Development of emergency medicine in Rwanda

AbstractRwanda, known as the “Land of a Thousand Hills,” is a small, East African country that was the site of the devastating 1994 genocide. In the past 18years, this post-conflict country has made tremendous progress in rebuilding itself and its health infrastructure. The country has recovered or surpassed many of its pre-1994 health levels, including reduction in HIV/AIDS prevalence, under-five mortality and road traffic accidents. Nevertheless, Rwanda continues to face a high burden of disease. The leading causes of mortality in Rwanda include complications of HIV/AIDS and related opportunistic infections, severe malaria, pulmonary infections, and trauma, and are best managed with emergency and acute care services. However, health care personal resources remain significantly lacking, and there is currently no emergency medicine-trained workforce.The Rwandan government, partnering with international organizations, has launched a campaign to improve human resources for health, and as a part of that effort the creation of training programs in emergency medicine is now underway. The Rwandan Human Resources for Health program can serve as a guide to the development of similar programs within other African countries. The emergency medicine component of this program includes two tracks: a 2-year postgraduate diploma course, followed by a 3-year Masters of Medicine in Emergency Medicine. The program is slated to graduate its first cohort of trained Emergency Physicians in 2017

Musculoskeletal Injuries and Outcomes Pre- and Post- Emergency Medicine Training Program

Introduction: Musculoskeletal injuries (MSI) comprise a large portion of the trauma burden in low- and middle-income countries (LMIC). Rwanda recently launched its first emergency medicine training program (EMTP) at the University Teaching Hospital-Kigali (UTH-K), which may help to treat such injuries; yet no current epidemiological data is available on MSI in Rwanda.Methods: We conducted this pre-post study during two data collection periods at the UTH-K from November 2012 to July 2016. Data collection for MSI is limited and thus is specific to fractures. We included all patients with open, closed, or mixed fractures, hereafter referred to as MSI. Gathered information included demographics and outcomes including death, traumatic complications, and length of hospital stay, before and after the implementation of the EMTP.Results: We collected data from 3609 patients. Of those records, 691 patients were treated for fractures, and 674 of them had sufficient EMTP data measured for inclusion in the analysis of results (279 from pre-EMTP and 375 from post-EMTP). Patient demographics demonstrate that a majority of MSI cases are male (71.6% male vs 28.4% female) and young (64.3% below 35 years of age). Among mechanisms of injury, major causes included road traffic accidents (48.1%), falls (34.2%), and assault (6.0%). There was also an observed association between EMTP and trends of the three primary outcomes: a reduction of death in the emergency department (ED) from those with MSI by 89.9%, from 2.51% to 0.25% (p = 0.0077); a reduction in traumatic complications for MSI patients by 71.7%, from 3.58% to 1.01% (p = 0.0211); and a reduction in duration of stay in the ED among those with MSI by 52.7% or 2.81 days on average, from 5.33 to 2.52 days (p = 0.0437).Conclusion: This study reveals the current epidemiology of MSI morbidity and mortality for a major Rwandan teaching hospital and the potential impacts of EM training implementation among those with MSI. Residency training programs such as EMTP appear capable of reducing mortality, complications, and ED length of stay among those with MSI caused by fractures. Such findings underscore the efficacy and importance of investments in educating the next generation of health professionals to combat prevalent MSI within their communities

Clinical emergency care research in low-income and middle-income countries: Opportunities and challenges

Disease processes that frequently require emergency care constitute approximately 50% of the total disease burden in low-income and middle-income countries (LMICs). Many LMICs continue to deal with emergencies caused by communicable disease states such as pneumonia, diarrhoea, malaria and meningitis, while also experiencing a marked increase in non-communicable diseases, such as cardiovascular diseases, diabetes mellitus and trauma. For many of these states, emergency care interventions have been developed through research in high-income countries (HICs) and advances in care have been achieved. However, in LMICs, clinical research, especially interventional trials, in emergency care are rare. Furthermore, there exists minimal research on the emergency management of diseases, which are rarely encountered in HICs but impact the majority of LMIC populations. This paper explores challenges in conducting clinical research in patients with emergency conditions in LMICs, identifies examples of successful clinical research and highlights the system, individual and study design characteristics that made such research possible in LMICs. Derived from the available literature, a focused list of high impact research considerations are put forth

