The Influence of HIV Status on Acute Appendicitis: A Retrospective Study from South Africa.

BACKGROUND: Despite the human immunodeficiency virus (HIV) being the most common comorbidity in South African surgical patients, its impact on appendicitis has not been well-described. We aimed to determine HIV status' influence on patients' presentation, assessment, management and outcomes with acute appendicitis. METHODS: The retrospective chart review included all patients aged 12 years and older who were HIV-positive or HIV-negative and presented with acute appendicitis between 1 January 2013 and 31 December 2019. The primary outcome measure was survival to discharge. Secondary outcomes included analysis of the presentation (vital signs), assessment (biochemical, inflammatory markers) and management (intraoperative anatomical severity grading, length of hospital stay). RESULTS: Of the 1096 patients with appendicitis, 196 (17.9%) were HIV-positive, and CD4 counts were available for 159. The median age was 23 years, with the HIV-positive patients being older and HIV-negative group having more males (58.7%). While the HIV-positive patients had a longer median length of hospital stay, there was no statistically significant difference in the two groups' incidence of high-grade appendicitis (p = 0.670). The HIV-positive patients had a higher median shock index (OR 7.65; 95% [CI 2.042-28.64]) than their HIV-negative counterparts. HIV-positivity had a significant association with mortality (OR 9.56; 95% CI [1.68-179.39]), and of the seven HIV-positive patients who died, 66.7% (n = 4) had a CD4 < 200 cells/mm3 (OR 8.6; 95% CI [1.6-63.9]). CONCLUSION: HIV-positive patients, those with CD4 < 200 cells/mm3 or not on ART, have increased mortality risk and may benefit from increased perioperative surveillance. Patients with an unknown HIV status in a high-prevalence population should be offered HIV testing to risk stratify more accurately.

The Efficacy of VAMMFT Compared to "Bogota Bag" in Achieving Sheath Closure Following Temporary Abdominal Closure at Index Laparotomy for Trauma.

INTRODUCTION: The open abdomen (OA) is a necessary component of damage control surgery and closure is often challenging. Our aim was to review our ten-year experience with OA in trauma patients and to compare the success of a dual closure technique termed vacuum-assisted, mesh-mediated fascial traction (VAMMFT) to an exclusively Bogota Bag (BB) approach. METHODS: A retrospective analysis was performed using the HEMR database from 2012 to 2022, comparing demographics, mechanism of injury, admission vitals and biochemistry between patients with BB and VAMMFT applications. Rate of secondary abdominal closure and complications were assessed in both groups. Logistic regression was used to find predictors of closure. RESULTS: OA was required by 348 patients at index laparotomy. Of these, 133 (38.2%) were managed with VAMMFT and 215 (61.8%) exclusively with a BB. There were no statistical differences between the BB and VAMMFT groups in terms of demographics, injuries, admission vitals and biochemistry. The VAMMFT group achieved a closure rate of 73% compared to 54.9% in the BB group (OR of 2.2 [1.4-3.7]). There was no significant difference in fistulation rate between the two groups (p = 0.103). Length of hospital stay was 30 versus 17 days in the VAMMFT and BB groups, respectively (OR 1.41 [1.30-1.54]). There were no independent predictors of closure identified in the VAMMFT group. Older patients were less likely to achieve closure when BB was used (OR 0.97 [0.95-0.99]). VAMMFT failure was commonly due to lack of stock (39%) and protocol violations (33%). CONCLUSION: The VAMMFT approach to the OA is efficacious and safe. VAMMFT achieves a much higher rate of secondary closure than BB alone with a low rate of enteric fistula formation.

Using Machine Learning to Establish Predictors of Mortality in Patients Undergoing Laparotomy for Emergency General Surgical Conditions.

