Road traffic collisions in Malawi: Trends and patterns of mortality on scene

Background: Worldwide, 90% of injury deaths occur in low- and middle-income countries (LMIC). Road traffic collisions (RTCs) are increasingly common and result in more death and disability in the developing world than in the developed world. We aimed to examine the prehospital case fatality rate from RTCs in Malawi.Material and Methods: A retrospective study was performed utilizing the Malawian National Road Safety Council (NRSC) registry from 2008-2012. The NRSC data were collected at the scene by police officers. Victim, vehicle, and environmental factors were used to describe the characteristics of fatal collisions. Case fatality rate was defined as the number of fatalities divided by the number of people involved in RTCs each year. Logistic regression analysis was used to determine predictors of crash scene fatality.Results: A total of 11,467 RTCs were reported by the NRSC between 2008 and 2012. Of these, 34% involved at least one fatality at the scene. The average age of fatalities was 32 years and 82% were male. Drivers of motor vehicles had the lowest odds of mortality following RTCs. Compared to drivers; pedestrians had the highest odds of mortality (OR 39, 95% CI 34, 45) followed by bicyclists (OR 26, 95% CI 22, 31). The average case fatality rate was 17% / year, and showed an increased throughout the study period.Conclusions: RTCs are a common cause of injury in Malawi. Approximately one-third of RTCs involved at least one death at the scene. Pedestrians were particularly vulnerable, exhibiting very high odds of mortality when involved in a road traffic collision. We encourage the use of these data to develop strategies in LMIC countries to protect pedestrians and other road users from RTCs

Illuminating Collaboration in Emergency Helath Care Situations: Paramedic-Physician Collaboration and 3D Telepresence Technology

Introduction. This paper focuses on paramedics' perspectives regarding paramedic-physician collaboration today, and their perspectives regarding the potential of 3D telepresence technology in the future. Method. Interviews were conducted with forty practicing paramedics. Analysis. The interview data were analysed using open and axial coding. An agreement of 0.82 using Cohen's kappa inter-coder reliability measure was reached. After coding was completed themes and relationships among codes were synthesised using topic memos. Results. Paramedics expressed concern about the lack of respect and trust exhibited towards them by other medical professionals. They discussed how they paint the picture for physicians and the importance of the physician trusting the paramedic. They further reported 3D telepresence technology would make their work visible in ways not previously possible. They also reported the technology would require additional training, changes to existing financial models used in emergency health care, and increased access to physicians. Conclusions. Teaching collaboration skills and strategies to physicians and paramedics could benefit their collaboration today, and increase their readiness to effectively use collaboration technologies in the future

An Observational Study of the Etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi

<p>Abstract</p> <p>Introduction</p> <p>Peritonitis is a life-threatening condition with a multitude of etiologies that can vary with geographic location. The aims of this study were to elucidate the etiology, clinical presentation and outcomes associated with peritonitis in Lilongwe, Malawi.</p> <p>Methods</p> <p>All patients admitted to Kamuzu Central Hospital (KCH) who underwent an operation for treatment of peritonitis during the calendar year 2008 were eligible. Peritonitis was defined as abdominal rigidity, rebound tenderness, and/or guarding in one or more abdominal quadrants. Subjects were identified from a review of the medical records for all patients admitted to the adult general surgical ward and the operative log book. Those who met the definition of peritonitis and underwent celiotomy were included.</p> <p>Results</p> <p>190 subjects were identified. The most common etiologies were appendicitis (22%), intestinal volvulus (17%), perforated peptic ulcer (11%) and small bowel perforation (11%). The overall mortality rate associated with peritonitis was 15%, with the highest mortality rates observed in solid organ rupture (35%), perforated peptic ulcer (33%), primary/idiopathic peritonitis (27%), tubo-ovarian abscess (20%) and small bowel perforation (15%). Factors associated with death included abdominal rigidity, generalized (versus localized) peritonitis, hypotension, tachycardia and anemia (p < 0.05). Age, gender, symptoms (obstipation, vomiting) and symptom duration, tachypnea, abnormal temperature, leukocytosis, hemoconcentration, thrombocytopenia and thrombocytosis were not associated with mortality (p = NS).</p> <p>Conclusions</p> <p>There are several signs and laboratory findings predictive of poor outcome in Malawian patients with peritonitis. Tachycardia, hypotension, anemia, abdominal rigidity and generalized peritonitis are the most predictive of death (P < 0.05 for each). Similar to studies from other African countries, in our population the most common cause of peritonitis was appendicitis, and the overall mortality rate among all patients with peritonitis was 15%. Identified geographical differences included intestinal volvulus, rare in the US but the 2^ndmost common cause of peritonitis in Malawi and gallbladder disease, common in Ethiopia but not observed in Malawi. Future research should investigate whether correction of factors associated with mortality might improve outcomes.</p