Exploring Multimodal Large Language Models for Radiology Report Error-checking

This paper proposes one of the first clinical applications of multimodal large language models (LLMs) as an assistant for radiologists to check errors in their reports. We created an evaluation dataset from real-world radiology datasets (including X-rays and CT scans). A subset of original reports was modified to contain synthetic errors by introducing three types of mistakes: "insert", "remove", and "substitute". The evaluation contained two difficulty levels: SIMPLE for binary error-checking and COMPLEX for identifying error types. At the SIMPLE level, our fine-tuned model significantly enhanced performance by 47.4% and 25.4% on MIMIC-CXR and IU X-ray data, respectively. This performance boost is also observed in unseen modality, CT scans, as the model performed 19.46% better than the baseline model. The model also surpassed the domain expert's accuracy in the MIMIC-CXR dataset by 1.67%. Notably, among the subsets (N=21) of the test set where a clinician did not achieve the correct conclusion, the LLaVA ensemble mode correctly identified 71.4% of these cases. However, all models performed poorly in identifying mistake types, underscoring the difficulty of the COMPLEX level. This study marks a promising step toward utilizing multimodal LLMs to enhance diagnostic accuracy in radiology. The ensemble model demonstrated comparable performance to clinicians, even capturing errors overlooked by humans

Global Emergency Medicine: A Review of the Literature From 2012

Objectives The Global Emergency Medicine Literature Review ( GEMLR ) conducts an annual search of peer‐reviewed and grey literature relevant to global emergency medicine ( EM ) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners. Methods This year, our search identified 4,818 articles written in six languages. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM . Two additional reviewers searched and screened the grey literature. A total of 224 articles were deemed appropriate by at least one reviewer and were approved by their editor for formal scoring of overall quality and importance. Results Of the 224 articles that met our predetermined inclusion criteria, 56% were categorized as Emergency Care in Resource‐limited Settings, 18% as EM development, and 26% as Disaster and Humanitarian Response. A total of 28 articles received scores of 16 or higher and were selected for formal summary and critique. Inter‐rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.625 (95% confidence interval = 0.512 to 0.711). Conclusions In 2012 there were more disaster and humanitarian response articles than in previous years. As in prior years, the majority of articles addressed the acute management of infectious diseases or the care of vulnerable populations such as children and pregnant women. Resumen Medicina de Urgencias y Emergencias Global: Una Revisión de la Literatura de 2012 Objetivos La revisión de la literatura publicada en Medicina de Urgencias y Emergencias ( MUE ) global comporta una búsqueda anual de los trabajos relevantes para la MUE global, tanto publicados tras revisión por pares como corresponedientes a literatura gris. La finalidad es identificar, revisar y diseminar las investigaciones novedosas más importantes en este campoa médicos clínicos y universitarios de todo el mundo. Metodología Este año, nuestra búsqueda identificó 4.818 artículos escritos en seis lenguas. Estos artículos se distribuyeron entre 20 revisores para el despistaje inicial basándose en su relevancia para el campo de la MUE global. Dos revisores adicionales buscaron y filtraron la literatura gris. Un total de 224 artículos se consideraron apropiados por al menos un revisor, y se aprobaron por su editor para la puntuación formal de la calidad e importancia totales. Resultados De los 224 artículos que cumplieron nuestros criterios de inclusión predeterminados, un 56% se clasificaron como atención de urgencias y emergencias en ámbitos de recursos limitados, un 18% como desarrollo de la MUE y un 26% como catástrofes y respuesta humanitaria. Un total de 28 artículos recibieron una puntuación de 16 o más y se seleccionaron para el resumen y la crítica formal. La fiabilidad interobservador para los 2 revisores usando nuestro sistema de puntuación fue buena, con un coeficiente de correlación intraclase de 0,625 ( IC 95% = 0,512 a 0,711). Conclusiones En 2012 hubo más artículos sobre catástrofes y respuesta humanitaria que en años anteriores. Como en los años previos, la mayoría de los artículos valoraron el manejo agudo de enfermedades infecciosas o la atención de poblaciones vulnerables como los niños y las mujeres embarazadas.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/99685/1/acem12173.pd