INTRODUCTION: Patients undergoing laparotomy for emergency general surgery (EGS) conditions, constitute a high-risk group with poor outcomes. These patients have a high prevalence of comorbidities. This study aims to identify patient factors, physiological and time-related factors, which place patients into a group at increased risk of mortality. METHODOLOGY: In a retrospective analysis of all patients undergoing an emergency laparotomy at Greys Hospital from December 2012 to 2018, we used decision tree discrimination to identify high-risk groups. RESULTS: Our cohort included 1461 patients undergoing a laparotomy for an EGS condition. The mortality rate was 12.4% (181). Nine hundred and ten patients (62.3%) had at least one known comorbidity on admission. There was a higher rate of comorbidities among those that died (154; 85.1%). Patient factors found to be associated with mortality were the age of 46 years or greater (p < 0.001), current tuberculosis (p < 0.001), hypertension (p = 0.014), at least one comorbidity (0.006), and malignancy (0.033). Significant physiological risk factors for mortality were base excess less than -6.8 mmol/L (p < 0.001), serum urea greater than 7.0 mmol/L (p < 0.001) and waiting time from admission to operation (p = 0.014). In patients with an enteric breach, those younger than 46 years and a Shock Index of more than 1.0 were high-risk. Patients without an enteric breach were high-risk if operative duration exceeded 90 min (p = 0.004) and serum urea exceeding 7 mmol/dl (p = 0.016). CONCLUSION: In EGS patients, patient factors as well as physiological factors place patients into a high-risk group. Identifying a high-risk group should prompt consideration for an adjusted approach that ameliorates outcomes.

Health-Related Behaviours, HIV and Active Tuberculosis are Associated with Perioperative Adverse Events Following Emergency Laparotomy at a Tertiary Surgical Service in KwaZulu-Natal, South Africa.

INTRODUCTION: This project aims to define the common comorbidities associated with patients undergoing emergency laparotomy in South Africa, to review the impact of these comorbidities on outcome and to attempt to model these various factors. METHOD: A retrospective review of all patients undergoing emergency laparotomy for an emergency general surgical condition was performed from the prospectively entered Hybrid Electronic Medical Registry (HEMR). Univariate and multiple logistic regression analysis was performed to establish associations and independent risk factors for developing an adverse event. RESULTS: Over a six-year time period, a total of 1464 patients underwent emergency laparotomy. The median age was 34 years. Males constituted 58.8% (861) of the patients and 754 patients (51.5%) experienced at least one adverse event. The mortality rate was 12 percent. Comorbidities and social factors were documented in 912 patients (62.3%). The rate of adverse events among patients with comorbidities was 59% (538). Patients without comorbidities or significant social factors had an adverse event rate of 39.1% (216). This difference was statistically significant (p < 0.001). The most frequent comorbidity in our sample was HIV, followed by hypertension, underlying malignancy, diabetes mellitus, active TB and cardiovascular disease. CONCLUSION: Emergency laparotomy in South Africa is associated with significant morbidity and mortality. The patients are younger than in high-income countries. Diabetes mellitus, hypertension, HIV and active TB are associated with the development of an AE.

Evolving Indications for Lower Limb Amputations in South Africa Offer Opportunities for Health System Improvement.

BACKGROUND: Rapid urbanization and westernization have precipitated dramatic changes in the profile and prevalence of surgical diseases in sub-Saharan Africa. Disease of lifestyle is now common. We aimed to review our experience with lower-limb amputations at our surgical service in South Africa. METHODS: A single-center retrospective review of a prospectively collected database was performed of all patients who underwent a lower limb amputation. Inferential and descriptive statistics were performed. Patient demographics, indication, type of amputation, and management were reviewed. The primary outcome was 30-day in-patient mortality rate. RESULTS: Over a 5-year period (2013-2018), 348 patients underwent lower limb amputations. The median age was 61.5 years. 53.7% were diabetic and 56.3% were hypertensive. 53.2% had associated peripheral vascular disease and 8% preexisting cardiac disease. 30.7% smoked. Guillotine below-knee amputation was frequently performed (44.5% of amputations). 16.1% of these patients required a further operation. The in-hospital mortality rate was 8%. Underlying renal disease was an independent risk factor for mortality (p = 0.004). CONCLUSION: Currently, the most common indications for LLA in South Africa are diabetes mellitus and atherosclerosis. This reflects the changing pattern of disease in the country. There is a major problem with access to health care in rural areas in South Africa with significant delays in getting patients to tertiary units for evaluation by specialists. Foot care and prevention at a primary health care level is also lacking. Global improvements in the healthcare system are needed to improve LLA rates in South Africa.

Predicting the Outcome of Non-operative Management of Splenic Trauma in South Africa.

