Surgical Simulation Training for Medical Students: Strategies and Implications in Botswana.

BACKGROUND: The role of simulation in teaching technical skills to medical students is not yet well defined. Strategies for its use may be especially relevant where teachers, time, and resources are limited, especially in low-middle-income countries. METHODS: Sixty-seven third-year and 67 fifth-year medical students at the University of Botswana were taught surgical skills by a trained peer medical student, a medical officer with no specialty training or a staff surgeon. Pre- and post-intervention performance of two basic tasks (simple interrupted suture (SIS) and laparoscopic peg transfer (LPT)) and one complex task (laparoscopic intracorporeal suture (LIS)) were assessed. Subjective measures of self-perceived performance, preparedness for internship, and interest in surgery were also measured. RESULTS: The simulation program decreased the time to complete the two basic tasks and improved the objective score for the complex task. Performance of the basic skills improved regardless of the seniority of the instructor while performance of the advanced skill improved more when taught by a staff surgeon. All students had similar improvements in their self-reported confidence to perform the skills, preparedness to assist in an operation and preparedness for internship, regardless of the seniority of their instructor. Students taught by a staff surgeon felt better prepared to assist in laparoscopic procedures. CONCLUSION: Simulation-based teaching of defined surgical skills can be effectively conducted by peers and near-peers. The implications are widespread and may be most relevant where time and resources are limited, and where experienced teachers are scarce.

Sustaining a laparoscopic program in resource-limited environments: results and lessons learned over 13 years in Botswana.

BACKGROUND: Metrics of sustainability and frank descriptions of the unique challenges, successes, failures, and lessons learned from a longitudinal laparoscopic program in resource-limited environments are lacking. We set out to evaluate the safety and sustainability of the laparoscopic cholecystectomy program at Princess Marina Hospital, the largest tertiary and teaching hospital in Botswana. METHODS: We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy from January 2013 to December 2018. Technical independence and sustainability factors were measured and discussed. RESULTS: Two hundred and twenty-six laparoscopic cholecystectomies (LC) and 39 open cholecystectomies (OC) were performed. Four surgeons who trained as part of the inaugural laparoscopic program performed 48.2% of LC. Eleven surgeons who trained elsewhere performed the remainder. Overall, 94.2% of LC were performed without expatriate surgeons. The conversion rate was 25/226 (11.1%). There were 3 bile duct injuries in the LC group (3/226, 1.3%) and none in the OC group. There was one mortality in the OC group (1/39, 2.6%) and none in the LC group. Fostering a trusting relationship among all stakeholder was identified as the major key to success, while the development of a system-based strategy was identified as the most significant ongoing challenge. CONCLUSION: The laparoscopic cholecystectomy program in Botswana initially established between 2006 and 2012 has moved into its sustainability phase, characterized by increased usage of laparoscopy and greater independent operating by local surgeons, all while maintaining patient safety. Sustaining a laparoscopic program in resource-limited environments has particular challenges which may differ from country to country.

HIV Infection: Its Impact on Patients with Appendicitis in Botswana.

BACKGROUND: To compare the presentation, management, and outcome of HIV-positive patients with appendicitis to those of HIV-negative patients with appendicitis. SUMMARY BACKGROUND DATA: The literature is limited regarding the impact of HIV infection on patients with appendicitis. METHODS: A retrospective review of patients with appendicitis and known HIV status admitted to Princess Marina Hospital, Gaborone, Botswana, aged 13 years and greater was performed from January 2013 to December 2015. Data on patient demographics, presentation, laboratory findings, management, and outcomes were analyzed. RESULTS: A total of 295 patients with appendicitis and known HIV status were identified, of which 119 (40.3%) were HIV positive. The median [IQR] ages for HIV-positive and HIV-negative patients were 34 [29-42] and 26 [20-33] years, respectively. The male-to-female ratio for the same two groups was 0.8:1 and 1.4:1, respectively. Presenting symptoms, signs, and white blood cell count were similar in both groups. HIV-positive patients had significantly higher overall (4.2 vs. 0.0%, p = 0.010) and postoperative (4.4 vs. 0.0%, p = 0.024) mortality rates. There was no significant difference in the total complication rate between HIV-positive and HIV-negative patients (13.2 vs. 7.9%, p = 0.192). Compared to HIV-positive patients with a CD4 count ≥200, patients with a CD4 count <200 have a significantly higher postoperative mortality rate (17.6 vs. 1.4%, p = 0.023) and a trend toward a higher total postoperative complication rate (31.3 vs. 10.8%, p = 0.054). CONCLUSION: Within our setting, HIV infection, particularly with a CD4 <200, was correlated with significantly higher mortality in patients with acute appendicitis.