Illuminating collaboration in emergency health care situations:Paramedic-physician collaboration and 3D telepresence technology

Introduction. This paper focuses on paramedics\u27 perspectives regarding paramedic-physician collaboration today, and their perspectives regarding the potential of 3D telepresence technology in the future. Method. Interviews were conducted with forty practicing paramedics. Analysis. The interview data were analysed using open and axial coding. An agreement of 0.82 using Cohen\u27s kappa inter-coder reliability measure was reached. After coding was completed themes and relationships among codes were synthesised using topic memos. Results. Paramedics expressed concern about the lack of respect and trust exhibited towards them by other medical professionals. They discussed how they paint the picture for physicians and the importance of the physician trusting the paramedic. They further reported 3D telepresence technology would make their work visible in ways not previously possible. They also reported the technology would require additional training, changes to existing financial models used in emergency health care, and increased access to physicians. Conclusions. Teaching collaboration skills and strategies to physicians and paramedics could benefit their collaboration today, and increase their readiness to effectively use collaboration technologies in the future

A prolonged outbreak of KPC-3-producing Enterobacter cloacae and Klebsiella pneumoniae driven by multiple mechanisms of resistance transmission at a large academic burn center

Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacter cloacae have been recently recognized in the United States. Whole-genome sequencing (WGS) has become a useful tool for analysis of outbreaks and for determining transmission networks of multidrug-resistant organisms in healthcare settings, including carbapenem-resistant Enterobacteriaceae (CRE). We experienced a prolonged outbreak of CRE of E. cloacae and K. pneumoniae over a three-year period at a large academic burn center despite rigorous infection control measures. To understand the molecular mechanisms that sustained this outbreak, we investigated the CRE outbreak isolates using WGS. Twenty-two clinical isolates of CRE, including E. cloacae (N=15) and K. pneumoniae (N=7), were sequenced and analyzed genetically. WGS revealed that this outbreak, which seemed epidemiologically unlinked, was in fact genetically linked over a prolonged period. Multiple mechanisms were found to account for the ongoing outbreak of KPC-3-producing E. cloacae and K. pneumoniae . This outbreak was primarily maintained by a clonal expansion of E. cloacae ST114 with distribution of multiple resistance determinants. Plasmid and transposon analysis suggested that the majority of bla KPC-3 was transmitted via an identical Tn 4401 b element on part of a common plasmid. WGS analysis demonstrated complex transmission dynamics within the burn center at levels of strain and/or plasmid in association with transposon, highlighting the versatility of KPC-producing Enterobacteriaceae in their ability to utilize multiple modes to resistance-gene propagation

Next-Generation Sequencing and Comparative Analysis of Sequential Outbreaks Caused by Multidrug-Resistant Acinetobacter baumannii at a Large Academic Burn Center

Next-generation sequencing (NGS) analysis has emerged as a promising molecular epidemiological method for investigating health care-associated outbreaks. Here, we used NGS to investigate a 3-year outbreak of multidrug-resistant Acinetobacter baumannii (MDRAB) at a large academic burn center. A reference genome from the index case was generated using de novo assembly of PacBio reads. Forty-six MDRAB isolates were analyzed by pulsed-field gel electrophoresis (PFGE) and sequenced using an Illumina platform. After mapping to the index case reference genome, four samples were excluded due to low coverage, leaving 42 samples for further analysis. Multilocus sequence types (MLST) and the presence of acquired resistance genes were also determined from the sequencing data. A transmission network was inferred from genomic and epidemiological data using a Bayesian framework. Based on single-nucleotide variant (SNV) differences, this MDRAB outbreak represented three sequential outbreaks caused by distinct clones. The first and second outbreaks were caused by sequence type 2 (ST2), while the third outbreak was caused by ST79. For the second outbreak, the MLST and PFGE results were discordant. However, NGS-based SNV typing detected a recombination event and consequently enabled a more accurate phylogenetic analysis. The distribution of resistance genes varied among the three outbreaks. The first- and second-outbreak strains possessed a bla OXA-23-like group, while the third-outbreak strains harbored a bla OXA-40-like group. NGS-based analysis demonstrated the superior resolution of outbreak transmission networks for MDRAB and provided insight into the mechanisms of strain diversification between sequential outbreaks through recombination