INTRODUCTION: We aimed to expand on the global surgical discussion around splenic trauma in order to understand locally and clinically relevant factors for operative (OP) and non-operative management (NOM) of splenic trauma in a South African setting. METHODS: A retrospective cohort study was performed using 2013-2017 data from the Pietermaritzburg Metropolitan Trauma Service. All adult patients (≥15 years) were included. Those managed with OP or NOM for splenic trauma were identified and analyzed descriptively. Multiple logistic regression analysis identified patients and clinical factors associated with management type. RESULTS: There were 127 patients with splenic injury. Median age was 29 [19-35] years with 42 (33%) women and 85 (67%) men. Blunt injuries occurred in the majority (81, 64%). Organ Injury Scale (OIS) grades included I (25, 20%), II (43, 34%), III (36, 28%), IV (15, 11%), and V (8, 6%). Nine patients expired. On univariate analysis, increasing OIS was associated with OP management, need for intensive care unit (ICU) admission, and hospital and ICU duration of stay, but not mortality. In patients with a delayed compared to early presentation, ICU utilization (62% vs. 36%, p = 0.008) and mortality (14% vs. 4%, p = 0.03) were increased. After adjusting for age, sex, presence of shock, and splenic OIS, penetrating trauma (adjusted odds ratio, 5.7; 95%CI, 1.7-9.8) and admission lactate concentration (adjusted odds ratio, 1.4; 95%CI 1.1-1.9) were significantly associated with OP compared to NOM (p = 0.002; area under the curve 0.81). CONCLUSIONS: We have identified injury mechanism and admission lactate as factors predictive of OP in South African patients with splenic trauma. Timely presentation to definitive care affects both ICU duration of stay and mortality outcomes. Future global surgical efforts may focus on expanding non-operative management protocols and improving pre-hospital care in patients with splenic trauma.

Comparison of the Pediatric Resuscitation and Trauma Outcome (PRESTO) Model and Pediatric Trauma Scoring Systems in a Middle-Income Country.

BACKGROUND: The pediatric resuscitation and trauma outcome (PRESTO) model was developed to aid comparisons of risk-adjusted mortality after injury in low- and middle-income countries (LMICs). We sought to validate PRESTO using data from a middle-income country (MIC) trauma registry and compare its performance to the Pediatric Trauma Score (PTS), Revised Trauma Score, and pediatric age-adjusted shock index (SIPA). METHODS: We included children (age < 15 years) admitted to a single trauma center in South Africa from December 2012 to January 2019. We excluded patients missing variables necessary for the PRESTO model-age, systolic blood pressure, pulse, oxygen saturation, neurologic status, and airway support. Trauma scores were assigned retrospectively. PRESTO's previously high-income country (HIC)-validated optimal threshold was compared to MIC-validated threshold using area under the receiver operating characteristic curves (AUROC). Prediction of in-hospital death using trauma scoring systems was compared using ROC analysis. RESULTS: Of 1160 injured children, 988 (85%) had complete data for calculation of PRESTO. Median age was 7 (IQR: 4, 11), and 67% were male. Mortality was 2% (n = 23). Mean predicted mortality was 0.5% (range 0-25.7%, AUROC 0.93). Using the HIC-validated threshold, PRESTO had a sensitivity of 26.1% and a specificity of 99.7%. The MIC threshold showed a sensitivity of 82.6% and specificity of 89.4%. The MIC threshold yielded superior discrimination (AUROC 0.86 [CI 0.78, 0.94]) compared to the previously established HIC threshold (0.63 [CI 0.54, 0.72], p < 0.0001). PRESTO showed superior prediction of in-hospital death compared to PTS and SIPA (all p < 0.01). CONCLUSION: PRESTO can be applied in MIC settings and discriminates between children at risk for in-hospital death following trauma. Further research should clarify optimal decision thresholds for quality improvement and benchmarking in LMIC settings.

Surgical Considerations for Pediatric Snake Bites in Low- and Middle-Income Countries.

