Fifteen years of emergency medicine literature in Africa: A scoping review.

INTRODUCTION: Emergency medicine (EM) throughout Africa exists in various stages of development. The number and types of scientific EM literature can serve as a proxy indicator of EM regional development and activity. The goal of this scoping review is a preliminary assessment of potential size and scope of available African EM literature published over 15 years. METHODS: We searched five indexed international databases as well as non-indexed grey literature from 1999-2014 using key search terms including "Africa", "emergency medicine", "emergency medical services", and "disaster." Two trained physician reviewers independently assessed whether each article met one or more of five inclusion criteria, and discordant results were adjudicated by a senior reviewer. Articles were categorised by subject and country of origin. Publication number per country was normalised by 1,000,000 population. RESULTS: Of 6091 identified articles, 633 (10.4%) were included. African publications increased 10-fold from 1999 to 2013 (9 to 94 articles, respectively). Western Africa had the highest number (212, 33.5%) per region. South Africa had the largest number of articles per country (171, 27.0%) followed by Nigeria, Kenya, and Ghana. 537 (84.8%) articles pertained to facility-based EM, 188 (29.7%) to out-of-hospital emergency medicine, and 109 (17.2%) to disaster medicine. Predominant content areas were epidemiology (374, 59.1%), EM systems (321, 50.7%) and clinical care (262, 41.4%). The most common study design was observational (479, 75.7%), with only 28 (4.4%) interventional studies. All-comers (382, 59.9%) and children (91, 14.1%) were the most commonly studied patient populations. Undifferentiated (313, 49.4%) and traumatic (180, 28.4%) complaints were most common. CONCLUSION: Our review revealed a considerable increase in the growth of African EM literature from 1999 to 2014. Overwhelmingly, articles were observational, studied all-comers, and focused on undifferentiated complaints. The articles discovered in this scoping review are reflective of the relatively immature and growing state of African EM.

Adolescent and Young Adult Injuries in Developing Economies: A Comparative Analysis from Oman and Kenya.

BACKGROUND: Adolescence is a distinct period of rapid and dramatic biological, cognitive, psychological, and social development. The burden of injuries among young people (aged 10-24) is both substantial and maldistributed across regions and levels of economic development. OBJECTIVES: Our objective was to compare sociodemographic correlates of injury cause, intentionality, and mortality between Kenya and Oman, 2 countries with different levels of economic development and position in the demographic and epidemiologic transitions. METHODS: Data on 566 patients in Oman and 5859 in Kenya between 10 and 24 years old were extracted from 2 separate multicenter trauma registries. Multivariable log binomial and Poisson regressions were used to evaluate social and demographic factors associated with injury cause, intentionality, and mortality. Literature on adolescent development was used to parameterize variables, and Akaike information criteria were used in the final model selections. FINDINGS: The trauma registry data indicated a substantial burden of adolescent and young adult injury in both Oman and Kenya, particularly among males. The data indicated significant differences between countries (P < .001) in age category, gender distributions, level of education, occupation, cause of injury, and place where injury occurred. Consistent with other literature, road traffic injuries emerged as the most common type of injury as well as the most severe and fatal, with interpersonal violence also resulting in severe injury across contexts. Both road traffic injuries and interpersonal violence were more common among older adolescents and young adults. Education and being in school were protective against injury, after controlling for gender, age category, occupation, and country. CONCLUSIONS: A rising burden of injuries among young people has been documented in every region of the world, irrespective on income status or level of development. Cost-effective injury control measures targeting this age group exist, including involvement in educational, vocational, and other prosocial activities; environmental alterations; and road safety measures.

Nine-point plan to improve care of the injured patient: A case study from Kenya.

BACKGROUND: Injury rates in low- and middle-income countries are among the greatest in the world, with >90% of unintentional injury occurring in low- or middle-income countries. The risk of death from injuries is 6 times more in low- and middle-income countries than in high-income countries. This increased rate of injury is partly due to the lack of availability and access to timely and appropriate medical care for injured individuals. Kenya, like most low- and middle-income countries, has seen a 5-fold increase in injury fatalities throughout the past 4 decades, in large part related to the absence of a coordinated, integrated system of trauma care. METHODS: We aimed to assess the trauma-care system in Kenya and to develop and implement a plan to improve it. A trauma system profile was performed to understand the landscape for the care of the injured patient in Kenya. This process helped identify key gaps in care ranging from prehospital to hospital-based care. RESULTS: In response to this observation, a 9-point plan to improve trauma care in Kenya was developed and implemented in close collaboration with local stakeholders. The 9-point plan was centered on engagement of the stakeholders, generation of key data to guide and improve services, capacity development for prehospital and hospital care, and strengthening policy and legislation. CONCLUSION: There is an urgent need for coordinated strategies to provide appropriate and timely medical care to injured individuals in low- or middle-income countries to decrease the burden of injuries and related fatalities. Our work in Kenya shows that such an integrated system of trauma care could be achieved through a step-by-step integrated and multifaceted approach that emphasizes engagement of local stakeholders and evidence-based approaches to ensure effectiveness, efficiency, and sustainability of system-wide improvements. This plan and lessons learned in its development and implementation could be adaptable to other similar settings to improve the care of the injured patient in low- or middle-income countries.