External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study

BACKGROUND: Dehydration due to diarrhoea is a leading cause of child death worldwide, yet no clinical tools for assessing dehydration have been validated in resource-limited settings. The Dehydration: Assessing Kids Accurately (DHAKA) score was derived for assessing dehydration in children with diarrhoea in a low-income country setting. In this study, we aimed to externally validate the DHAKA score in a new population of children and compare its accuracy and reliability to the current Integrated Management of Childhood Illness (IMCI) algorithm. METHODS: DHAKA was a prospective cohort study done in children younger than 60 months presenting to the International Centre for Diarrhoeal Disease Research, Bangladesh, with acute diarrhoea (defined by WHO as three or more loose stools per day for less than 14 days). Local nurses assessed children and classified their dehydration status using both the DHAKA score and the IMCI algorithm. Serial weights were obtained and dehydration status was established by percentage weight change with rehydration. We did regression analyses to validate the DHAKA score and compared the accuracy and reliability of the DHAKA score and IMCI algorithm with receiver operator characteristic (ROC) curves and the weighted kappa statistic. This study was registered with ClinicalTrials.gov, number NCT02007733. FINDINGS: Between March 22, 2015, and May 15, 2015, 496 patients were included in our primary analyses. On the basis of our criterion standard, 242 (49%) of 496 children had no dehydration, 184 (37%) of 496 had some dehydration, and 70 (14%) of 496 had severe dehydration. In multivariable regression analyses, each 1-point increase in the DHAKA score predicted an increase of 0.6% in the percentage dehydration of the child and increased the odds of both some and severe dehydration by a factor of 1.4. Both the accuracy and reliability of the DHAKA score were significantly greater than those of the IMCI algorithm. INTERPRETATION: The DHAKA score is the first clinical tool for assessing dehydration in children with acute diarrhoea to be externally validated in a low-income country. Further validation studies in a diverse range of settings and paediatric populations are warranted. FUNDING: National Institutes of Health Fogarty International Center

Global Emergency Medicine: A Review of the Literature From 2014

ObjectivesThe Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer‐reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners.MethodsThis year 6,376 articles written in six languages were identified by our search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. An additional two reviewers searched the gray literature. A total of 477 articles were deemed appropriate by at least one reviewer and approved by the editor for formal scoring of overall quality and importance.ResultsOf the 477 articles that met our predetermined inclusion criteria, 63% were categorized as emergency care in resource‐limited settings, 13% as EM development, and 23% as disaster and humanitarian response. Twenty‐five articles received scores of 17.5 or higher and were selected for formal summary and critique. Inter‐rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.657 (95% confidence interval = 0.589 to 0.713). Studies and reviews focusing on infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource‐limited settings represented the majority of articles selected for final review.ConclusionsIn 2014, there were fewer total articles, but a slightly higher absolute number of articles screening in for formal scoring, when compared to the 2013 review. The number of EM development articles decreased, while the number of disaster and humanitarian response articles increased. As in prior years, the majority of articles focused on infectious diseases and trauma.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/113141/1/acem12733.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/113141/2/acem12733_am.pd

External validation of the DHAKA score and comparison with the current IMCI algorithm for the assessment of dehydration in children with diarrhoea: a prospective cohort study

Background Dehydration due to diarrhoea is a leading cause of child death worldwide, yet no clinical tools for assessing dehydration have been validated in resource-limited settings. The Dehydration: Assessing Kids Accurately (DHAKA) score was derived for assessing dehydration in children with diarrhoea in a low-income country setting. In this study, we aimed to externally validate the DHAKA score in a new population of children and compare its accuracy and reliability to the current Integrated Management of Childhood Illness (IMCI) algorithm. Methods DHAKA was a prospective cohort study done in children younger than 60 months presenting to the International Centre for Diarrhoeal Disease Research, Bangladesh, with acute diarrhoea (defi ned by WHO as three or more loose stools per day for less than 14 days). Local nurses assessed children and classifi ed their dehydration status using both the DHAKA score and the IMCI algorithm. Serial weights were obtained and dehydration status was established by percentage weight change with rehydration. We did regression analyses to validate the DHAKA score and compared the accuracy and reliability of the DHAKA score and IMCI algorithm with receiver operator characteristic (ROC) curves and the weighted κ statistic. This study was registered with ClinicalTrials.gov, number NCT02007733. Findings Between March 22, 2015, and May 15, 2015, 496 patients were included in our primary analyses. On the basis of our criterion standard, 242 (49%) of 496 children had no dehydration, 184 (37%) of 496 had some dehydration, and 70 (14%) of 496 had severe dehydration. In multivariable regression analyses, each 1-point increase in the DHAKA score predicted an increase of 0·6% in the percentage dehydration of the child and increased the odds of both some and severe dehydration by a factor of 1·4. Both the accuracy and reliability of the DHAKA score were signifi cantly greater than those of the IMCI algorithm. Interpretation The DHAKA score is the fi rst clinical tool for assessing dehydration in children with acute diarrhoea to be externally validated in a low-income country. Further validation studies in a diverse range of settings and paediatric populations are warranted