BACKGROUND: Snake envenomation is associated with major morbidity especially in low- and middle-income countries and may require fasciotomy. We determined patient factors associated with the need for fasciotomy after venomous snake bites in children located in KwaZulu-Natal, South Africa. METHODS: Single institutional review of historical data (2012-2017) for children (<18 years) sustaining snake envenomation was performed. Clinical data, management, and outcomes were abstracted. Syndromes after snake bite were classified according to Blaylock nomenclature: progressive painful swelling (PPS), progressive weakness (PW), or bleeding (B), as it is difficult to reliably identify the species of snake after a bite. Comparative and multivariable analyses to determine factors associated with fasciotomy were performed. RESULTS: There were 72 children; mean age was 7 (±3) years, 59% male. Feet were most commonly affected (n = 27, 38%) followed by legs (n = 18, 25%). Syndromes (according to Blaylock) included PPS (n = 63, 88%), PW (n = 5, 7%), and B (n = 4, 5%). Eighteen patients underwent fasciotomy, and one required above knee amputation. Nine patients received anti-venom. Few patients (15%) received prophylactic beta-lactam antibiotics. Hemoglobin < 11 mg/dL, leukocytosis, INR >1.2, and age-adjusted shock index were associated with fasciotomy. On regression, age-adjusted shock index and hemoglobin concentration < 11 mg/dL, presentation >24 h after snake bite, and INR >1.2 were independently associated with fasciotomy. Model sensitivity was 0.89 and demonstrated good fit. CONCLUSIONS: Patient factors were associated with the fasciotomy. These factors, coupled with clinical examination, may identify those who need early operative intervention. Improving time to treatment and the appropriate administration of anti-venom will minimize the need for surgery. LEVEL OF EVIDENCE: III.

Trauma registry data as a tool for comparison of practice patterns and outcomes between low- and middle-income and high-income healthcare settings.

PURPOSE: There is a lack of data-driven, risk-adjusted mortality estimates for injured children outside of high-income countries (HIC). To inform injury prevention and quality improvement efforts, an upper middle-income country (UMIC) pediatric trauma registry was compared to that of a HIC. METHODS: Clinical data, injury details, and mortality of injured children (< 18 years) hospitalized in two centers (USA and South African (SA)) from 2013 to 2017 were abstracted. Univariate and multivariable analyses evaluated risk of mortality and were expressed as odds ratios (OR) with 95% confidence intervals (CI). RESULTS: Of 2089 patients, SA patients had prolonged transfer times (21.1 vs 3.4 h) and were more likely referred (78.2% vs 53.9%; both p < 0.001). Penetrating injuries were more frequent in SA (23.2% vs 7.4%, p < 0.001); injury severity (9 vs 4) and shock index (0.90 vs 0.80) were greater (both p < 0.001). SA utilized cross-sectional imaging more frequently (66.4% vs 37.3%, p < 0.001). In-hospital mortality was similar (1.9% SA, 1.3% USA, p = 0.31). Upon multivariable analysis, ISS > 25 [210.50 (66.0-671.0)] and penetrating injury [5.5 (1.3-23.3)] were associated with mortality, while institution [1.7 (0.7-4.2)] was not. CONCLUSIONS: Despite transfer time, the centers demonstrated comparable survival rates. Comparison of registry data can alert clinicians to problematic practice patterns, assisting initiatives to improve trauma systems.

Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade.

OBJECTIVE: To assess whether the American Association for the Surgery of Trauma (AAST) grading system accurately corresponds with appendicitis outcomes in a US pediatric population. STUDY DESIGN: This single-institution retrospective review included patients <18 years of age (n = 331) who underwent appendectomy for acute appendicitis from 2008 to 2012. Demographic, clinical, procedural, and follow-up data (primary outcome was measured as Clavien-Dindo grade of complication severity) were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and multivariable regression analyses were performed to compare AAST grade and outcomes. RESULTS: Overall, 331 patients (46% female) were identified with a median age of 12 (IQR, 8-15) years. Appendectomy was laparoscopic in 90% and open in 10%. AAST grades included: Normal (n = 13, 4%), I (n = 152, 46%), II (n = 90, 27%), III (n = 43, 13%), IV (n = 24 7.3%), and V (n = 9 2.7%). Increased AAST grade was associated with increased Clavien-Dindo severity, P =.001. The overall complication rate was 13.6% and was comprised by superficial surgical site infection (n = 13, 3.9%), organ space infection (n = 15, 4.5%), and readmission (n = 17, 5.1%). Median duration of stay increased with AAST grade (P < .0001). Nominal logistic regression identified the following as predictors of any complication (P < .05): AAST grade and febrile temperature at admission. CONCLUSIONS: The AAST appendicitis grading system is valid in a single-institution pediatric population. Increasing AAST grade incrementally corresponds with patient outcomes including increased risk of complications and severity of complications. Determination of the generalizability of this grading system is required.

Acute Kidney Injury on Presentation to a Major Trauma Service is Associated with Poor Outcomes.

