Global and local road traffic injury epidemiology in children and adolescents

Background: Every year around the globe, more than 800,000 children and adolescents under the age of 20 die due to injuries from any cause. Globally, low-and middle-income countries bear a disproportionate 95% of the burden of all childhood injury mortality. There is a paucity of data on all injuries in children and road traffic injuries by type of road users among adolescents particularly from low and middle-income countries. The aim of this thesis is to increase the knowledge on the epidemiology of injuries in children 1-4 years and road traffic injuries in adolescents 10-19 years by type of road users in high-income, upper and lower- middle-income and low-income countries with a focus in Pakistan. Methods: The studies I and II have an ecological study design and used the database by global burden of disease study for the year 2010 and 1990-2019 respectively. The setting for the studies III and IV is Karachi, city of a lower-middle-income country, Pakistan. The study III is a survey of adolescents about their independent mobility and road traffic injuries and the data for study IV are motorcycle injuries from hospitals. Results: The highest injury rate was 94 per 100,000 in low-income countries of Sub-Saharan Africa and the lowest injury rate was 6 per 100,000 in the high-income countries of Eastern Europe/Central Asia (Study I). The reduction in mortality rates of adolescents’ road traffic injuries is more prominent in high-income countries than any other income level from 1990 to 2019. For instance, the mortality reduction in pedestrians 15-19 years in HICs was IRR 0.94 (95% CI 0.90 to 0.98) (Study II). Adolescents who had parental permission to cross main roads alone (adjusted odds ratio 1.39; 95% confidence interval 1.04 to 1.86) and who participated in one or more activities outside the home alone on the previous weekend (adjusted odds ratio 2.61; 95% confidence interval 1.42 to 5.13) had higher odds of road traffic injuries (Study III). Motorcyclists aged 13-17 years (adjusted odds ratio 1.25; 95% confidence interval 1.11, 1.42) and 18-19 years (adjusted odds ratio 1.26; 95% confidence interval 1.10, 1.43) had higher odds of severe injury compared to aged 20-24 years (Study IV). Conclusions: Child injury mortality is unevenly distributed across income level, to the detriment of low-income countries. There are decreasing trends in mortality for all types of road users in adolescents from 1990 to 2019 at all income levels but high-income countries have a larger decrease in mortality rates for all types of road users as compared with any other income level. Adolescents in Karachi who were allowed to cross main roads alone and who had weekend activities on their own were associated with road traffic injuries. In addition, adolescents aged 13-17 and 18-19 years were associated with higher odds of severe road traffic injuries compared to motorcyclists aged 20-24 years in Karachi, Pakistan

Importance of clinical toxicology teaching and its impact in improving knowledge: sharing experience from a workshop

Objective: To assess the impact of a one-day clinical toxicology workshop in improving knowledge.Methods: A one-day clinical toxicology workshop was conducted as a pre-conference workshop of the Annual Emergency Medicine Conference at the Aga Khan University Hospital, Karachi, in April 2012. The course was composed of poisoning-related common clinical scenarios. The pre-test and post-test understanding was used to assess the impact of the course in improving knowledge. The participants also evaluated the workshop as a whole thorough written evaluation forms. SPSS 19 was ued for statistical analysis of the data.RESULT: There were 22 participants in the course. The pre-test mean score was 31.6 +/- 15.1% (95% CI; 24-40; n = 19) compared to the post-test the mean score of 56.0 +/- 10.8% (95% CI; 47- 61; n = 17). The positive difference was also statistically significant (p \u3c 0.001). The overall workshop was evaluated as excellent by 08 (47.46%) and very good by 10 (52.63%) participants.CONCLUSION: Short training in clinical toxicology improved knowledge of the participants

Global trends in adolescents\u27 road traffic injury mortality, 1990-2019

Objective: The aim of this study was to determine the trends of road traffic injury (RTI) mortality among adolescents aged 10-14 years and 15-19 years across different country income levels with respect to the type of road users from 1990 to 2019.Methods: We conducted an ecological study. Adolescents\u27 mortality rates from RTIs at the level of high-income countries (HICs), upper-income to middle-income countries (UMICs), lower-income to middle-income countries and low-income countries were extracted from the Global Burden of Disease study. Time series were plotted to visualise the trends in mortality rates over the years. We also conducted Poisson regression using road traffic mortality rates as the dependent variable and year as the independent variable to model the trend of the change in the annual mean mortality rate, with incidence rate ratios (IRRs) and 95% CIs.Results: There were downward mortality trends in all types of road users and income levels among adolescents from 1990 to 2019. HICs had more pronounced reductions in mortality rates than countries of any other income level. For example, the reduction in pedestrians in HICs was IRR 0.94 (95% CI 0.90 to 0.98), while that in UMICs was IRR 0.97 (95% CI 0.95 to 0.99) in adolescents aged 10-14 years.Conclusions: There are downward trends in RTI mortality in adolescents from 1990 to 2019 globally at all income levels for all types of road users. The decrease in mortality rates is small but a promising finding. However, prevention efforts should be continued as the burden is still high

