A Machine Learning-Based Triage Tool for Children With Acute Infection in a Low Resource Setting.

OBJECTIVES: To deploy machine learning tools (random forests) to develop a model that reliably predicts hospital mortality in children with acute infections residing in low- and middle-income countries, using age and other variables collected at hospital admission. DESIGN: Post hoc analysis of a single-center, prospective, before-and-after feasibility trial. SETTING: Rural district hospital in Rwanda, a low-income country in Sub-Sahara Africa. PATIENTS: Infants and children greater than 28 days and less than 18 years of life hospitalized because of an acute infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Age, vital signs (heart rate, respiratory rate, and temperature) capillary refill time, altered mental state collected at hospital admission, as well as survival status at hospital discharge were extracted from the trial database. This information was collected for 1,579 adult and pediatric patients admitted to a regional referral hospital with an acute infection in rural Rwanda. Nine-hundred forty-nine children were included in this analysis. We predicted survival in study subjects using random forests, a machine learning algorithm. Five prediction models, all including age plus two to five other variables, were tested. Three distinct optimization criteria of the algorithm were then compared. The in-hospital mortality was 1.5% (n = 14). All five models could predict in-hospital mortality with an area under the receiver operating characteristic curve ranging between 0.69 and 0.8. The model including age, respiratory rate, capillary refill time, altered mental state exhibited the highest predictive value area under the receiver operating characteristic curve 0.8 (95% CI, 0.78-0.8) with the lowest possible number of variables. CONCLUSIONS: A machine learning-based algorithm could reliably predict hospital mortality in a Sub-Sahara African population of 949 children with an acute infection using easily collected information at admission which includes age, respiratory rate, capillary refill time, and altered mental state. Future studies need to evaluate and strengthen this algorithm in larger pediatric populations, both in high- and low-/middle-income countries.

Increasing Evidence-Based Interventions in Patients with Acute Infections in a Resource-Limited Setting: A Before-and-After Feasibility Trial in Gitwe, Rwanda.

OBJECTIVE: To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections. DESIGN: Single-center, prospective, before-and-after feasibility trial. SETTING: Emergency department of a sub-Saharan African district hospital. PATIENTS: Patients > 28 days of life admitted to the study hospital for an acute infection. INTERVENTIONS: The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases. MEASUREMENTS AND MAIN RESULTS: Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed. CONCLUSIONS: Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).

Association of the Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) Score With Excess Hospital Mortality in Adults With Suspected Infection in Low- and Middle-Income Countries.

Importance: The quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score has not been well-evaluated in low- and middle-income countries (LMICs). Objective: To assess the association of qSOFA with excess hospital death among patients with suspected infection in LMICs and to compare qSOFA with the systemic inflammatory response syndrome (SIRS) criteria. Design, Settings, and Participants: Retrospective secondary analysis of 8 cohort studies and 1 randomized clinical trial from 2003 to 2017. This study included 6569 hospitalized adults with suspected infection in emergency departments, inpatient wards, and intensive care units of 17 hospitals in 10 LMICs across sub-Saharan Africa, Asia, and the Americas. Exposures: Low (0), moderate (1), or high (≥2) qSOFA score (range, 0 [best] to 3 [worst]) or SIRS criteria (range, 0 [best] to 4 [worst]) within 24 hours of presentation to study hospital. Main Outcomes and Measures: Predictive validity (measured as incremental hospital mortality beyond that predicted by baseline risk factors, as a marker of sepsis or analogous severe infectious course) of the qSOFA score (primary) and SIRS criteria (secondary). Results: The cohorts were diverse in enrollment criteria, demographics (median ages, 29-54 years; males range, 36%-76%), HIV prevalence (range, 2%-43%), cause of infection, and hospital mortality (range, 1%-39%). Among 6218 patients with nonmissing outcome status in the combined cohort, 643 (10%) died. Compared with a low or moderate score, a high qSOFA score was associated with increased risk of death overall (19% vs 6%; difference, 13% [95% CI, 11%-14%]; odds ratio, 3.6 [95% CI, 3.0-4.2]) and across cohorts (P < .05 for 8 of 9 cohorts). Compared with a low qSOFA score, a moderate qSOFA score was also associated with increased risk of death overall (8% vs 3%; difference, 5% [95% CI, 4%-6%]; odds ratio, 2.8 [95% CI, 2.0-3.9]), but not in every cohort (P < .05 in 2 of 7 cohorts). High, vs low or moderate, SIRS criteria were associated with a smaller increase in risk of death overall (13% vs 8%; difference, 5% [95% CI, 3%-6%]; odds ratio, 1.7 [95% CI, 1.4-2.0]) and across cohorts (P < .05 for 4 of 9 cohorts). qSOFA discrimination (area under the receiver operating characteristic curve [AUROC], 0.70 [95% CI, 0.68-0.72]) was superior to that of both the baseline model (AUROC, 0.56 [95% CI, 0.53-0.58; P < .001) and SIRS (AUROC, 0.59 [95% CI, 0.57-0.62]; P < .001). Conclusions and Relevance: When assessed among hospitalized adults with suspected infection in 9 LMIC cohorts, the qSOFA score identified infected patients at risk of death beyond that explained by baseline factors. However, the predictive validity varied among cohorts and settings, and further research is needed to better understand potential generalizability.