BACKGROUND: This study sought to describe the burden of disease of acute kidney injury (AKI) among adult South African trauma patients who presented to a tertiary level trauma service. METHODS: The trauma database was interrogated for the period from December 2012 to July 2017. All patients over the age of 18 y, who were admitted following trauma, were included. Outcome data were reviewed. This included in-hospital mortality, need for intensive care unit admission, and length of stay. AKI was defined according to the latest Kidney Disease Improving Global Outcomes guidelines using the presentation serum creatinine. RESULTS: A total of 7613 patients were admitted for trauma over the period under review. Four thousand two hundred sixty-six patients were suitable for analysis. A total of 238 (5.6%) patients presented with AKI, 149 (62.6%) had stage 1 AKI, 40 (16.8%) had stage 2 AKI, and 49 (20.6%) had stage 3 AKI. There was a higher incidence of AKI in patients with blunt trauma. The length of stay, need for intensive care unit admission, and mortality were significantly higher in patients presenting with AKI than in those who did not present with AKI. There were 172 deaths (4.0%). The patients who died were older and had significantly higher Injury Severity Score than survivors. They were more acidotic on presentation, had lower Glasgow Coma Scale, and were more likely to be hypotensive on presentation. They also were significantly more likely to have AKI on presentation. (30.2% versus 5.6% P < 0.001). AKI on presentation was an independent risk factor for mortality (odds ratio 3.038 95% confidence interval 1.260-7.325). CONCLUSIONS: AKI is common in patients presenting to our center with acute trauma. The presence of AKI is associated with increased morbidity and mortality. Efforts must be directed to improving recognition of at-risk patients. Prompt referral and adequate resuscitation of trauma patients before transfer must be prioritized.

The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective.

BACKGROUND: This paper reviews our experience with penetrating cervical venous trauma and aims to validate the selective non-operative management (SNOM) of these injuries. METHODS: This was a retrospective review of a prospectively maintained registry. All patients presenting alive with an injury to the internal jugular vein, subclavian vein or innominate vein following a PNI were reviewed for a 6-year period. RESULTS: Among 817 patients admitted for the management of PNI, 76 (9.3%) had a venous injury. Of these, 37 (48.7%) patients were managed non-surgically, 20 (26.3%) required immediate surgical exploration, seven of whom had an associated arterial injury, and 19 (25%) underwent surgery following a diagnostic CTA, 16 of whom had an associated arterial or aero-digestive injury. In total, only 16 (21.1%) of the 76 patients required exploration for venous injury alone. The majority (63.2%) of patients had a history of severe bleeding or hemodynamic instability prior to arrival, but only 20 (26.3%) required immediate exploration. Two (2.6%) patients died as a result of venous injury. No patients developed complications related to the venous injury. CONCLUSIONS: SNOM is applicable to a well-defined subset of patients with isolated penetrating cervical venous trauma to the IJV and SCV identified on CTA.

Appendicitis: Rural Patient Status is Associated with Increased Duration of Prehospital Symptoms and Worse Outcomes in High- and Low-Middle-Income Countries.

INTRODUCTION: Appendicitis is a significant economic and healthcare burden in low-, middle-, and high-income countries. We aimed to determine whether urban and rural patient status would affect outcomes in appendicitis in a combined population regardless of country of economic status. We hypothesize that patients from rural areas and both high- and low-middle-income countries would have disproportionate outcomes and duration of symptoms compared to their urban counterparts. METHODS: Adults (≥18 years) with appendicitis during 2010-2016 in South Africa and USA were reviewed using multi-institutional data. Baseline demographic, operative details, durations of stay, and complications (Clavien-Dindo index) were collected. AAST grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and multivariable analyses of rural and urban patients in both countries were performed. RESULTS: There were 2602 patients with a median interquartile range [IQR] of 26 [18-40] years; 45% were female. Initial management included McBurney incisions (n = 458, 18%), laparotomy (n = 915, 35%), laparoscopic appendectomy (n = 1185, 45%), and laparoscopy converted to laparotomy (n = 44, 2%). Comparing rural versus urban patient status, there were increased overall median [IQR] AAST grades (3 [1-5] vs. 2 [1-3], p = 0.001), prehospital duration of symptoms (2 [1-5] vs. 2 [1-3], p = 0.001), complications (44.3 vs. 23%, p = 0.001), and need for temporary abdominal closure (20.3 vs. 6.9%, p = 0.001). CONCLUSION: Despite socioeconomic status and country of origin, patients from more rural environments demonstrate poorer outcomes notwithstanding significant differences in overall disease severity. The AAST grading system may serve a potential benchmark to recognize areas with disparate disease burdens. This information could be used for strategic improvements for surgeon placement and availability.

