Epidemiology of paediatric injuries in Rwanda using a prospective trauma registry.

BACKGROUND: Child survival initiatives historically prioritized efforts to reduce child morbidity and mortality from infectious diseases and maternal conditions. Little attention has been devoted to paediatric injuries in resource-limited settings. This study aimed to evaluate the demographics and outcomes of paediatric injury in a sub-Saharan African country in an effort to improve prevention and treatment. METHODS: A prospective trauma registry was established at the two university teaching campuses of the University of Rwanda to record systematically patient demographics, prehospital care, initial physiology and patient outcomes from May 2011 to July 2015. Univariable analysis was performed for demographic characteristics, injury mechanisms, geographical location and outcomes. Multivariable analysis was performed for mortality estimates. RESULTS: Of 11 036 patients in the registry, 3010 (27·3 per cent) were under 18 years of age. Paediatric patients were predominantly boys (69·9 per cent) and the median age was 8 years. The mortality rate was 4·8 per cent. Falls were the most common injury (45·3 per cent), followed by road traffic accidents (30·9 per cent), burns (10·7 per cent) and blunt force/assault (7·5 per cent). Patients treated in the capital city, Kigali, had a higher incidence of head injury (7·6 per cent versus 2·0 per cent in a rural town, P < 0·001; odds ratio (OR) 4·08, 95 per cent c.i. 2·61 to 6·38) and a higher overall injury-related mortality rate (adjusted OR 3·00, 1·50 to 6·01; P = 0·019). Pedestrians had higher overall injury-related mortality compared with other road users (adjusted OR 3·26, 1·37 to 7·73; P = 0·007). CONCLUSION: Paediatric injury is a significant contributor to morbidity and mortality. Delineating trauma demographics is important when planning resource utilization and capacity-building efforts to address paediatric injury in low-resource settings and identify vulnerable populations.

ANTECEDENTES: Históricamente, las iniciativas relativas a la supervivencia pediátrica han priorizado los esfuerzos para reducir la morbilidad y la mortalidad debida a enfermedades infecciosas y patología materna. Se ha prestado escasa atención a los traumatismos en pediatría en entornos de recursos limitados. El objetivo de este estudio ha sido evaluar la demografía y los resultados de los traumatismos pediátricos en un país del África subsahariana en un intento para mejorar la prevención y el tratamiento. MÉTODOS: Se estableció un registro prospectivo de traumatismos en dos campus universitarios de Ruanda para recoger sistemáticamente las características demográficas, atención pre-hospitalaria, fisiología inicial y resultados, de mayo de 2011 a julio de 2015. Se efectuó un análisis univariado para los datos demográficos, mecanismos del traumatismo, localización geográfica y resultados. Para las estimaciones de mortalidad se llevó a cabo un análisis multivariable. RESULTADOS: De un total de 11.036 pacientes incluidos en el registro, 3.010 (27,3%) tenían menos de 18 años. Los pacientes pediátricos eran predominantemente varones (69,9%) con una edad media de 8,3 años. Las caídas fueron la causa más frecuente del traumatismo (45,3%) seguidas de los accidentes de tráfico (30,9%), quemaduras (10,7%) y traumatismo cerrado/asalto (7,5%). Los pacientes tratados en la capital presentaban una incidencia más elevada de traumatismos craneales (7,5% versus 2,0%, P < 0,0001, razón de oportunidades, odds ratio, OR 4,08, i.c. del 95% 2,6-6,4) y una mayor mortalidad global relacionada con el traumatismo (P = 0,019, OR ajustado 3,00, i.c. del 95% 1,5-6,0). Los peatones presentaron una mortalidad global relacionada con el traumatismo más alta en comparación con otros usuarios de la carretera (P = 0,0074, OR ajustado 3,26, i.c. del 95% 1,37-7,73). CONCLUSIÓN: Los traumatismos pediátricos contribuyen significativamente a la morbilidad y mortalidad. Delinear la demografía de los traumatismos es importante a la hora de planificar el uso de recursos y el desarrollo de capacidades dirigidas al esfuerzo para abordar los traumatismos pediátricos en entornos de bajos recursos e identificar poblaciones vulnerables.

Adult and elderly population access to trauma centers: an ecological analysis evaluating the relationship between injury-related mortality and geographic proximity in the United States in 2010.

Background: Ongoing development and expansion of trauma centers in the United States necessitates empirical analysis of the effect of investment in such resources on population-level health outcomes. Methods: Multiple linear regressions were performed to predict state-level trauma-related mortality among adults and the elderly across 50 US states in 2010. The number of trauma centers per capita in each state and the percentage of each state's population living within 45-min of a trauma center served as the key independent variables and injury-related mortality served as the dependent variable. All analyses were stratified by age (adult versus elderly; elderly ≥ 65 years old) and were performed in SPSS. Results: The proportion of a population with geographic proximity to a trauma center demonstrates a consistent inverse linear relationship to injury-related mortality. The relationship reliably retains its significance in models including demographic covariates. Interestingly, access to Levels I and II trauma centers demonstrates a stronger correlation with mortality than was observed with Level III centers. Conclusion: Trauma center access is associated with reduced trauma-related mortality among both adults and the elderly as measured by state reported mortality rates. Ongoing efforts to designate and verify new trauma centers, particularly in poorly-served 'trauma deserts', could lead to lower mortality for large populations.

Ratio of cesarean sections to total procedures as a marker of district hospital trauma capacity.