Mucinous Adenocarcinoma of Gallbladder: An Incidental Finding of Acute Cholecystitis With Cholelithiasis.

The biliary tract's most frequent malignancy is gallbladder cancer (GBC). Due to the growing number of laparoscopic cholecystectomy procedures, the majority of GBC cases in the United States are diagnosed as incidental findings. Roughly 5% of the reported cases of gallbladder adenocarcinomas are of the mucinous type. Mucinous adenocarcinoma tumors contain more than 50% of mucin materials and are clinically characterized by poor prognosis. Initial presentation can mimic acute cholecystitis or cholelithiasis; meanwhile, histological findings post-cholecystectomy are the main diagnostic criteria of mucinous adenocarcinoma of the gallbladder. This case presents a patient who has been diagnosed with cholelithiasis and cholecystitis and subsequently underwent laparoscopic cholecystectomy. Histopathological examination of the gallbladder specimen was consistent with incidental gallbladder adenocarcinoma, the mucinous subtype to be specific.

Pylephlebitis: A Rare Complication of Acute Appendicitis.

Pylephlebitis is defined as an infective suppurative thrombosis of the portal vein and its tributaries - a rare complication of intra-abdominal infections. It is most commonly seen in patients with diverticulitis and appendicitis. Prompt diagnosis with abdominal ultrasound and computerized tomography (CT) scan along with early and aggressive treatment with broad-spectrum antibiotics is crucial because of its high mortality rates. However, this diagnosis is often missed due to the nature of its nonspecific clinical symptoms. We discuss a case of a 22-year-old male who presented with pylephlebitis as a complication of acute gangrenous appendicitis. The patient was treated successfully with appropriate surgical intervention, antibiotics, and anticoagulation.

Performance of the Universal Vital Assessment (UVA) mortality risk score in hospitalized adults with infection in Rwanda: A retrospective external validation study.

BACKGROUND: We previously derived a Universal Vital Assessment (UVA) score to better risk-stratify hospitalized patients in sub-Saharan Africa, including those with infection. Here, we aimed to externally validate the performance of the UVA score using previously collected data from patients hospitalized with acute infection in Rwanda. METHODS: We performed a secondary analysis of data collected from adults ≥18 years with acute infection admitted to Gitwe District Hospital in Rwanda from 2016 until 2017. We calculated the UVA score from the time of admission and at 72 hours after admission. We also calculated quick sepsis-related organ failure assessment (qSOFA) and modified early warning scores (MEWS). We calculated amalgamated qSOFA scores by inserting UVA cut-offs into the qSOFA score, and modified UVA scores by removing the HIV criterion. The performance of each score determined by the area under the receiver operator characteristic curve (AUC) was the primary outcome measure. RESULTS: We included 573 hospitalized adult patients with acute infection of whom 40 (7%) died in-hospital. The admission AUCs (95% confidence interval [CI]) for the prediction of mortality by the scores were: UVA, 0.77 (0.68-0.85); modified UVA, 0.77 (0.68-0.85); qSOFA, 0.66 (0.56-0.75), amalgamated qSOFA, 0.71 (0.61-0.80); and MEWS, 0.74 (0.64, 0.83). The positive predictive values (95% CI) of the scores at commonly used cut-offs were: UVA >4, 0.35 (0.15-0.59); modified UVA >4, 0.35 (0.15-0.59); qSOFA >1, 0.14 (0.07-0.24); amalgamated qSOFA >1, 0.44 (0.20-0.70); and MEWS >5, 0.14 (0.08-0.22). The 72 hour (N = 236) AUC (95% CI) for the prediction of mortality by UVA was 0.59 (0.43-0.74). The Chi-Square test for linear trend did not identify an association between mortality and delta UVA score at 72 hours (p = 0.82). CONCLUSIONS: The admission UVA score and amalgamated qSOFA score had good predictive ability for mortality in adult patients admitted to hospital with acute infection in Rwanda. The UVA score could be used to assist with triage decisions and clinical interventions, for baseline risk stratification in clinical studies, and in a clinical definition of sepsis in Africa.

Epidemiology and Outcome of Sepsis in Adults and Children in a Rural, Sub-Sahara African Setting.