Deaths from acute abdominal conditions and geographic access to surgical care in India: a nationally representative population-based spatial analysis.

BACKGROUND: Acute abdominal conditions have high case-fatality rates in the absence of timely surgical care. In India, and many other low-income and middle-income countries, few population-based studies have quantified mortality from surgical conditions and related mortality to access to surgical care. We aimed to describe the spatial and socioeconomic distributions of deaths from acute abdomen (DAA) in India and to quantify potential access to surgical facilities in relation to such deaths. METHODS: We examined deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million Indian households and linked these to nationally representative facility data. Spatial clustering of deaths from acute abdominal conditions was calculated with the Getis-Ord Gi* statistic from about 4000 postal codes. We compared high or low acute abdominal mortality clusters for their geographic access to well-resourced surgical care (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology). FINDINGS: 923 (1·1%) of 86 806 study deaths in those aged 0-69 years were identified as deaths from acute abdominal conditions, corresponding to an estimated 72 000 deaths nationally in India in 2010. Most deaths occurred at home (71%), in rural areas (87%), and were caused by peptic ulcer disease (79%). There was wide variation in rates of deaths from acute abdominal conditions. We identified 393 high-mortality geographic clusters and 567 low-mortality clusters. High-mortality clusters of acute abdominal conditions were located significantly further from well-resourced hospitals than were low-mortality clusters. The odds ratio of a postal code area being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 for >100 km), after adjustment for socioeconomic status and caste. INTERPRETATION: Improvements in human and physical resources at existing public hospitals are required to reduce deaths from acute abdominal conditions in India. Had all of the Indian population had access to well-resourced hospitals within 50 km, more than 50 000 deaths from acute abdominal conditions could have been averted in 2010, and likely more from other emergency surgical conditions. Our geocoded facility data were limited to public district hospitals. However, noting the high rate of catastrophic health expenditures in India, we chose to focus on publicly provided services which are the only option usually available to the poor. FUNDING: The Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, and Canadian Institute of Health Research.

The International Association of Student Surgical Societies: creation and dissemination.

SUMMARY: While initiatives exist to address the worldwide need for surgeons, none involve a student-driven solution from low- and middle-income countries (LMICs). In response to falling surgical residency enrolment in South Africa, the students at the University of Cape Town (UCT) founded the UCT Surgical Society and were subsequently instrumental in creating the International Association of Student Surgical Societies (IASSS). The IASSS currently includes 25 societies in 15 countries. Its primary objectives are building sustainable networks for mutually beneficial exchanges, supporting student-driven projects, understanding issues impacting student interest in surgery, promoting global fellowship, creating an elective database and providing assistance to student surgical societies. The IASSS is a unique student-led initiative trying to improve surgical care in LMICs.

Establishing a contextually appropriate laparoscopic program in resource-restricted environments: experience in Botswana.

OBJECTIVE: Differences in opinion exist as to the feasibility of establishing sustainable laparoscopic programs in resource-restricted environments. At the request of local surgeons and the Ministry of Health in Botswana, a training program was established to assist local colleagues with laparoscopic surgery. We reviewed our multifaceted and evolving international collaboration and highlighted those factors that have helped or hindered this program. METHODS: From 2006 to 2012, a training program consisting of didactic teaching, telesimulation, Fundamentals of Laparoscopic Surgery certification, yearly workshops, and ongoing mentorship was established. We assessed the clinical outcomes of patients who underwent laparoscopic cholecystectomy, comparing them with patients who underwent open cholecystectomy, and measured the indicators of technical independence and program sustainability. RESULTS: Twelve surgeons participated in the training program and performed 270 of 288 laparoscopic cholecystectomies. Ninety-six open cases were performed by these and 5 additional surgeons. Fifteen laparoscopic cases were converted (5.2%). The median postoperative length of hospital stay was significantly shorter in the laparoscopic group than in the open group (1 day vs 7 days, P < 0.001). As the training program progressed, the proportion of laparoscopic cases completed without an expatriate surgeon present increased significantly (P = 0.001). CONCLUSIONS: A contextually appropriate long-term partnership may assist with laparoscopic upskilling of colleagues in low- and middle-income countries. This type of collaboration promotes local ownership and may translate into better patient outcomes associated with laparoscopic surgery. In resource-restricted environments, the factors threatening sustainability may differ from those in high-income countries and should be identified and addressed.

