Salvage of severely injured limbs in a developing country

Background: Severe injuries of the limb are common in Nigeria as well as other developing countries.  Management of such injuries usually presents serious challenges to the health care personnel, the patients and the relations.  In most developing countries such as Nigeria, because of inherent factors, most of these injuries are treated by primary amputation despite that some can be salvaged. Amputation on its own is not readily accepted in Nigeria because of associated medical, social, religious and financial problems.  This study highlights the need to carefully select the patients with severe limb injuries who may benefit from limb salvage rather than primary amputation.Aim: To report three patients who presented with extensive limb injuries following trauma and had successful limb salvage.Setting: Teme Clinic, a trauma centre in Port Harcourt, Nigeria.Case reports: The 1st patient  was a 35-year-old mother of three who presented with type IIIB open fracture of the tibia which was complicated by infection. Patient 2 was an eleven-year- old boy who presented with type IIIA open fracture of the right femur and an extensive degloving injury of the right leg. Patient 3 was a 25-year- old male with type IIIB open fracture of the tibia. All the three patients had injuries from traffic collisions and all had successful limb salvage after amputation was rejected by the patients and their families.Conclusion: Limb salvage in Nigeria is feasible if patients are carefully selected using established criteria and sound clinical judgment. Amputation should be highly considered when the conditions for limb salvage are not adequate or the patient's life is threatened. Keywords: Severe limb injuries, Limb salvage, Amputation, Port Harcourt, Nigeri

Circus and Theatre, A tense relationship around the turn of the 20th century

Background: Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time. Methods: We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights. Findings: Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions. Interpretation: Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results