Exploring injury severity measures and in-hospital mortality: A multi-hospital study in Kenya.

INTRODUCTION: Low- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya. METHODS: This study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations. RESULTS: A total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866-0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852-0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736-0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures. CONCLUSIONS: This multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya.

Understanding patterns of injury in Kenya: Analysis of a trauma registry data from a National Referral Hospital.

BACKGROUND: Injuries contribute to a substantial proportion of the burden of disease in Kenya. Trauma registries can be a very useful source of data to understand patterns of injuries and serve to provide information about potential improvements in the care of injured patients. In Kenya, health facility-based injury data has been largely administrative. Our aim was to develop and implement a prospective trauma registry at the largest trauma hospital in Kenya, the Kenyatta National Hospital, and to understand the nature of injuries presenting to the hospital, their treatment and care, and their outcomes. METHODS: An electronic, tablet-based instrument was developed and implemented between January 2014 and June 2015. Data were collected at the emergency department, and patients were followed through disposition from the emergency department or in-patient wards if admitted. Variables included demographics, type of prehospital care received, details of the injury, and initial assessment and disposition from the emergency department or in-patient wards. Bivariate and multiple logistic regressions were used to assess potential risk factors associated with outcomes. RESULTS: A total of 8,701 injury patients were included in the registry during the study period. The mean age of the injured patients was 28 years (standard deviation, 26 years). The majority of these patients were males (81.7%). The leading mechanisms of injuries were road traffic injury (41.7%), assault (25.3%), and falls (18.9%). Only 7.4% of patients received prehospital care; 49.6% of injured patients arrived within 1 hour after their injury. Hospital mortality was 4.4% and close to 1% of patients died in the emergency department. The independent predictors of in-hospital death were older age (≥60 years), injury mechanism (burns and road traffic injuries), and admission type (transfer) after controlling for injury severity. CONCLUSION: The establishment of hospital-based trauma registries can be an important tool for injury surveillance. This information will facilitate identifying priority areas for trauma care and quality improvement, as well as guiding the development of injury prevention and control programs.

Epidemiology and outcomes of injuries in Kenya: A multisite surveillance study.

BACKGROUND: Injury is a leading cause of disability and death worldwide, accounting for over 5 million deaths each year. The injury burden is higher in low- and middle-income countries where more than 90% of injury-related deaths occur. Despite this burden, the use of prospective trauma registries to describe injury epidemiology and outcomes is limited in low- and middle-income countries. Kenya lacks robust data to describe injury epidemiology and care. The objective of this study was to investigate the epidemiology and outcomes of injuries at 4 referral hospitals in Kenya using hospital-based trauma registries. METHODS: From January 2014 to May 2015, all injured patients presenting to the casualty departments of Kenyatta National, Thika Level 5, Machakos Level 5, and Meru Level 5 Hospitals were enrolled prospectively. Data collected included demographic characteristics, type of prehospital care received, prehospital time, injury pattern, and outcomes. RESULTS: A total of 14,237 patients were enrolled in our study. Patients were predominantly male (76.1%) and young (mean age 28 years). The most common mechanisms of injury were road traffic injuries (36.8%), falls (26.4%), and being struck/hit by a person or object (20.1%). Burn was the most common mechanism of injury in the age category under 5 years. Body regions commonly injured were lower extremity (35.1%), upper extremity (33.4%), and head (26.0%). The overall mortality rate was 2.4%. Significant predictors of mortality from multivariate analysis were Glasgow Coma Scale ≤12, estimated injury severity score ≥9, burns, and gunshot injuries. CONCLUSION: Hospital-based trauma registries can be important sources of data to study the epidemiology of injuries in low- and middle-income countries. Data from such trauma registries can highlight key needs and be used to design public health interventions and quality-of-care improvement programs.

Vascular access modifies the protective effect of obesity on survival in hemodialysis patients.

BACKGROUND: The protective effect of obesity on the survival of patients undergoing hemodialysis (HD) for end-stage renal disease (ESRD), described as the obesity paradox, has been established previously. Survival benefits also have been ascribed to permanent modes of HD access (fistula/graft) compared with catheter at first HD. The purpose of this study is to evaluate the impact of incident HD access type on the obesity paradox. METHODS: A retrospective study of all patients with ESRD in the US Renal Database System who initiated HD between 2006 and 2010 was carried out. Multivariate logistic, Cox regression, and propensity score matched analyses were used to evaluate the association between body mass index (BMI), modes of HD access (fistula/graft vs catheter), and mortality. RESULTS: There were 501,920 dialysis initiates studied; 83% via catheter, 14% via fistula, and 3% via grafts. Mortality was lesser for patients initiating hemodialysis with permanent forms of access compared with catheter (adjusted odds ratio 0.68, 95% confidence interval 0.67-0.69, P < .001). High body mass index (BMI) was associated with lower mortality. Patients with high BMI were more likely to initiate hemodialysis via permanent modes of access compared with patients with normal BMI. CONCLUSION: The highly popularized protective effect of increased BMI on survival in HD patients is significantly influenced by the method of hemodialysis access. There is greater use of permanent access among patients with high BMI compared with patients with normal BMI. There remains a critical need to increase permanent access utilization at incident hemodialysis so as to improve survival irrespective of BMI status.