Is activity restriction appropriate for patients with hereditary spherocytosis? A population-based analysis.

Patients with hereditary spherocytosis (HS) are often thought to have an increased risk of blunt splenic injury (BSI) from trauma due to splenomegaly. We aim to quantify this risk. Using a population-based database consisting of all injury-related admissions in Canada from 2001 to 2010, we identified patients with BSI and HS based on the discharge diagnoses. Intercensal population estimates were used to derive rates of BSI. The HS population at risk for BSI was estimated based on population rates of HS obtained from the literature. Rates of BSI in the HS population were estimated and the relative rates of BSI were calculated to compare the populations with and without HS. There were 10,106 patients with BSI over 202,405,788 person-years of observation, yielding an overall rate of BSI in the general population of 5.0 BSI per 100,000 person-years. Of these BSI patients, only two had a history of HS. Population rates of HS in the literature range from 1 in 2,000 to 5,000, corresponding to a low estimate of 2.0 and a high estimate of 4.9 BSI per 100,000 person-years in the HS population. The relative rate of BSI in the population with HS compared to the population without HS ranged from a low of 0.4 (95 % CI 0.1-1.4) to a high of 1.0 (0.1-3.6). The rate of BSI in the HS patient population appears not to differ significantly from those in the general population.

Effects of tuberculosis and/or HIV-1 infection on COVID-19 presentation and immune response in Africa.

Few studies from Africa have described the clinical impact of co-infections on SARS-CoV-2 infection. Here, we investigate the presentation and outcome of SARS-CoV-2 infection in an African setting of high HIV-1 and tuberculosis prevalence by an observational case cohort of SARS-CoV-2 patients. A comparator group of non SARS-CoV-2 participants is included. The study includes 104 adults with SARS-CoV-2 infection of whom 29.8% are HIV-1 co-infected. Two or more co-morbidities are present in 57.7% of participants, including HIV-1 (30%) and active tuberculosis (14%). Amongst patients dually infected by tuberculosis and SARS-CoV-2, clinical features can be typical of either SARS-CoV-2 or tuberculosis: lymphopenia is exacerbated, and some markers of inflammation (D-dimer and ferritin) are further elevated (p < 0.05). Amongst HIV-1 co-infected participants those with low CD4 percentage strata exhibit reduced total, but not neutralising, anti-SARS-CoV-2 antibodies. SARS-CoV-2 specific CD8 T cell responses are present in 35.8% participants overall but undetectable in combined HIV-1 and tuberculosis. Death occurred in 30/104 (29%) of all COVID-19 patients and in 6/15 (40%) of patients with coincident SARS-CoV-2 and tuberculosis. This shows that in a high incidence setting, tuberculosis is a common co-morbidity in patients admitted to hospital with COVID-19. The immune response to SARS-CoV-2 is adversely affected by co-existent HIV-1 and tuberculosis.

Higher mortality associated with the SARS-CoV-2 Delta variant in the Western Cape, South Africa, using RdRp target delay as a proxy: a cross-sectional study.

Background: The SARS-CoV-2 Delta variant (B.1.617.2) has been associated with more severe disease, particularly when compared to the Alpha variant. Most of this data, however, is from high income countries and less is understood about the variant's disease severity in other settings, particularly in an African context, and when compared to the Beta variant. Methods: A novel proxy marker, RNA-dependent RNA polymerase (RdRp) target delay in the Seegene Allplex TM 2019-nCoV (polymerase chain reaction) PCR assay, was used to identify suspected Delta variant infection in routine laboratory data. All cases diagnosed on this assay in the public sector in the Western Cape, South Africa, from 1 April to 31 July 2021, were included in the dataset provided by the Western Cape Provincial Health Data Centre (PHDC). The PHDC collates information on all COVID-19 related laboratory tests, hospital admissions and deaths for the province. Odds ratios for the association between the proxy marker and death were calculated, adjusted for prior diagnosed infection and vaccination status. Results: A total of 11,355 cases with 700 deaths were included in this study. RdRp target delay (suspected Delta variant) was associated with higher mortality (adjusted odds ratio [aOR] 1.45; 95% confidence interval [CI]: 1.13-1.86), compared to presumptive Beta infection. Prior diagnosed infection during the previous COVID-19 wave, which was driven by the Beta variant, was protective (aOR 0.32; 95%CI: 0.11-0.92) as was vaccination (aOR [95%CI] 0.15 [0.03-0.62] for complete vaccination [≥28 days post a single dose of Ad26.COV2.S or ≥14 days post second BNT162b2 dose]). Conclusion: RdRp target delay, a proxy for infection with the Delta variant, is associated with an increased risk of mortality amongst those who were tested for COVID-19 in our setting.

