5/5 (IQR:5,5) post-course, and in emergency transportation it went from 4/5 (IQR:3, 4) to 5/5 (IQR:5, 5), (p < 0.001). LFR course participants rated the quality of education content and TOT instructors to be 5/5 (IQR:5,5). 144 responders provided emergency care in the six-months following training for a total of 351 interventions. Active responders provided a median of 2 (IQR:1,3) interventions.

CONCLUSIONS

This is the first time that a digital hybrid instruction for first responder trainers in low- and middle-income countries has been investigated. Our findings demonstrate negligible attrition, high educational quality ratings, equally effective knowledge acquisition to that of prior in-person courses, and high post-training skill usage. Future work will examine the cost-effectiveness of the training of LFRs and the effect of LFRs on trauma outcomes.

Acute spinal cord injury in Africa: exploring the long-term outcomes and future directions of acute spinal cord injury - short communication

Acute spinal cord injury (ASCI), a key factor behind serious sensory, motor, and autonomic dysfunctions, holds on as a fundamental cause of morbidity, psychological disturbances, and high socioeconomic burden. This study sheds light, particularly on the African countries where it is found that traumatic ASCI, mainly due to road traffic accidents, remains the leading cause, with 130 cases per million in this part of the world. Moreover, limited resources, with the lack of funds and equipment, as well as widespread poverty, restrict the availability of suitable diagnostic, management, and treatment options. The weight of the evidence suggests that there is an ultimate need for well-developed infrastructure embracing a multidisciplinary approach to rehabilitation in Africa. Furthermore, international collaborations, posing a significantly wide background for evidence-based information and resources, are indispensable for ASCI prospects and future studies among the African population. The purpose of this study is to fill a part of the persistent gap in the research era regarding the ASCI in Africa and direct future research toward investigating its different aspects as well as exploring its interventional needs.

Pre-Hospital and Post-Hospital Quality of Care in Traumatic Spinal Column and Cord Injuries in Iran

STUDY DESIGN

A retrospective study.

OBJECTIVES

The quality of care (QoC) for spinal column/cord injury patients is a major health care concern. This study aimed to implement the QoC assessment tool (QoCAT) in the National Spinal Cord/Column Injury Registry of Iran (NSCIR-IR) to define the current state of pre- and post-hospital QoC of individuals with Traumatic Spinal Column and Spinal Cord Injuries (TSC/SCIs).

METHODS

The QoCAT, previously developed by our team to measure the QoC in patients with TSC/SCIs, was implemented in the NSCIR-IR. The pre-hospital QoC was evaluated through a retrospective analysis of NSCIR-IR registry data. Telephone interviews and follow-ups of patients with SCI evaluated the QoC in the post-hospital phase.

RESULTS

In the pre-hospital phase, cervical collars and immobilization were implemented in 46.4% and 48.5% of the cases, respectively. Transport time from the scene to the hospital was documented as <1 hour and <8 hours in 33.4% and 93.9% of the patients, respectively. Post-hospital indicators in patients with SCI revealed a first-year mortality rate of 12.5% (20/160), a high incidence of secondary complications, reduced access to electrical wheelchairs (4.2%) and modified cars (7.7%), and low employment rate (21.4%).

CONCLUSION

These findings revealed a significant delay in transport time to the first care facilities, low use of immobilization equipment indicating low pre-hospital QoC. Further, the high incidence of secondary complications, low employment rate, and low access to electrical wheelchairs and modified cars indicate lower post-hospital QoC in patients with SCI. These findings imply the need for further planning to improve the QoC for patients with TSC/SCIs.

Out of hospital emergency care in Nigeria: A narrative review

Introduction

Out of Hospital Emergency Care (OHEC) in Nigeria, the most populous country with the highest GDP in Africa, is considered inadequate. A better understanding of the current state of OHEC is essential to address the country's unique challenges and offer potential solutions.

Objectives

This paper sought to identify gaps, barriers, and facilitators in implementing an OHEC model in Nigeria and provide recommendations for improvement.