Pediatric Appendicitis Severity in KwaZulu-Natal, South Africa: A Retrospective Cohort Analysis.

BACKGROUND: Acute appendicitis is a common pediatric surgical emergency; however, there are few grading systems to assign disease severity. The American Association for the Surgery of Trauma (AAST) recently developed a grading system for a variety of emergency surgical conditions, including appendicitis. The severity of acute appendicitis in younger patients in KwaZulu-Natal (South Africa) is unknown. We aimed to describe the disease severity in this patient population using the AAST grading system hypothesizing that the AAST grade would correlate with morbidity, management type, and duration of stay. MATERIALS: Single institutional review of patients <18 years old with a final diagnosis of acute appendicitis during 2010-2016 in KwaZulu-Natal, South Africa, was performed. Demographics, physiologic and symptom data, procedural details, postoperative complications, and Clavien-Dindo classification were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and nominal logistic regression analyses were performed to compare AAST grade and outcomes. RESULTS: A total of 401 patients were identified with median [IQR] age of 11 [5-13], 65% male. Appendectomy was performed in all patients; 2.4% laparoscopic, 37.6% limited incision, and 60% midline laparotomy. Complications occurred in 41.6%, most commonly unplanned relaparotomy (22.4%), surgical site infection (8.9%), pneumonia (7.2%), and acute renal failure (2.9%). Complication rate and median length of stay increased with greater AAST grade (all p < 0.001). AAST grade was independently associated with increased risk of complications. CONCLUSION: Pediatric appendicitis is a morbid disease in a developing middle-income country. The AAST grading system is generalizable and accurately corresponds with management strategies as well as key clinical outcomes. LEVEL OF EVIDENCE: Retrospective study, Level IV. STUDY TYPE: Retrospective single institutional study.

Application of the AAST EGS Grade for Adhesive Small Bowel Obstruction to a Multi-national Patient Population.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) anatomic severity grading system for adhesive small bowel obstruction (ASBO) has demonstrated to be a valid tool in North American patient populations. Using a multi-national patient cohort, we retrospectively assessed the validity the AAST ASBO grading system and estimated disease severity in a global population in order to correlate with several key clinical outcomes. METHODS: Multicenter retrospective review during 2012-2016 from four centers, Minnesota USA, Bologna Italy, Pietermaritzburg South Africa, and Bucharest Romania, was performed. Adult patients (age ≥ 18) with ASBO were identified. Baseline demographics, physiologic parameters, laboratory results, operative and imaging details, outcomes were collected. AAST ASBO grades were assigned by independent reviewers. Univariate and multivariable analyses with odds ratio (OR) and 95% confidence intervals (CIs) were performed. RESULTS: There were 789 patients with a median [IQR] age of 58 [40-75] years; 47% were female. The AAST ASBO grades were I (n = 180, 23%), II (n = 443, 56%), III (n = 87, 11%), and IV (n = 79, 10%). Successful non-operative management was 58%. Conversion rate from laparoscopy to laparotomy was 33%. Overall mortality and complication and temporary abdominal closure rates were 2, 46, and 4.7%, respectively. On regression, independent predictors for mortality included grade III (OR 4.4 95%CI 1.1-7.3), grade IV (OR 7.4 95%CI 1.7-9.4), pneumonia (OR 5.6 95%CI 1.4-11.3), and failing non-operative management (OR 2.4 95%CI 1.3-6.7). CONCLUSION: The AAST EGS grade can be assigned with ease at any surgical facility using operative or imaging findings. The AAST ASBO severity grading system has predictive validity for important clinical outcomes and allows for standardization across institutions, providers, and future research. Disease severity and outcomes varied between countries. LEVEL OF EVIDENCE III: Study type Retrospective multi-institutional cohort study.

The role of computed tomography angiography in the detection of aerodigestive tract injury following penetrating neck injury.

