Citywide trauma experience in Kampala, Uganda: a call for intervention.

OBJECTIVES: To describe injuries and their emergency care at five city hospitals. SETTING: Data were collected between January and December 1998 from casualty departments of the five largest hospitals of Kampala city, Uganda, with bed capacity ranging from 60 to 1200. METHODS: Registry forms were completed on trauma patients. All patients with injuries were eligible. Outcome at two weeks was determined for admitted patients. RESULTS: Of the 4359 injury patients, 73% were males. Their mean age was 24.2 years, range 0.1-89, and a 5-95 centile of 5-50 years. Patients with injuries were 7% of all patients seen. Traffic crashes caused 50% of injuries, and were the leading cause for patients > or = 10 years. Fifty eight per cent of injuries occurred on the road, 29% at home, and 4% in a public building. Falls, assaults, and burns were the main causes in homes. Fourteen per cent of injuries were intentional. Injuries were severe in 24% as determined with the Kampala trauma score. One third of patients were admitted; two thirds arrived at the hospital within 30 minutes of injury, and 92% were attended within 20 minutes of arrival. CONCLUSIONS: Injuries in Kampala are an important public health problem, predominantly in young adult males, mostly due to traffic. The majority of injuries are unintentional. Hospital response is rapid, but the majority of injuries are minor. Without pre-hospital care, it is likely that patients with serious injuries die before they access care. Preventive measures and a pre-hospital emergency service are urgently needed.

Hospital-based trauma registries in Uganda.

OBJECTIVES: Toward the establishment of an injury surveillance system in Uganda, the first step was to initiate hospital-based trauma registries that generate relevant and timely data on the causes, severity, morbidity, mortality, and outcomes of injuries at Mulago and Kawolo hospitals. This would help establish injury patterns and priorities in these hospital populations. The registries are based on a minimal data set and a new injury severity instrument, the Kampala Trauma Score (KTS). The usefulness of the registry and the qualities of the KTS are presented. METHODS: The Accident and Emergency Department of Mulago, an urban 1,500-bed, tertiary hospital, and the Casualty Unit of Kawolo, a 100-bed district-level hospital. Trained staff in the hospitals used a one-page, 19-item registry form to collect data on demographic, injury incident, and outcome data. The registry describes injuries based on cause, frequency, and severity. The inter-rater reliability and the predictive validity of the KTS were evaluated. Registry subjects include all injured persons that come to the above hospitals. RESULTS: Results are based on the first 5,210 records. Gender distribution was 27.7% female and 71.3% male. The younger than 5 years old category was 7.4%, whereas 3.9% were older than 55 years old. Admitted patients composed 37.3% of cases, and three of four injuries were unintentional. The KTS is highly predictive of need for admission or death (adults, Az = 0.95 +/- 0.01; children, Az = 0.89 +/- 0.01). CONCLUSION: A trauma registry and injury severity measurement are both possible and useful in sub-Saharan Africa. This minimal data set and the KTS are recommended for investigators with similar resource constraints.

The comparison of injury severity instrument performance using likelihood ratio and ROC curve analyses.

BACKGROUND: The relative merits of injury severity instruments are often difficult to determine because the statistical techniques, study populations, and outcomes used in trauma research tend to obscure rather than elucidate differences in performance. OBJECTIVE: To describe the advantages of likelihood ratio and receiver operator characteristic (ROC) curve analyses and to demonstrate them using study populations and outcomes that facilitate instrument discrimination. MATERIALS AND METHODS: Previously published data on the performance of the "Injury Severity Score" and of four triage instruments in the prediction of mortality; paired comparison of two instruments in a previously unpublished trauma registry dataset; use of likelihood ratio and ROC analyses. MEASUREMENTS AND MAIN RESULTS: In a comparison of triage instruments this study clearly showed that CRAMS, PHI, and RTI, which contain nonphysiological information, have higher performance levels than the Revised Trauma Score (RTS), which is restricted to physiological information. Absolute performance gains of these instruments over the RTS ranged from 5.9% to 43.5%. This study also noted that the ISS performs equally well for blunt and penetrating trauma, and affirms concerns about the adequacy of its performance. CONCLUSIONS: Likelihood ratio and ROC curve analyses demonstrate differences in injury severity instrument performance that were obscured by less rigorous methods of comparison.

Induction of resistance to Schistosoma mansoni infection in mice by purified parasite paramyosin.

Freeze-thaw (FT)-disrupted schistosomula or their membrane extract induced significant resistance in mice to Schistosoma mansoni infection (34 and 25%, respectively) without the use of adjuvant. Antigens identified in schistosome extracts by sera from immunized animals were then evaluated for protective potential. Immunization with schistosomal antigens of 97 and 68-70 kD resulted in significant protection that was equivalent to that obtained by FT schistosomula. Since the 97-kD antigen was suggested to be parasite paramyosin, we used a biochemical technique to purify this muscle protein. Purified schistosome paramyosin ran as a single band on 10% SDS-PAGE and was recognized both by sera from mice immunized with FT schistosomula and a polyclonal antiserum raised against the 97-kD parasite protein. Preincubation of schistosome paramyosin with sera from mice immunized with FT schistosomula resulted in the removal of reactivity with the 97-kD protein in crude worm extracts. Paramyosin was identified by Western blotting to be in the tegument of schistosomula. The purified schistosome paramyosin resulted in significant protection in three separate experiments (24, 46, and 53%) without the use of adjuvant. Addition of BCG to paramyosin resulted in enhanced protection.

Isolation and characterization of a protective antigen for adjuvant-free immunization against Schistosoma mansoni.

A single, 68,000 m.w. glycoprotein antigen from adult Schistosoma mansoni was purified by immunoaffinity chromatography with the use of a newly developed, protective, anti-schistosome murine monoclonal antibody. Immunization with two doses of 0.5 microgram or 1 microgram of purified antigen, without adjuvants, afforded a mean 28% reduction in parasite recovery in CF1 mice, and 2-% reduction in parasite BALB/c mice. On immunoblotting, the 68,000 m.w. antigen was common to S. mansoni adults and schistosomula, whereas parasite eggs contained only cross-reacting low m.w. antigens of 19,100 and 16,000. Immunization resulted in the development of anti-antigen antibody and enhanced immediate cutaneous hypersensitivity to the 31-3B6 antigen. By contrast, delayed-type hypersensitivity and sensitization to circumoval granuloma formation were not observed in immunized mice. It was concluded that the 68,000 m.w. 31-3B6 antigen represents a candidate vaccine for adjuvant-free immunization against S. mansoni.