Methods

We searched MEDLINE (PubMed), Embase (OVID), CINAHL (EBSCO), and Google Scholar, using combinations of "emergency medical care" ('FRC,' 'PHC,' and 'EMS') OR prehospital care OR emergency training' AND 'Nigeria.' We included papers that described OHEC in Nigeria and were published in English. Of the initial 73 papers, those that met our inclusion criteria and those obtained after examination of reference lists comprised the 20 papers that contributed to our final review. Two authors independently reviewed all the papers, extracted data relevant to our objectives and performed a content analysis. All authors reviewed, discussed, and refined the proposed recommendations.

Key recommendations

For OHEC to meet the needs of Nigerians and achieve international standards, the following challenges need to be addressed: harmful cultural practices, inadequate training of citizens in the provision of first aid or of professionals that provide prehospital care, lack of proper infrastructure, poor communication, absent policy, and poor funding. Based on the available literature, this paper proposes key recommendations to improve OHEC with the hope of improving the standards of living. The federal government should provide general oversight, but this will require political will on the part of the country's leadership and the provision of adequate funding.

Prehospital Emergency Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

An under-developed and fragmented prehospital Emergency Medical Services (EMS) system is a major obstacle to the timely care of emergency patients. Insufficient emphasis on prehospital emergency systems in low- and middle-income countries (LMICs) currently causes a substantial number of avoidable deaths from time-sensitive illnesses, highlighting a critical need for improved prehospital emergency care systems. Therefore, this systematic review aimed to assess the prehospital emergency care services across LMICs.

METHODS

This systematic review used four electronic databases, namely: PubMed/MEDLINE, CINAHL, EMBASE, and SCOPUS, to search for published reports on prehospital emergency medical care in LMICs. Only peer-reviewed studies published in English language from January 1, 2010 through November 1, 2022 were included in the review. The Newcastle-Ottawa Scale (NOS) and Critical Appraisal Skills Programme (CASP) checklist were used to assess the methodological quality of the included studies. Further, the protocol of this systematic review has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (Ref: CRD42022371936) and has been conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Of the 4,909 identified studies, a total of 87 studies met the inclusion criteria and were therefore included in the review. Prehospital emergency care structure, transport care, prehospital times, health outcomes, quality of information exchange, and patient satisfaction were the most reported outcomes in the considered studies.

CONCLUSIONS

The prehospital care system in LMICs is fragmented and uncoordinated, lacking trained medical personnel and first responders, inadequate basic materials, and substandard infrastructure.

Delays in Presentation After Traumatic Spinal Cord Injury-A Systematic Review

BACKGROUND

Prompt surgical decompression after traumatic spinal cord injury (TSCI) may be associated with improved sensorimotor outcomes. Delays in presentation may prevent timely decompression after TSCI.

OBJECTIVE

To systematically review existing studies investigating delays in presentation after TSCI in low- and middle-income countries (LMICs) and high-income countries (HICs).

METHODS

A systematic review was conducted and studies featuring quantitative or qualitative data on prehospital delays in TSCI presentation were included. Studies lacking quantitative or qualitative data on prehospital delays in TSCI presentation, case reports or series with <5 patients, review articles, or animal studies were excluded from our analysis.

RESULTS

After exclusion criteria were applied, 24 studies were retained, most of which were retrospective. Eleven studies were from LMICs and 13 were from HICs. Patients with TSCI in LMICs were younger than those in HICs, and most patients were male in both groups. A greater proportion of patients with TSCI in studies from LMICs presented >24 hours after injury (HIC average proportion, 12.0%; LMIC average proportion, 49.9%; P = 0.01). Financial barriers, lack of patient awareness and education, and prehospital transportation barriers were more often cited as reasons for delays in LMICs than in HICs, with prehospital transportation barriers cited as a reason for delay by every LMIC study included in this review.

CONCLUSIONS

Disparities in prehospital infrastructure between HICs and LMICs subject more patients in LMICs to increased delays in presentation to care.

The effect of transfer status on trauma outcomes in low- and middle-income countries: A systematic review and meta-analysis

INTRODUCTION

Injuries are a leading cause of disability and death worldwide, and low- and middle-income countries (LMICs) are disproportionately burdened by trauma. Prior studies have shown that transfer status (direct transfer from injury scene to a referral hospital versus indirect transfer from another facility to a referral hospital) may affect patient outcomes. The purpose of this study is to evaluate the relationship between transfer status and trauma patient outcomes in LMICs by conducting a systematic review and meta-analysis.