BACKGROUND: The purpose of this study was to audit our experience with computed tomography angiography (CTA) for the detection of aerodigestive tract injury (ADTI) following penetrating neck injury (PNI) and to assess the significance of deep surgical emphysema on CTA. METHODS: A prospectively maintained trauma registry at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa was retrospectively interrogated. The data of all patients with PNI investigated with CTA over a 4-y period were reviewed. All findings of deep surgical emphysema were correlated to an aggregate standard of reference for ADTI as demonstrated by results from clinical examination, surgical neck exploration, endoscopy or contrasted swallow to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of this finding. RESULTS: A total of 383 patients underwent a CTA for PNI. A total of 94 vascular injuries were identified on 78 positive CTA studies. The sensitivity and specificity of CTA in detecting a vascular injury were 94.4% and 96.7%. Of the 383 patients investigated a total of 38 patients were diagnosed with digestive tract injury (DTI), and all of these patients were found to have deep surgical emphysema on CTA, except for one patient with a clinically insignificant oral cavity injury. Another 126 patients also had deep surgical emphysema on CTA but no DTI. The sensitivity, specificity, PPV, and NPV of deep surgical emphysema for the diagnosis of confirmed DTI in PNI were therefore 97.4%, 63.5%, 22.7%, and 99.5%, respectively. The sensitivity and NPV were, however, 100% when clinically insignificant injuries were excluded. Including patients with confirmed airway injuries and excluding all patients with pneumothoraces yielded a sensitivity, specificity, PPV, and NPV of 94.1%, 71.9%, 30.0%, and 98.9%, respectively, for the identification of ADTI. When excluding surgically irrelevant injuries, the sensitivity and NPV were again both 100%. CONCLUSIONS: CTA for PNI has a high sensitivity and specificity for demonstrating vascular injury. The absence of deep surgical emphysema in the deep cervical fascial planes virtually excludes surgically significant ADTI. The presence of deep surgical emphysema is nonspecific but warrants further investigation.

In-Hospital Mortality Following Traumatic Injury in South Africa.

Trauma is a leading cause of death worldwide and in South Africa. We aimed to quantify the in-hospital trauma mortality rate in Pietermaritzburg, South Africa. Background: The in-hospital trauma mortality rate in South Africa remains unknown, and it is unclear whether deficits in hospital care are contributing to the high level of trauma-related mortality. Methods: All patients hospitalized because of trauma at the Department of Surgery at Grey's Hospital, Pietermaritzburg Metropolitan Trauma Service, were prospectively entered in an electronic database starting in 2013 and the data were retrospectively analyzed. The trauma service adheres to Advanced Trauma Life Support and the doctors have attended basic and advanced courses in trauma care. The primary outcome was in-hospital mortality. Results: Of 9795 trauma admissions, 412 (4.2%) patients died during hospital care between January 2013 and January 2019. Forty-six percent died after road traffic accidents, 19% after gunshot wounds, 13% after stab wounds, and 10% after assaults. Sixteen percent were classified as avoidable deaths due to inappropriate care and resource limitations. Fifty percent died because of traumatic brain injury and 80% of them were unavoidable. Conclusions: In conclusion, the in-hospital trauma mortality rate at a South African trauma center using systematic trauma care is lower than that reported from other trauma centers in the world during the past 20 years. Nevertheless, 16% of death cases were assessed as avoidable if there had been better access to intensive care, dialysis, advanced respiratory care, blood for transfusion, and improvements in surgery and medical care.

CT scans for pediatric injury in a middle-income country trauma center: Are we repeating past mistakes?

PURPOSE: Sustained efforts in high-income countries have decreased the rate of unnecessary computed tomography (CT) among children, aiming to minimize radiation exposure. There are little data regarding CT use for pediatric trauma in low- and middle-income countries. We aimed to assess the pattern and utility of CT performed during evaluation of trauma patients presenting to a middle-income country (MIC) trauma center. METHODS: We reviewed pediatric (age<18) trauma admissions at a single tertiary referral center in South Africa. Patient demographics, injury details, surgical intervention(s), and mortality were abstracted from the medical record. CT indications, results, and necessity were determined by review. RESULTS: Of 1,630 children admitted to the trauma center, 826 (51%) had CT imaging. Children undergoing imaging were younger (median age 11 [IQR: 6, 16] vs 13 [IQR: 7, 17]) and had higher median ISS [9 [IQR: 4, 13] vs 4 [2, 9]) compared to those without imaging (both p<0.001). Overall, 1,224 scans were performed with normal findings in 609 (50%). A median of 1 scan was performed per patient (range: 1-5). The most common location was CT head (n = 695, 57%). Among patients with positive findings on CT head (n = 443), 31 (7%) underwent either intracranial pressure monitoring or surgery. CT of the cervical spine had positive findings in 12 (7%) with no patients undergoing spine surgery. Of 173 patients with abdominal CT imaging, 83 (48%) had abnormal findings and 18 (10%) required operative exploration. Thirteen (16%) patients with abnormal findings on abdominal CT had exploratory laparotomy. Of 111 children undergoing whole body CT, 8 (7%) underwent thoracic and/or abdominal operations. CONCLUSION: Use of CT during evaluation of pediatric trauma is common in an MIC center. A high rate of normal findings and low rates of intervention following head, cervical spine, and abdominal CT suggest potential overuse of this resource. LEVEL OF EVIDENCE: Level III.