School-based injury outcomes in children from a low-income setting: results from the pilot injury surveillance in Rawalpindi city, Pakistan

Background School-based injuries account for one in five unintentional childhood injuries. Little is known about the epidemiology of school-based injuries in low-income settings. The objective of our study was to compare emergency department (ED) outcomes of the school-based injuries with respect to age, sex, and injury mechanisms in a Pakistani urban setting. Findings A pilot injury surveillance study was conducted at the EDs of three major tertiary-care hospitals of Rawalpindi city from July 2007 to June 2008 and included children of less than 15 years injured at school. The World Health Organization’s questionnaire for injury surveillance was used. There were 923 school injury cases. Mean age of children involved was 8.3 years (SD ± 3.3) with male female ratio 2.9:1. Most injuries occurred while playing 85.6% (n = 789); of which the most common mechanism was falls (n = 797, 86.4%). Nineteen of twenty cases were directly discharged home from the ED (N = 861). Compared to ED discharged cases, injury characteristics overrepresented in hospital admitted cases (n = 46) were age 10–14 years (65.2% vs. 40.9%, p = 0.005), male (88.6% vs. 25.9%), involved in educational activities (39.1% vs. 5.3%), injured from fire/heat (37.8% vs. 0.6%), had burns (39.5% vs. 0.9%) and head injuries (27.9% vs. 6.4%). Conclusion Falls while playing are the commonest injury mechanism in school-based injuries reported in our ED sample. School officials need to prevent these injuries. Studying injury hazards present in school environment in Pakistan might facilitate developing specific prevention strategies

current state of poison control centers in Pakistan and the need for capacity building.

Background: Chemical exposure is a major health problem globally. Poison control centers (PCCs) play a leading role both in developed and developing countries in the prevention and control of poisonous chemical exposures. In this study, we aimed to assess the current state of PCCs in Pakistan and highlight capacity building needs in these centers. Methods: A cross-sectional survey of the two registered PCCs was done during August – December 2011. Necessary services of the PCCs were evaluated and the data were recorded on a predesigned checklist. Results: Both PCCs are affiliated to a tertiary care hospital. Clinical services to poisoned patients were available 24 hours a day / 7 days a week. Information on common local products was available to poison center staff. Both centers were involved in undergraduate and post graduate teaching. Telephone poison information service was not available in either of centers. There was a limited capacity for qualitative and analytical toxicology. Common antidotes were available. There were limited surveillance activities to capture toxic risks existing in the community and also a deficiency was observed in chemical disaster planning. Conclusion: PCCs in Pakistan need capacity building for specialized training in toxicology, toxicovigilance, chemical disaster planning, analytical laboratory tests and telephone service for consultation in poisoning cases

Pattern of emergency department visits by elderly patients: study from a tertiary care hospital, Karachi

Background Worldwide the proportion of elderly people in the population is increasing. Currently in Pakistan 7.3 million people (5.6% of total population) are more than 60 years old. This age shift has emerged as an important health issue and is associated with an increased utilization of emergency services by the elderly. We carried out this study to assess the pattern of elderly patients (\u3e60 years) who visit emergency departments in comparison to young adults (18–60 years). Methods Data was collected retrospectively of patients aged 18 years or more who visited the Emergency Department (ED) of Aga Khan University Hospital, Karachi (AKUH) during September, 2009 to September, 2011. The data collection sheet included patient’s demographic information, triage category, reason for visit, clinical presentation, ED length of stay, day and time of presentation and their disposition. Data was entered and analyzed using SPSS version 19.0. Descriptive statistics were used to describe patient’s demographics. Chi-square (χ2) test was used as a test of significance to compare differences between groups for categorical data and t-test for continuous data. Multiple logistic regression analysis was done to find out the association between the patient characteristics and outcomes (admission and expiry). Results Almost 24% (n = 13014) of all adults (n = 54588) presenting to the ED were over the age of 60 years. More than 57% of elderly patients belonged to the high priority triage category compared to 35% in younger patients. Most of the elderly patients ( 27%) presented with nonspecific complaints followed by shortness of breath (13%) and fever (9%). The median length of stay (LOS) in the ED for elderly was 379 minutes (252 min in under-60 yrs patients) and they were more likely to get admitted to in-patient departments compared to younger patients (OR 1.7 95% CI 1.6-1.8). A high proportion of those admitted (20%) required intensive or special care. Mortality in elderly patients was 2.3% as compared to 0.7% in young adults. This was accompanied by a higher mortality risk in the elderly with an odds ratio of 2.3 (CI 2–2.5). Conclusion Elderly ED users differ significantly from younger adults in terms of criticality on presentation, ED LOS and final disposition

Trends of acute poisoning: 22 years experience from a tertiary care hospital in Karachi, Pakistan.