Response to a cluster of Severe Acute Respiratory Syndrome Coronavirus 2 cases at a diagnostic laboratory.

INTRODUCTION: We report on the first documented cluster of Coronavirus Disease 2019 cases amongst diagnostic laboratory staff and outline some of the initial and ongoing steps that are being implemented to manage and prevent the spread of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in our laboratory. CASE PRESENTATION: On 24 April 2020, three staff members of a tertiary diagnostic laboratory in Groote Schuur Hospital, Cape Town, South Africa, tested positive for SARS-CoV-2. Within seven days, a further nine cases were identified, which suggested an outbreak and prompted a full investigation. MANAGEMENT AND OUTCOME: A multifaceted strategic approach was adopted to halt the spread of SARS-CoV-2 in our laboratory. Interventions focused on simultaneously establishing appropriate risk mitigation and stratification strategies through the upscaling of infection prevention and control measures, whilst minimising disruption to service delivery. CONCLUSION: Laboratory Coronavirus Disease 2019 outbreaks have the potential to cripple a laboratory's testing capacity. Contingency planning and risk assessments should occur early, and interventions should be modified according to each laboratory's available resources and infrastructure.

"What do kids know": a survey of 420 Grade 5 students in Cambodia on their knowledge of burn prevention and first-aid treatment.

INTRODUCTION: Cambodia is a developing country of 13 million people where there are an estimated 20,000 burns and 2000 burn deaths annually. Two thirds of the burns occur to children under the age of 10 years. The purpose of this study was to determine the knowledge of burn prevention and first aid for burns in Grade 5 Cambodian school children, as baseline information to design a burn prevention campaign. METHODS: A 34-question survey regarding burn prevention and first-aid treatment for burn injuries was developed. Additional questions on TV watching habits were included to determine the feasibility of a targeted TV burn educational campaign. The survey was translated into Khmer language and tested on a trial class for accuracy and ease of administration. After obtaining the school director's permission and children's consent the survey was administered by Canadian medical students helped by trained translators and teachers to Grade 5 students from eight different elementary schools in the Kampot province. RESULTS: A total of 420 students were surveyed. Average age was 12.5 years (range 9-17 years) and 55% were females. Seventy-four percent routinely cared for other children. Only 52% had TV at home but still 78% managed to watch TV for an average 2h per day. Even though 36% of students indicated they had received information about burn prevention and first aid, only 13% mentioned application of cool water as initial treatment, only 7% knew to roll on the ground if their clothes caught fire, and nearly 50% would pour water on a burning pot of oil. Half of students indicated that they would not believe a TV message promoting application of cold water on acute burns. Top reasons given were parental influence, belief in other treatments, and not trusting TV messages. Interestingly, 62% of these skeptics would change their mind if the TV message was endorsed by an authority figure such as a physician, teacher, parent, or the Ministry of Health. A set of five Public Service Announcements for Cambodian TV were developed and produced based on the results of this survey. CONCLUSIONS: This survey identified significant inadequacies in Cambodian children's knowledge about burn prevention and first aid and suggested that a televised burn prevention campaign could be an effective method to improve their knowledge, especially if it was endorsed by an authority figure.

Steady-state kinetics and inhibition of anaerobically purified human homogentisate 1,2-dioxygenase.