Epidemiology of pediatric injury in Malawi: Burden of disease and implications for prevention

AbstractPurposePediatric injuries pose a significant health burden in sub-Saharan Africa, though historic data are too scarce to appreciate the extent of the problem. The purpose of this study is to utilize a comprehensive database to describe the epidemiology of pediatric injuries at a tertiary hospital in Malawi.MethodsData were prospectively collected on patients presenting to the emergency department for treatment of injuries from 2008 to 2010 (n = 23,625). The subset of pediatric patients (n = 7233) underwent cross-sectional analysis to examine demographics, injury environment, timing and mechanisms.ResultsPediatric patients, (0–16 years) comprised 30.6% of all trauma patients. Mean age was 7.2 years. Falls were the most common injury (43%), followed by burns (11.1%), pedestrian road traffic injuries (9.7%), foreign bodies (7.5%), and assaults (7.2%). Statistically significant differences in injury pattern were observed between gender, age groups and season. After logistic regression, predictors of fall included male gender, home setting, and rainy season, whereas predictors of burn included female gender, age 0–5 yrs, home setting, and cold season. Predictors of pedestrian injury included age 6–10 yrs, female, and roadside setting. Predictors of foreign body ingestion included age 0–5 yrs, female gender, home setting, and daytime, and predictors of assault include male gender, age 11–16 yrs, nighttime hours. All predictors were statistically significant (p < 0.05).ConclusionsThis study revealed patterns of injury based upon age, gender, location, and season. Our results may prove useful to stakeholders in injury prevention for designing, evaluating, and implementing programs to improve public safety in children in Malawi and similar resource poor nations

Specific Etiologies Associated With the Multiple Organ Dysfunction Syndrome in Children: Part 2

To describe a number of conditions and therapies associated with multiple organ dysfunction syndrome (MODS) presented as part of the Eunice Kennedy Shriver National Institute of Child Health and Human Development MODS Workshop (March 26–27, 2015). In addition, the relationship between burn injuries and MODS is also included although it was not discussed at the Workshop

Improved Survival of Patients With Extensive Burns: Trends in Patient Characteristics and Mortality Among Burn Patients in a Tertiary Care Burn Facility, 2004–2013

Classic determinants of burn mortality are age, burn size, and the presence of inhalation injury. Our objective was to describe temporal trends in patient and burn characteristics, inpatient mortality, and the relationship between these characteristics and inpatient mortality over time. All patients aged 18 years or older and admitted with burn injury, including inhalation injury only, between 2004 and 2013 were included. Adjusted Cox proportional hazards regression models were used to estimate the relationship between admit year and inpatient mortality. A total of 5540 patients were admitted between 2004 and 2013. Significant differences in sex, race/ethnicity, burn mechanisms, TBSA, inhalation injury, and inpatient mortality were observed across calendar years. Patients admitted between 2011 and 2013 were more likely to be women, non-Hispanic Caucasian, with smaller burn size, and less likely to have an inhalation injury, in comparison with patients admitted from 2004 to 2010. After controlling for patient demographics, burn mechanisms, and differential lengths of stay, no calendar year trends in inpatient mortality were detected. However, a significant decrease in inpatient mortality was observed among patients with extensive burns (≥75% TBSA) in more recent calendar years. This large, tertiary care referral burn center has maintained low inpatient mortality rates among burn patients over the past 10 years. While observed decreases in mortality during this time are largely due to changes in patient and burn characteristics, survival among patients with extensive burns has improved

Timing of early excision and grafting following burn in sub-Saharan Africa

This study sought to establish appropriate timing of burn wound excision and grafting in a resource-poor setting in sub-Saharan Africa