METHODS

We performed a systematic search to identify studies from LMICs that evaluated the relationship between transfer status and trauma patient outcomes. We extracted data on study country, design, patient characteristics, and outcomes. We report results in the form of a narrative summary stratified by type of outcome. We also performed a meta-analysis of studies that reported mortality by transfer status. We calculated a pooled odds ratio of mortality among indirectly transferred (IT) versus directly transferred (DT) patients using random-effects modeling.

RESULTS

We included 17 observational studies from 9 LMICs in this systematic review. Outcomes assessed were time from injury to arrival at a referral hospital, post-trauma functional status, hospital length of stay, and mortality. IT patients took between 0.6 and 37.9 h longer to arrive at referral hospitals than DT patients. Hospital length of stay was up to 6 days longer for IT patients than DT patients. The pooled odds ratio of mortality among IT patients compared to DT patients was 1.55 (95% CI 1.12 - 2.15; p = 0.009).

CONCLUSION

Trauma patients in LMICs who are indirectly transferred to referral hospitals have significantly higher mortality rates than patients who present directly to referral hospitals. These results conflict with findings from HICs and reflect the relative immaturity of trauma systems in LMICs. Strategies to narrow the mortality gap between IT and DT patients include improving prehospital and primary hospital care and developing more efficient transfer protocols.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial

STUDY DESIGN

Non-inferiority trial.

OBJECTIVE

Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels.

SETTING

Washington University in St. Louis.

METHODS

Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states.

RESULTS

C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CS_seated = 0.89, CS_supine = 0.47). Foam neck braces are inferior (CS_seated = 2.35, CS_supine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior.

CONCLUSIONS

Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Direct Transfer to a Tertiary Care Hospital After Traumatic Injury is Associated with a Survival Benefit in a Resource-Limited Setting

INTRODUCTION

Trauma is a leading cause of morbidity and mortality worldwide, and patients in low- and middle-income countries are disproportionately affected. Organized trauma systems, including appropriate transfer to a higher level of care, improve trauma outcomes. We sought to evaluate the relationship between transfer status and trauma mortality in Malawi.

METHODS

We performed a retrospective analysis of trauma patients admitted to Kamuzu Central Hospital (KCH), a trauma center in Lilongwe, Malawi, between January 1, 2013, and May 30, 2018. Transfer status was categorized as direct if a patient arrives at KCH from the injury scene and indirect if a patient comes to KCH from another health care facility. We used logistic regression modeling to evaluate the relationship between transfer status and in-hospital mortality.

RESULTS

A total of 8369 patients were included in the study. The mean age was 34.6 years (SD 15.8), and 81% of patients were male. The most common mechanism of injury was motor vehicle collision. Injury severity did not significantly differ between the two groups. Crude mortality was 4.8% for indirect and 2.6% for direct transfers. After adjusting for relevant covariates, odds ratio of mortality was 2.12 (1.49-3.02, p < 0.001) for indirect versus direct transfers.

CONCLUSION

Trauma patients indirectly transferred to a trauma center have nearly double the risk of mortality compared to direct transfers. Trauma outcome improvement efforts must focus on strengthening prehospital care, improving district hospital capacity, and developing protocols for early assessment, treatment, and transfer of trauma patients to a trauma center.

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review

INTRODUCTION

Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown.

METHODS

This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs.

RESULTS

Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability.

DISCUSSION

Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care.

Neurosurgical Emergencies at a Tertiary Referral Center in a Sub-Saharan African Country

Background  The practice of neurosurgery in a teaching hospital requires modern diagnostic tools and a rigorous organization of care.

Objectives  To present and discuss the management of neurosurgical emergencies in a teaching hospital in poor and low-income country.

Patients and Methods  This is a retrospective and descriptive study from April 2015 to March 2017 and includes traumatic and nontraumatic neurosurgical emergencies. Epidemiological, diagnostic, operative, and outcome data were evaluated.