OBJECTIVES: To identify the epidemiology and outcome of adults and children with and without sepsis in a rural sub-Sahara African setting. DESIGN: A priori planned substudy of a prospective, before-and-after trial. SETTING: Rural, sub-Sahara African hospital. PATIENTS: One-thousand four-hundred twelve patients (adults, n = 491; children, n = 921) who were admitted to hospital because of an acute infection. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic, clinical, laboratory data, danger signs, and the presence of sepsis (defined as a quick Sequential Organ Failure Assessment score count ≥ 2) at admission were extracted. Sepsis was observed in 69 adults (14.1%) and 248 children (26.9%). Sepsis patients differed from subjects without sepsis in several demographic and clinical aspects. Malaria was the most frequent type of infection in adults (66.7%) and children (63.7%) with sepsis, followed by suspected bacterial and parasitic infections other than malaria. Adults with sepsis more frequently developed respiratory failure (8.7% vs 2.1%; p = 0.01), had a higher in-hospital mortality (17.4% vs 8.3%; p < 0.001), were less often discharged home (81.2% vs 92.2%; p = 0.007), and had higher median (interquartile range) costs of care (30,300 [19,400-49,900] vs 42,500 Rwandan Francs [27,000-64,400 Rwandan Francs]; p = 0.004) than adults without sepsis. Children with sepsis were less frequently discharged home than children without sepsis (93.1% vs 96.4%; p = 0.046). Malaria and respiratory tract infections claimed the highest absolute numbers of lives. The duration of symptoms before hospital admission did not differ between survivors and nonsurvivors in adults (72 [24-168] vs 96 hr [72-168 hr]; p = 0.27) or children (48 [24-72] vs 36 [24-108 hr]; p = 0.8). Respiratory failure and coma were the most common causes of in-hospital death. CONCLUSIONS: In addition to suspected bacterial, viral, and fungal infections, malaria and other parasitic infections are common and important causes of sepsis in adults and children admitted to a rural hospital in sub-Sahara Africa. The in-hospital mortality associated with sepsis is substantial, primarily in adults.

The inability to walk unassisted at hospital admission as a valuable triage tool to predict hospital mortality in Rwandese patients with suspected infection.

OBJECTIVE: To assess the value of the inability to walk unassisted to predict hospital mortality in patients with suspected infection in a resource-limited setting. METHODS: This is a post hoc study of a prospective trial performed in rural Rwanda. Patients hospitalized because of a suspected acute infection and who were able to walk unassisted before this disease episode were included. At hospital presentation, the walking status was graded into: 1) can walk unassisted, 2) can walk assisted only, 3) cannot walk. Receiver operating characteristic (ROC) analyses and two-by-two tables were used to determine the sensitivity, specificity, negative and positive predictive values of the inability to walk unassisted to predict in-hospital death. RESULTS: One-thousand-sixty-nine patients were included. Two-hundred-one (18.8%), 315 (29.5%), and 553 (51.7%) subjects could walk unassisted, walk assisted or not walk, respectively. Their hospital mortality was 0%, 3.8% and 6.3%, respectively. The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90-100%) to predict in-hospital death (p = 0.00007). The value of the inability to walk unassisted to predict in-hospital mortality (AUC ROC, 0.636; CI95%, 0.564-0.707) was comparable to that of the qSOFA score (AUC ROC, 0.622; CI95% 0.524-0.728). Fifteen (7.5%), 34 (10.8%) and 167 (30.2%) patients who could walk unassisted, walk assisted or not walk presented with a qSOFA score count ≥2 points, respectively (p<0.001). The inability to walk unassisted correlated with the presence of risk factors for death and danger signs, vital parameters, laboratory values, length of hospital stay, and costs of care. CONCLUSIONS: Our results suggest that the inability to walk unassisted at hospital admission is a highly sensitive predictor of in-hospital mortality in Rwandese patients with a suspected acute infection. The walking status at hospital admission appears to be a crude indicator of disease severity.

The role of the vascular surgeon in anterior retroperitoneal spine exposure: preservation of open surgical training.