Objective: To determine the trends of acute poisoning in terms of frequency, nature of poisoning agent, clinical presentation and its outcome. Methods: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients who presented with poisoning between January 1989 and December 2010.The patients were randomly selected , and demographic, chemical information, clinical feature, treatment and outcome were analysed using SPSS 16. Results: Of the total hospital admissions during the period, 3,189(0.3%) were cases of poisoning. Of them, medical records of 705(22%) cases were reviewed; 462(65.5%) adult and 243(34.5%) paediatric cases below 16 years of age. The overall median age was 21 years (interquartile range: 4-32 years)Moreover, 544(87%) were critical at the time of presentation. In 647(92%) cases, the poisoning occurred at home. Psychiatric drugs were found involved in 205(29%) cases, followed by prescription drugs 172(24.4%), pesticides 108(15.3%), hydrocarbons 71(10%), analgesics 59(8.7%), household toxins 59(8.7%), alcohol and drug abuse 21(2.97%) and others 47(6.67%). Conclusion: Poisoning was a serious cause of morbidity in children and young adults. Medications were the leading cause and home was the most common place of incident

Quality of life of road traffic injury survivors aged 15-44 years suffered from moderate and severe head injuries in Karachi, Pakistan

Background: Most of Road traffic injuries are predicted to be the third leading contributor to the global burden of disease by 2020 and patients end up into head injuries which leave devastating impacts on individual and society. Quality of Life After Brain Injury (QOLIBRI) is a specific tool that measures quality of life in head injury patients.Methods: This was a cross sectional study among 300 patients aged 15-45 years, attended emergency department of the Aga khan University Hospital. Structured questionnaire included demography, injury details, QOLIBRI, GOSE and WHO Disability Assessment Scale (WHODAS 12 items). Severity of injury was determined by Glasgow coma score of subjects reported in emergency department on admission. This was one time telephonic survey in which bidirectional data was collected from subjects about injury and outcome (QOLIBRI). To identify the determinants of QOL among RTI survivors with head injury multiple linear regressions was applied.Results: The mean QOL score for study sample was 69.86 ± (15.89. Most of the patients 210 (70%) were motorbike rider followed by four-wheelers 69 (23%). Mean age of RTI participants was 28.10 ± (7.68) years. The quality of life decreases with increase in severity of head injury by -697.32 (95% CI; -1006.44, -388.20).Conclusions: This study suggests severity of head injury, recovery time, surgery resulting from RTA, employment, family system and disability to have long term impact on QOL of RTI survivors

Assessment of knowledge, attitude, and practice of child abuse amongst health care professionals working in tertiary care hospitals of Karachi, Pakistan

Introduction: UNICEF report (2004) states that a significant percentage of total child population under the age of 5 years suffered malnutrition. Child sexual abuse remains undiscussed across Pakistan. Health care professionals (HCPs) are usually the first notifiers of child abuse and are ethically obliged to manage and report it.Objective: This study was conducted to assess HCPs\u27 response in dealing with patients of child abuse. With a better understanding, we can have a better outcome for the victims.Methods: A total of 101 participants filled out a structured questionnaire by HCPs working in three tertiary hospitals of Karachi i.e., Aga Khan University, National Institute of Child Health (NICH), and Civil Hospital. Data were entered into SPSS 19.0.Results: HCPs believed that young male relatives were thought to be most likely the offender, and that every child regardless of class is prone to get abused triggered by financial stressors and the absence of parents. Proper physical exams helped identify cases. A proper system of reporting was required in hospitals, but HCPs were reluctant to report the cases to authorities. There was a significant difference noted between public and private hospitals.Conclusion: Our findings indicate that HCPs have limited knowledge in defining various types of abuse and most were unaware of any reporting facility in hospitals. Senior HCPs as consultants have a better understanding of child abuse than nurses or interns. Mandatory reporting should be implicated so that prompt action could be taken. There could be a more successful outcome of managing a child abuse victim with proper training

Heat emergencies: Perceptions and practices of community members and emergency department healthcare providers in Karachi, Pakistan: A qualitative study

Heat waves are the second leading cause of weather-related morbidity and mortality affecting millions of individuals globally, every year. The aim of this study was to understand the perceptions and practices of community residents and healthcare professionals with respect to identification and treatment of heat emergencies. A qualitative study was conducted using focus group discussions and in-depth interviews, with the residents of an urban squatter settlement, community health workers, and physicians and nurses working in the emergency departments of three local hospitals in Karachi. Data was analyzed using content analysis. The themes that emerged were (1) perceptions of the community on heat emergencies; (2) recognition and early treatment at home; (3) access and quality of care in the hospital; (4) recognition and treatment at the health facility; (5) facility level plan; (6) training. Community members were able to recognize dehydration as a heat emergency. Males, elderly, and school-going children were considered at high risk for heat emergencies. The timely treatment of heat emergencies was widely linked with availability of financial resources. Limited availability of water, electricity, and open public spaces were identified as risk factors for heat emergencies. Home based remedies were reported as the preferred practice for treatment by community members. Both community members and healthcare professionals were cognizant of recognizing heat related emergencies