Results  During the study period, 397 cases of neurosurgery were admitted. One hundred seventy-five of them were emergencies (43%), including 168 (96%) of traumatic origin. The average age was 32.5 years (1–80 years) with a male predominance: 149 men for 26 women, the sex ratio was 6.68. The cause of the neurotraumatological emergency was mostly road accidents with 143 cases (85.1%). The trauma was brain injury in 155 patients (92.3%) and spine injury in 13 patients (7.7%). In 64.3% of cases, diagnostic imaging was done beyond 48 hours. Surgery time was more than 48 hours when it was performed (21 cases). Outcome was good for 19 patients. Overall and postoperative mortality were, respectively, 34.5% (58 cases) and 9.5% (2 cases).

Conclusion  Neurosurgical emergencies care at the Departmental Teaching Hospital of Ouémé–Plateau has become a common activity with encouraging operating results despite difficult practice conditions.

Penetrating spinal cord injury causing paraplegia in a bird hunter in rural Tanzania

Introduction

Cultural and socioeconomic factors influence the risk of sustaining a Traumatic Spinal Cord Injury (TSCI). The standard of management and rehabilitation available to TSCI patients differs greatly between high-income and low-income countries.

Case presentation

We report a 17-year-old male bird hunter, with no prior medical history, presenting with paraplegia and sensory loss from the xiphoid process down after being struck by an arrow in the left lateral side of the neck.

Discussion

Penetrating neck injuries are potentially life threatening because of the complex arrangement of vital structures in the neck. Management of spinal cord trauma resulting from such injuries in low-resource settings is challenging.

Risk indicators of length of acute hospital stay after traumatic spinal cord injury in South Africa: a prospective, population-based study

STUDY DESIGN

Population-based cohort study.

OBJECTIVES

To determine non-modifiable and modifiable risk indicators of acute length of hospital stay (LOHS) after traumatic spinal cord injury (TSCI).

SETTING

Government-funded hospitals within the City of Cape Town, South Africa.

METHODS

Newly injured survivors of TSCI during a 1 year period were prospectively included. Non-modifiable (e.g., demographic factors and clinical characteristics) and modifiable risk indicators (e.g., clinical processes, timing of surgery, secondary complications) of prolonged LOHS (31 days) were determined using univariate and multivariable logistic regression analyses.

RESULTS

Of the total population-based cohort of 145 individuals, 139 (96%) had valid LOHS data and were included in the analyses. Significant univariate non-modifiable risk indicators of LOHS were age, complete injury and vertebral injury, whereas modifiable risk indicators were delayed spinal surgery (>72 h) and the occurrence of any secondary complications, as well as specifically pressure ulcers, pneumonia and urinary tract infection. In the final multivariable model showing good fit and acceptable discrimination (AUC = 0.86), older age (OR: 1.04, 95% CI: 1.00-1.07), vertebral injury (OR: 3.18, 95% CI: 1.07-9.44), pneumonia (OR: 8.40, 95% CI: 2.76-25.55) and pressure ulcers (OR: 7.16, 95% CI: 2.54-20.22) remained significant independent factors. Only injury completeness was insignificant in the final model.

CONCLUSIONS

Our findings shed light on the need of developing prevention programs for secondary complications to improve the quality and efficiency of acute SCI care in South Africa.

SPONSORSHIP

The National Research Foundation of South Africa.

Traumatic spinal cord injury in the north-east Tanzania - describing incidence, etiology and clinical outcomes retrospectively

Background: Causes, magnitude and consequences of traumatic spinal cord injury depend largely on geography, infrastructure, socioeconomic and cultural activities of a given region. There is a scarcity of literature on profile of traumatic spinal cord injury to inform prevention and rehabilitation of this health condition in African rural settings, particularly Tanzania.

Objective: To describe the incidence, etiology and clinical outcomes of traumatic spinal cord injury and issues related to retrospective study in underdeveloped setting.

Methods: Records for patients with traumatic spinal cord injury for five consecutive years (2010–2014) were obtained retrospectively from the admission wards and health records archives of the Kilimanjaro Christian Medical Center. Sociodemographic, cause, complications and patients’ condition on discharge were recorded and analyzed descriptively.