HGO (homogentisate 1,2-dioxygenase; EC 1.13.11.5) catalyses the O2-dependent cleavage of HGA (homogentisate) to maleylacetoacetate in the catabolism of tyrosine. Anaerobic purification of heterologously expressed Fe(II)-containing human HGO yielded an enzyme preparation with a specific activity of 28.3+/- 0.6 micromol x min(-1) x mg(-1) (20 mM Mes, 80 mM NaCl, pH 6.2, 25 degrees C), which is almost twice that of the most active preparation described to date. Moreover, the addition of reducing agents or other additives did not increase the specific activity, in contrast with previous reports. The apparent specificity of HGO for HGA was highest at pH 6.2 and the steady-state cleavage of HGA fit a compulsory-order ternary-complex mechanism (K(m) value of 28.6+/-6.2 microM for HGA, K(m) value of 1240+/-160 microM for O2). Free HGO was subject to inactivation in the presence of O2 and during the steady-state cleavage of HGA. Both cases involved the oxidation of the active site Fe(II). 3-Cl HGA, a potential inhibitor of HGO, and its isosteric analogue, 3-Me HGO, were synthesized. At saturating substrate concentrations, HGO cleaved 3-Me and 3-Cl HGA 10 and 100 times slower than HGA respectively. The apparent specificity of HGO for HGA was approx. two orders of magnitude higher than for either 3-Me or 3-Cl HGA. Interestingly, 3-Cl HGA inactivated HGO only twice as rapidly as HGA. This contrasts with what has been observed in mechanistically related dioxygenases, which are rapidly inactivated by chlorinated substrate analogues, such as 3-hydroxyanthranilate dioxygenase by 4-Cl 3-hydroxyanthranilate.

Phylogenetic Exploration of Nosocomial Transmission Chains of 2009 Influenza A/H1N1 among Children Admitted at Red Cross War Memorial Children's Hospital, Cape Town, South Africa in 2011.

Traditional modes of investigating influenza nosocomial transmission have entailed a combination of confirmatory molecular diagnostic testing and epidemiological investigation. Common hospital-acquired infections like influenza require a discerning ability to distinguish between viral isolates to accurately identify patient transmission chains. We assessed whether influenza hemagglutinin sequence phylogenies can be used to enrich epidemiological data when investigating the extent of nosocomial transmission over a four-month period within a paediatric Hospital in Cape Town South Africa. Possible transmission chains/channels were initially determined through basic patient admission data combined with Maximum likelihood and time-scaled Bayesian phylogenetic analyses. These analyses suggested that most instances of potential hospital-acquired infections resulted from multiple introductions of Influenza A into the hospital, which included instances where virus hemagglutinin sequences were identical between different patients. Furthermore, a general inability to establish epidemiological transmission linkage of patients/viral isolates implied that identified isolates could have originated from asymptomatic hospital patients, visitors or hospital staff. In contrast, a traditional epidemiological investigation that used no viral phylogenetic analyses, based on patient co-admission into specific wards during a particular time-frame, suggested that multiple hospital acquired infection instances may have stemmed from a limited number of identifiable index viral isolates/patients. This traditional epidemiological analysis by itself could incorrectly suggest linkage between unrelated cases, underestimate the number of unique infections and may overlook the possible diffuse nature of hospital transmission, which was suggested by sequencing data to be caused by multiple unique introductions of influenza A isolates into individual hospital wards. We have demonstrated a functional role for viral sequence data in nosocomial transmission investigation through its ability to enrich traditional, non-molecular observational epidemiological investigation by teasing out possible transmission pathways and working toward more accurately enumerating the number of possible transmission events.

Deaths from acute abdominal conditions and geographical access to surgical care in India: a nationally representative spatial analysis.

BACKGROUND: Few population-based studies quantify mortality from surgical conditions and relate mortality to access to surgical care in low-income and middle-income countries. METHODS: We linked deaths from acute abdominal conditions within a nationally representative, population-based mortality survey of 1·1 million households in India to nationally representative facility data. We calculated total and age-standardised death rates for acute abdominal conditions. Using 4064 postal codes, we undertook a spatial clustering analysis to compare geographical access to well-resourced government district hospitals (24 h surgical and anaesthesia services, blood bank, critical care beds, basic laboratory, and radiology) in high-mortality or low-mortality clusters from acute abdominal conditions. FINDINGS: 923 (1·1%) of 86,806 study deaths at ages 0-69 years were identified as deaths from acute abdominal conditions, corresponding to 72,000 deaths nationally in 2010 in India. Most deaths occurred at home (71%) and in rural areas (87%). Compared with 567 low-mortality geographical clusters, the 393 high-mortality clusters had a nine times higher age-standardised acute abdominal mortality rate and significantly greater distance to a well-resourced hospital. The odds ratio (OR) of being a high-mortality cluster was 4·4 (99% CI 3·2-6·0) for living 50 km or more from well-resourced district hospitals (rising to an OR of 16·1 [95% CI 7·9-32·8] for >100 km). No such relation was seen for deaths from non-acute surgical conditions (ie, oral, breast, and uterine cancer). INTERPRETATION: Improvements in human and physical resources at existing government hospitals are needed to reduce deaths from acute abdominal conditions in India. Full access to well-resourced hospitals within 50 km by all of India's population could have avoided about 50,000 deaths from acute abdominal conditions, and probably more from other emergency surgical conditions. FUNDING: Bill & Melinda Gates Foundation, Dalla Lana School of Public Health, Canadian Institute of Health Research.