Use of vital signs in predicting surgical intervention in a South African population: A cross-sectional study.

BACKGROUND: While vital signs are widely obtained for trauma patients around the world, the association of these signs with surgical intervention has yet to be defined. Early detection of trauma patients requiring surgery is essential to timely intervention and reduction of morbidity and mortality. OBJECTIVE: The aim of this study was to determine the association of vital signs with surgical intervention in a South African patient population. METHODS: This retrospective cohort included 7857 trauma patients admitted at Grey's Hospital in Pietermaritzburg, South Africa over a five-year period December 2012-April 2018. Exclusion criteria included missing key data points. Variables for analysis included sex, mechanism of injury, admission Glasgow Coma Scale (GCS), systolic blood pressure, diastolic blood pressure, temperature, heart rate, and respiratory rate. Surgical intervention was defined by the need for treatment requiring time in the operating room. Data were analyzed using a univariate and multivariate logistic regression to determine an association between admission vital signs and surgical intervention and was compared to the association of the Revised Trauma Score to surgical intervention. RESULTS: Of the 8722 trauma patient records available, exclusion of patients with incomplete data resulted in 7857 patient records available for analysis. Two thousand two hundred and ninety-six (29.2%) patients required surgical intervention in the operating room. Multivariate analysis revealed that male sex [odds ratio (OR) 1.25, 95% confidence interval (CI) 1.06-1.48], stab wound (OR 3.42, CI 2.99-3.09), gunshot wound (OR 4.27, CI 3.58-5.09), systolic hypotension (OR 1.81, CI 1.32-2.48), hypothermia (OR 1.77, CI 1.34-2.34), tachycardia (OR 1.84, CI 1.61-2.10), and tachypnea (OR 1.26, CI 1.08-1.45) were associated with an increased likelihood of surgical intervention. CONCLUSIONS: In this cohort of patients, the need for surgical intervention was best predicted by penetrating mechanisms of injury, tachycardia, and systolic hypotension. These data show that rapid and focused patient assessments should be used to triage patients for emergency surgery to avoid delays.

The search for a simple injury score to reliably discriminate the risk of in-hospital mortality in South Africa.

BACKGROUND: The Injury Severity Score and Trauma and Injury Severity Score are used commonly to quantify the severity of injury, but they require comprehensive data collection that is impractical in many low- and middle-income countries . We sought to develop an injury score that is more feasible to implement in low- and middle-income countries with discrimination similar to the Injury Severity Score and the Trauma and Injury Severity Score. METHODS: Clinical data from KwaZulu-Natal, South Africa were used to compare the discrimination of the Injury Severity Score and the Trauma and Injury Severity Score with that of the 5, simple injury scores that rely primarily on physiologic data: Revised Trauma Score for Triage, "Mechanism, Glasgow Coma Scale, Age, Pressure" Score, Kampala Trauma Score, modified Kampala Trauma Score, and "Reversed Shock Index Multiplied by Glasgow Coma Scale" Score. RESULTS: Data for 3,991 patients were analyzed. The Trauma and Injury Severity Score, the Injury Severity Score, and Kampala Trauma Score had similar discrimination (area under the receiver operating curve 0.85, 0.84, and 0.84, respectively). The simple injury scores demonstrated worse discrimination among patients presenting more than 6 hours postinjury, although Kampala Trauma Score maintained the best discrimination of the simple injury scores. CONCLUSION: In this patient population, Kampala Trauma Score demonstrated discrimination similar to the Injury Severity Score and the Trauma and Injury Severity Score and may be useful to quantify the severity of injury when calculation of the Injury Severity Score or the Trauma and Injury Severity Score is not feasible. Delay in presentation can degrade the discrimination of simple injury scores that rely primarily on physiologic data.