Results: The admission books in the wards registered 288 new traumatic spinal cord injury cases from January 2010 to December 2014. Of the 288 cases registered in the books, 224 were males and 64 females with mean age 39.1(39.1 ± 16.3) years and the majority of individuals 196(68.1%) were aged between 16 and 45 years. A search of the hospital archives provided 213 full patient records in which the leading cause of injury was falls 104(48.8%) followed by road traffic accidents 73(34.3%). Cervical 81(39.9%) and lumbar 71(34.74%) spinal levels were the most affected. The annual incidence for the Kilimanjaro region (population 1,640,087) was estimated at more than 26 persons per million population. The most documented complications were pressure ulcers 42(19.7%), respiratory complications 32(15.0%) and multiple complications 28(13.1%). The mean length of hospital stay was 64.2 ± 54.3 days and the mortality rate was 24.4%.

Conclusion: Prevention of traumatic spinal cord injury in North-east Tanzania should consider falls (particularly from height) as the leading cause, targeting male teenagers and young adults. Pressure ulcers, respiratory complications, in-hospital mortality and availability of wheelchairs should be addressed.

Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia

BACKGROUND

Africa accounts for one sixth of global road traffic deaths-most in the pre-hospital setting. Ambulance transport is expensive relative to other modes of pre-hospital transport, but has advantages in time-sensitive, high-acuity scenarios. Many countries, including Ethiopia, are expanding ambulance fleets, but clinical characteristics of patients using ambulances remain ill-defined.

METHODS

This is a cross-sectional study of 662 road traffic collisions (RTC) patients arriving to a single trauma referral center in Addis Ababa, Ethiopia, over 7 months. Emergency Department triage records were used to abstract clinical and arrival characteristics, including acuity. The outcome of interest was ambulance arrival. Secondary outcomes of interest were inter-facility referral and referral communication. Descriptive and multivariable statistics were computed to identify factors independently associated with outcomes.

RESULTS

Over half of patients arrived with either high (13.1%) or moderate (42.2%) acuity. Over half (59.0%) arrived by ambulance, and nearly two thirds (65.9%) were referred. Among referred patients, inter-facility communication was poor (57.7%). Patients with high acuity were most likely to be referred (aOR 2.20, 95%CI 1.16-4.17), but were not more likely to receive ambulance transport (aOR 1.56, 95%CI 0.86-2.84) or inter-facility referral communication (aOR 0.98, 95%CI 0.49-1.94) than those with low acuity. Nearly half (40.2%) of all patients were referred by ambulance despite having low acuity.

CONCLUSIONS

Despite ambulance expansion in Addis Ababa, ambulance use among RTC patients remains heavily concentrated among those with low-acuity. Inter-facility referral appears a primary contributor to low-acuity ambulance use. In other contexts, similar routine ambulance monitoring may help identify low-value utilization. Regional guidelines may help direct ambulance use where most valuable, and warrant further evaluation.

Analysis of Prehospital Transport Use for Trauma Patients in Lusaka, Zambia

Despite an increasing burden of injuries, prehospital transport systems remain underdeveloped in many low- and middle-income countries. Little information exists on the use of prehospital services for trauma patients in Zambia.

METHOD

A prospective, observational study of trauma presentations was undertaken for 6 months in Lusaka, Zambia, to establish the epidemiology and outcomes of injury in the region. In addition to demographics and mechanism of injury, data were collected on prehospital transport as well as inpatient resources utilization. Trained study personnel gathered data on trauma presentations 24 h a day. Statistical analysis was conducted using SAS 9.3 from a Microsoft^® Access database.

RESULTS

3498 trauma patients were enrolled in the study on arrival to University Teaching Hospital (UTH). 3264 patients had a transport means recorded (95.3 %). Two-thirds (66 %) arrived within 6 h of injury, and 23 % arrived within the first hour after injury. A majority arrived by private vehicle (53.4 %) or public transport (37.7 %); only 5.9 % were transported by public or private ambulance. Of those arriving within the first hour after injury, 69.1 % came by private car, 24.6 % by public transport and 3.1 % by ambulance. There was a small statistical increase in Kampala Trauma Score II among ambulance arrivals.

CONCLUSION

Trauma patient use a variety of transport methods to get to UTH. A majority of patients use no formal ambulance transport. Despite this fact, a majority arrives within 6 h of injury but receive no formal prehospital care. An integrated, multilayered prehospital care and transport system may be the most effective approach for Zambia.