OBJECTIVE: Open vascular surgical procedures have decreased since the advent of endovascular repair. Advances in spinal fusion techniques and artificial disc replacement have led to an increase in the need for anterior retroperitoneal exposure of the lumbar spine (ARES). Vascular surgeons participate as "exposure surgeons" for these cases due to their unique skills in dealing with retroperitoneal structures. We report a single center experience with this procedure and focus on injury pattern and preservation of open surgical training. METHODS: Patients undergoing ARES over an 8-year period were identified from our vascular registry. A two-team approach involving a vascular surgeon and spine surgeon has been routinely employed. ARES was performed for anterior lumbar interbody fusion or total disc replacement. The intraoperative techniques of vascular manipulation were reviewed. The need for suture repair of vascular structures and the incidence and timing of serious vascular injury was recorded. RESULTS: Four-hundred and five ARES procedures were performed. The levels exposed included L5-S1 alone (128), L4-5 (54), 4-5 and 5-S1 (139), and other combinations in 84 cases. The exposure involved the L4-5 disc in 243 cases (60%). Exposure of L4-5 was accomplished above the left common iliac artery (CIA) in 44%, between the left CIA and common iliac vein (CIV) in 45%, and below the left CIV in 11%. Minor vascular injuries (all venous) needing suture repair occurred in 24% of cases overall. Minor vascular injuries occurred during both exposure (43%) and instrumentation (57%). Minor vascular injuries were significantly more frequent in cases involving the L4-5 disc than in those not involving L4-5 (31.7% vs 11.1%, P < .001). Serious, life-threatening, vascular injuries occurred in 12 patients (3%), all during instrumentation, and included left CIV laceration (seven cases), right CIV laceration (two cases), and inferior vena cava laceration, distal aortic plaque disruption and left CIA laceration in one case each. There was no association between body mass index, prior surgery, or type of instrumentation and the occurrence of minor or major vascular injuries. Postoperative vascular complications included three deep vein thromboses; two of which occurred in patients with CIV laceration. CONCLUSION: Vascular expertise is important in anterior retroperitoneal lumbar spine exposure. Minor venous injuries frequently occur during exposure and instrumentation. Significant vascular injuries, while rare, occur during instrumentation, therefore the vascular surgeon should remain present throughout the entire procedure. The vascular manipulations required during exposure of the L4-5 disc offer an excellent opportunity for open vascular surgical experience. Vascular surgeon involvement in these cases allows for prompt repair of vascular injuries and provides opportunities for the vascular surgery resident to augment his/her open surgical training.

Gastrointestinal stromal tumors: a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are rare neoplasms of the gastrointestinal tract associated with high rates of malignant transformation. Most GISTs present asymptomatically. They are best identified by computed tomography (CT) scan and most stain positive for CD117 (C-Kit), CD34, and/or DOG-1. There have been many risk stratification classifications systems which are calculated based on tumor size, mitotic rate, location, and perforation. The approaches to treating GISTs are to resect primary low-risk tumors, resect high-risk primary or metastatic tumors with imatinib 400 mg daily for 12 months, or if the tumor is unresectable, neoadjuvant imatinib 400 mg daily followed by surgical resection is recommended. Sunitinib is required for KIT exon 9, 13, and 14 mutations, while ponatinib is used for exon 17 mutations and regorafenib for highly refractory tumors. High-risk tumors should be monitored for recurrence with serial abdominal CT scans. Radiofrequency ablation has shown to be effective when surgery is not suitable. Newer therapies of ipilimumab, nivolumab, and endoscopic ultrasound alcohol ablation have shown promising results. This report addresses the epidemiology, clinical presentation, diagnostic imaging, histologic diagnosis, classification and risk stratification, staging and grading, surgical treatment, adjuvant treatment, and metastasis of GISTs.

Increasing evidence-based interventions in patients with acute infections in a resource-limited setting: a before-and-after feasibility trial in Gitwe, Rwanda.

OBJECTIVE: To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections. DESIGN: Single-center, prospective, before-and-after feasibility trial. SETTING: Emergency department of a sub-Saharan African district hospital. PATIENTS: Patients > 28 days of life admitted to the study hospital for an acute infection. INTERVENTIONS: The trial had three phases (each of 4 months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases. MEASUREMENTS AND MAIN RESULTS: Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 h after hospital admission; and at discharge. A total of 1594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 h (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed. CONCLUSIONS: Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population ( http://www.clinicaltrials.gov : NCT02697513).

Management of acute appendicitis in a rural population.

BACKGROUND: Our system uses a hub and spoke approach to provide surgical care for our rural population. Patients access care anywhere in the system but are transferred centrally for surgical care. We sought to determine if surgical outcome differed depending on where initial care occurred. We chose acute appendicitis (AA) to investigate our care model. METHODS: We identified patients admitted with the diagnosis of AA. Patients were divided into 2 groups, Bassett Medical Center presentation and satellite center (SAT) presentation. Demographics were compared and, time from system access to surgery, time of surgery, and clinical information associated with care. RESULTS: There were no differences regarding any clinically relevant factor. SAT patients had longer mean surgery times, 60.7 minutes vs 51.5 (P=.008). Time to surgery, LOS, and complications were similar. CONCLUSIONS: It is safe to care for AA patients with a hub and spoke approach without putting SAT patients at a disadvantage.