BACKGROUND: There are few established metrics to define surgical capacity in resource-limited settings. Previous work hypothesizes that the relative frequency of cesarean sections (CS) at a hospital, expressed as a proportion of total operative procedures (%CS), may serve as a proxy measure of surgical capacity. We attempted to evaluate this hypothesis as it specifically relates to hospital capacity for emergency interventions for injury. METHODS: We conducted a WHO survey of emergency surgical capacity at 40 Rwandan district hospitals in November 2010 and extracted annual operative volume for 2010 from the Ministry of Health centralized statistical system. We dichotomized the 40 hospitals into low and high %CS groups below and above the median proportion of CS performed. We compared low and high %CS groups across self-reported capabilities related to facility characteristics, trauma supplies, procedural capacity, and surgical training using bivariate χ(2) statistics with significance indicated at p ≤ 0.05. We evaluated herniorrhaphy proportion of total procedures (%Hernia) as a representative general surgery procedure in the same manner. RESULTS: High %CS hospitals were less likely to report capability related to blood banking (p = 0.05), amputation (p = 0.04), closed fracture repair (p = 0.04), inhalational anesthesia (p = 0.05), and chest tube insertion (p = 0.05). Availability of reliable electricity was the only measure that showed statistical significance with the %Hernia measure (p = 0.02). CONCLUSIONS: Cesarean section proportion shows some utility as a marker for district hospital injury-care capacity in resource-limited settings.

Comprehensive national analysis of emergency and essential surgical capacity in Rwanda.

BACKGROUND: Disparities in the global availability of operating theatres, essential surgical equipment and surgically trained providers are profound. Although efforts are ongoing to increase surgical care and training, little is known about the surgical capacity in developing countries. The aim of this study was to create a baseline for surgical development planning at a national level. METHODS: A locally adapted World Health Organization survey was conducted in November 2010 to assess emergency and essential surgical capacity and volumes, with on-site interviews at 44 district and referral hospitals in Rwanda. Results were compiled for education and capacity development discussions with the Rwandan Ministry of Health and the Rwanda Surgical Society. RESULTS: Among 10·1 million people, there were 44 hospitals and 124 operating rooms (1·2 operating rooms per 100,000 persons). There was a total of 50 surgeons practising full- or part-time in Rwanda (0·49 total surgeons per 100,000 persons). The majority of consultant surgeons worked in the capital (covering 10 per cent of the population). Anaesthesia was performed primarily by anaesthesia technicians, and six of 44 hospitals had no trained anaesthesia provider. Continuous availability of electricity, running water and generators was lacking in eight hospitals, and 19 reported an absence or shortage in the availability of pulse oximetry. Equipment for life-saving surgical airway procedures, particularly in children, was lacking. A dedicated emergency area was available in only 19 hospitals. In 2009 and 2010 over 80,000 surgical procedures (major and minor) were recorded annually in Rwanda. CONCLUSION: A comprehensive countrywide assessment of surgical capacity in resource-limited settings found severe shortages in available resources. Immediate local feedback is a useful tool for creating a baseline of surgical capacity to inform country-specific surgical development.

Outpatient laparoscopic cholecystectomy: patient outcomes after implementation of a clinical pathway.

OBJECTIVE: To determine the success of a clinical pathway for outpatient laparoscopic cholecystectomy (LC) in an academic health center, and to assess the impact of pathway implementation on same-day discharge rates, safety, patient satisfaction, and resource utilization. SUMMARY BACKGROUND DATA: Laparoscopic cholecystectomy is reported to be safe for patients and acceptable as an outpatient procedure. Whether this experience can be translated to an academic health center or larger hospital is uncertain. Clinical pathways guide the care of specific patient populations with the goal of enhancing patient care while optimizing resource utilization. The effectiveness of these pathways in achieving their goals is not well studied. METHODS: During a 12-month period beginning April 1, 1999, all patients eligible for an elective LC (n = 177) participated in a clinical pathway developed to transition LC to an outpatient procedure. These were compared with all patients undergoing elective LC (n = 208) in the 15 months immediately before pathway implementation. Successful same-day discharges, reasons for postoperative admission, readmission rates, complications, deaths, and patient satisfaction were compared. Average length of stay and total hospital costs were calculated and compared. RESULTS: After pathway implementation, the proportion of same-day discharges increased significantly, from 21% to 72%. Unplanned postoperative admissions decreased as experience with the pathway increased. Patient characteristics, need for readmission, complications, and deaths were not different between the groups. Patients surveyed were highly satisfied with their care. Resource utilization declined, resulting in more available inpatient beds and substantial cost savings. CONCLUSIONS: Implementation of a clinical pathway for outpatient LC was successful, safe, and satisfying for patients. Converting LC to an outpatient procedure resulted in a significant reduction in medical resource use, including a decreased length of stay and total cost of care.

Genetic syndromes and genetic tests in colorectal cancer.

Our understanding of the biology of colon cancer has matured to the point that it is a useful general paradigm for understanding solid tumor development. Recent advances provide insight into the genetic alterations underlying the development of colon cancer. These insights provide unique opportunities for genetic testing in predisposed, asymptomatic patients that can direct screening efforts and their clinical management. This review examines several inherited colon cancer predispositions, well described clinically for a century, that are now amenable to genetic testing. Additional discussion focuses on colon cancer predisposition traits that occur with high frequency but low penetrance characteristics. Finally, genetic tests for tumor markers that potentially have prognostic or therapeutic implications are reviewed.