Population-based analysis of blunt splenic injury management in children: operative rate is an informative quality of care indicator.

BACKGROUND: In hemodynamically normal children with blunt splenic injury (BSI), the standard of care is non-operative management. Several studies have reported that non-paediatric and non-trauma centres have higher operative rates in children with BSI compared to paediatric hospitals and trauma centres. We investigate the feasibility of using operative rate for BSI as a quality of care indicator. METHODS: We performed a population-based retrospective cohort study of children (≤18 years) with BSI admitted to all acute-care hospitals in Canada from 2001 to 2010. The main outcome was rate of operative management for BSI. Hierarchical multivariable logistic regression models were constructed to evaluate the relationship between operative rate and different hospital types (paediatric or non-paediatric, trauma or non-trauma). These models also allowed for generation of hospital-level observed to expected (O/E) ratios for rate of operative management. RESULTS: We identified 3122 children with BSI. The majority (74%) were isolated splenic injuries and the grade of splenic injury was specified in 45% of cases (n=1391, 38% grade I or II; 62% grade III, IV, or V). The overall operative rate was 11% (n=315), of which 9% were total splenectomy and 2% were spleen-preserving operations. After adjusting for age, gender, mechanism of injury, splenic injury grade, ISS, and centre volume, admission to non-paediatric hospitals was associated with a higher probability of operative management (OR 7.6, 95% CI 2.4-24.4), whereas there was no significant difference in operative management between trauma and non-trauma centres (OR 1.6, 95% CI 0.8-3.2). Outlier status based on O/E ratio was determined to identify centres with higher or lower than expected operative rates. CONCLUSIONS: The operative rates for children with BSI are significantly higher in non-paediatric hospitals. In these hospitals that do not routinely care for children and have higher than expected operative rates, we have used operative rate for BSI as a quality of care indicator and identified opportunities for quality improvement initiatives. LEVEL OF EVIDENCE: III, Retrospective comparative study.

Emergency access to neurosurgical care for patients with traumatic brain injury.

BACKGROUND: Traumatic brain injury (TBI) is one of the most common causes of injury-related morbidity and mortality. Access to neurosurgical services is critical to optimal outcomes through reduction of secondary injury. We sought to evaluate variations in access to neurosurgical care across a regional trauma system. STUDY DESIGN: This is a population-based retrospective cohort study of patients who sustained isolated severe TBI from 2005 to 2009. Administrative datasets capturing all emergency department visits and hospitalizations were linked deterministically. Differences between access to a trauma center (TC), defined as direct transport from scene or transfer from a nontrauma center (NTC) as opposed to no access, were evaluated; this included patient level determinants of access to TC and delineation of mortality differences between TC and NTC care. Transfer patterns from NTC to TC were also evaluated. RESULTS: We identified 9,448 patients with isolated severe TBI. Almost two-thirds (60%, n = 5,701) received initial care at an NTC. Of these patients, 30% (n = 1,737) were subsequently transferred to a TC. Thirty-day mortality rates of patients treated at a TC vs NTC were 19% vs 18%, respectively (p = 0.19). Among patients younger than 65 years, 67% received TC care; only 41% of patients older than 65 were treated at a TC (p < 0.01). Mechanism, age, brain hemorrhage, and injury severity were associated with TC care. CONCLUSIONS: Considerable variation in delivery of initial care to TBI patients was identified. Factors such as age and injury characteristics were associated with TC access. Because early TC care in TBI confers survival benefits, the demonstrated variability necessitates improvements in access to care for patients with severe head injuries.

Benchmarking trauma center performance in traumatic brain injury: the limitations of mortality outcomes.