EMS Systems in Lower-Middle Income Countries: A Literature Review

Introduction Prehospital care is one of the many issues that require addressing by lower-middle income countries (LMICs) where approximately 90% of global injuries occur. This may arise from more traffic in LMICs, poor road conditions, lack of public awareness of the importance of road safety, and the lack of ability to provide first aid to the victims. However, prehospital care in LMICs remains underdeveloped. Problem There is insufficient evidence regarding the development of prehospital care among LMICs. Thus, the objective of this study was to investigate the status of Emergency Medical Services (EMS) systems in these countries.

METHODS

A review of medical-related electronic databases was designed to identify the development of EMS systems in LMICs. A search of the literature was undertaken using three electronic databases, CINAHL, Ovid Medline, and EMBASE via Ovid, from their commencement date until the end of July 2015. The grey literature was searched using Google Scholar. Articles were included if they reported on the establishment and current status of an EMS system and were excluded if they were letters to the editor, articles focusing on disaster management, a combination of more than one country if the other country was not a LMIC, written in a language other than English or Bahasa Indonesia, and/or focusing only on in-hospital care.

RESULTS

There were 337 articles identified in CINAHL, 731 in Ovid Medline, 891 in EMBASE via Ovid, and 41 in Google Scholar. Based on the title and abstract, 31 articles from CINAHL, 40 from Ovid Medline, 43 from EMBASE, and 11 from Google Scholar were retrieved for further review. There were 92 articles that met the inclusion criteria with 35 articles removed, as they were duplicated, leaving 57 articles to be reviewed. From those 48 countries categorized as LMICs, there were 16 (33.3%) countries that had information about an EMS system, including injury types, patient demographic, prehospital transport, and the obstacles in implementing the prehospital care system.

CONCLUSION

The implementation and development of an EMS system is varied among LMICs. Many LMICs lack an organized EMS system with most ambulances used purely for transport and not as an emergency care vehicle. Financial issues are the most common problems faced by LMICs with support from developed countries a necessity. Suryanto , Plummer V , Boyle M . EMS systems in lower-middle income countries: a literature review. Prehosp Disaster Med. 2017;32(1):64-70.

Outcomes after acute traumatic spinal cord injury in Botswana: from admission to discharge

STUDY DESIGN

Prospective follow-up study.

OBJECTIVES

To increase the knowledge regarding clinical and functional outcomes after traumatic spinal cord injuries (TSCI) in a resource-constrained setting. A special focus was placed on secondary complications such as pressure ulcers.

SETTING

The national referral hospital in Gaborone, Botswana.

METHODS

The study included all patients admitted with an acute TSCI during a 2-year period (n=39). Data collection was conducted at the time of discharge, and clinical characteristics, length of stay and pressure ulcers were analysed using descriptive and inferential statistics.

RESULTS

Completeness of injury and presence of pressure ulcers were the factors found to significantly prolong hospitalization, which was 5 months (median). One patient died before discharge and one was discharged to rehabilitation in South Africa; all other patients were living with close or distant family members after discharge. Patients were supplied with electrical or manual active wheelchairs. Self-catheterization or suprapubic catheters were the main methods for bladder management, and ano-rectal stimulation to manage the bowel. Pressure ulcers, urinary tract infections and pain were the most frequent complications during in-patient care.

CONCLUSIONS

Rehabilitation of patients with TSCI in Botswana has been going through big changes, and new rehabilitation objectives, such as techniques used for the management of bladder and bowel dysfunctions and the provision of technical aids, have been implemented, which likely can contribute to an overall improvement in the outcomes. However, basic care at the general wards is still lagging behind, causing high rates of pressure ulcers that significantly extend hospitalization periods.

Mortality and longevity after a spinal cord injury: systematic review and meta-analysis

BACKGROUND/AIMS

Mortality and longevity studies of spinal cord injury (SCI) are essential for informing healthcare systems and policies. This review evaluates the current evidence among people with SCIs worldwide in relation to the WHO region and country income level; demographic and lesion characteristics; and in comparison with the general population.