BACKGROUND: Trauma centers (TCs) generally use mortality to gauge performance. However, differences in mortality outcomes might reflect different approaches or philosophies toward end-of-life care. We postulate that discharge home (DH) as a proxy for functional outcome may be a more useful measure of quality and may have significant implications on the assessment of TC performance and external benchmarking efforts. METHODS: Data were derived from the National Trauma Data Bank (2007-2009). We included patients (18 years or older) with isolated, severe blunt head injuries who were admitted to Level I and Level II TCs. Observed-to-expected (O/E) mortality ratios were calculated and used to rank TC performance by mortality and then DH. Concordance between performance measures was calculated using a weighted kappa statistic. RESULTS: In total, 19,705 patients in 240 TCs were identified. Crude mortality ranged from 4% to 60%, whereas rates of DH ranged from 3% to 66%. When O/E ratios for mortality were evaluated, five centers were identified as high performers. Of these five centers, only two were also high performers for DH. The concordance of outlier status and correlation across O/E ratios between mortality and DH high performers was 0.16 (poor). CONCLUSION: Centers that are characterized as high performers when evaluating mortality are not high performers for functional outcome as evaluated by DH. DH may provide an alternative way of assessing quality of care delivered to patients with traumatic brain injury. LEVEL OF EVIDENCE: Care management study, level III.

Road traffic injury mortality and its mechanisms in India: nationally representative mortality survey of 1.1 million homes.

OBJECTIVES: To quantify and describe the mechanism of road traffic injury (RTI) deaths in India. DESIGN: We conducted a nationally representative mortality survey where at least two physicians coded each non-medical field staff's verbal autopsy reports. RTI mechanism data were extracted from the narrative section of these reports. SETTING: 1.1 million homes in India. PARTICIPANTS: Over 122 000 deaths at all ages from 2001 to 2003. PRIMARY AND SECONDARY OUTCOME MEASURES: Age-specific and sex-specific mortality rates, place and timing of death, modes of transportation and injuries sustained. RESULTS: The 2299 RTI deaths in the survey correspond to an estimated 183 600 RTI deaths or about 2% of all deaths in 2005 nationally, of which 65% occurred in men between the ages 15 and 59 years. The age-adjusted mortality rate was greater in men than in women, in urban than in rural areas, and was notably higher than that estimated from the national police records. Pedestrians (68 000), motorcyclists (36 000) and other vulnerable road users (20 000) constituted 68% of RTI deaths (124 000) nationally. Among the study sample, the majority of all RTI deaths occurred at the scene of collision (1005/1733, 58%), within minutes of collision (883/1596, 55%), and/or involved a head injury (691/1124, 62%). Compared to non-pedestrian RTI deaths, about 55 000 (81%) of pedestrian deaths were associated with less education and living in poorer neighbourhoods. CONCLUSIONS: In India, RTIs cause a substantial number of deaths, particularly among pedestrians and other vulnerable road users. Interventions to prevent collisions and reduce injuries might address over half of the RTI deaths. Improved prehospital transport and hospital trauma care might address just over a third of the RTI deaths.

Surgery for suspected rotation abnormality: selection of open vs laparoscopic surgery using a rational approach.

BACKGROUND: Laparoscopy is increasingly used for children with suspected rotation abnormalities. However, indications for open and laparoscopic approaches are not well defined. We reviewed our experience with both open and laparoscopic approaches to develop a rational approach to these patients. METHODS: Charts of all children undergoing surgery for a suspected rotation abnormality for 10 years were retrospectively reviewed. RESULTS: There were 173 patients. Of 73 neonates presenting with suspected volvulus, 71 underwent initial laparotomy and 2 were converted from initial laparoscopy. Eighty percent underwent Ladd procedure, 64% had volvulus, and 2 died of midgut volvulus. Of 18 neonates presenting without suspected volvulus, 14 underwent initial laparotomy and 4 had a laparoscopic approach with 1 conversion to laparotomy. Seventy-eight percent underwent Ladd procedure, and 22% had volvulus. Of the 82 older patients, 37 underwent laparotomy and 45 had initial laparoscopy, 8 of which were converted. Sixty-seven percent underwent Ladd procedure, and 28% had volvulus. Postoperative complication rate, median time to full diet, and median hospital stay were comparable with those previously reported in the literature. CONCLUSION: Based on our results, we advocate open surgery for neonates with suspected volvulus. Laparoscopy represents an excellent alternative for older children and for neonates presenting without suspected volvulus.