METHODS

A systematic review of relevant databases for original studies. Pooled estimates were derived using random effects meta-analysis, restricted to traumatic SCI.

RESULTS

Seventy-four studies were included. In-hospital mortality varied, with pooled estimates of 24.1% (95% confidence interval (CI) 14.1-38.0), 7.6% (95% CI 6.3-9.0), 7.0% (95% CI 1.5-27.4), and 2.1% (95% CI 0.9-5.0) in the WHO regions of Africa, the Americas, Europe and Western Pacific. The combined estimate for low- and middle-income countries was nearly three times higher than for high-income countries. Pooled estimates of first-year survival were 86.5% (95% CI 75.3-93.1), 95.6% (95% CI 81.0-99.1), and 94.0% (95% CI 93.3-94.6) in the Americas, Europe and Western Pacific. Pooled estimates of standardized mortality ratios in tetraplegics were 2.53 (2.00-3.21) and 2.07 (1.47-2.92) in paraplegics.

CONCLUSION

This study found substantial variation in mortality and longevity within the SCI population, compared to the general population, and between WHO regions and country income level. Improved standardization and quality of reporting is needed to improve inferences regarding the extent to which mortality outcomes following an SCI are related to healthcare systems, services and policies.

Pressure ulcers in people with spinal cord injury in developing nations

STUDY DESIGN

Literature review.

OBJECTIVES

To explore the prevalence or incidence, risk factors, and costs of pressure ulcers among individuals with spinal cord injury (SCI), specifically in the context of the developing world. To highlight important targets for intervention and research for pressure ulcer management the world over.

SETTING

World Bank 'low-income' and 'middle-income' countries with a gross national income per capita <$12 746.

METHODS

PubMed search.

RESULTS

SCI-associated pressure ulcers are very prevalent in developing nations; however, reported prevalence and incidence numbers are highly variable. Risk factors for pressure ulcers are similar in developed and developing countries however many of the risk factors are more prevalent in developing nations.

CONCLUSION

SCI-associated pressure ulcers are common but can be prevented in the developing world. Key targets for interventions include acute care, nurse-to-patient ratios, support surfaces and education.

Where do I go? A trauma victim's plea in an informal trauma system

BACKGROUND

The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality.

OBJECTIVE

To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations.

MATERIALS AND METHODS

A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center.

RESULTS

The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care.

CONCLUSIONS

Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions.

[Challenge of the management of severe trauma of cervical spine in sub-developed country]

BACKGROUND AND PURPOSE

The management of cervical spine injuries requires a multidisciplinary approach based on emergency management and rehabilitation. In our context this chain fails, especially on the post-hospital care. Our goal is to explain the difficulties we had in the management of these patients in Dakar.

METHODS

This retrospective cohort study (2005-2009) included 99 patients admitted for severe cervical spinal cord injury in two hospitals in Dakar. The clinical signs, treatment and outcome were studied. The follow up was between 3 and 54 months.

RESULTS

The average age of patients was 36.1 years and the traffic accidents were the main etiology (73.7%). Medical transport of patients was done in 65.7% with an admission average time of 64.86 hours. On admission, 57.6% of patients had Frankel score A or B. Dislocations (59.6%) and Tear drop fractures (16.2%) were the main lesions. The surgery was performed in 83.8% with a mean interval of 128.84 hours after the trauma. Outpatient rehabilitation was offered whatever the patient's neurological status. Recovery was complete in 20.2% and partial in 31.3% with a mortality rate of 37.4%. Most deaths occurred between 1 and 6 months (59.5%) mainly due to decubitus complications (56.8%).

CONCLUSION

The efficacy of the management of severe spinal cord injuries is based on reducing the preoperative time and rehabilitation.

The challenge of spinal cord injury care in the developing world

Great strides have been made in reducing morbidity and mortality following spinal cord injury (SCI), and improving long-term health and community participation; however, this progress has not been uniform across the globe. This review highlights differences in global epidemiology of SCI and the ongoing challenges in meeting the needs of individuals with SCI in the developing world, including post-disaster. Significant disparities persist, with life expectancies of 2 years or less not uncommon for persons living with paraplegia in many developing countries. The international community has an important role in improving access to appropriate care following SCI worldwide.