"Injury-prone areas" Repeat Presentations for Injuries in Childhood

Background: Injury remains a leading cause of childhood morbidity and mortality in the developing world. Probability of injury occurrence is influenced by agent, host and environmental factors. Studies of repeat injuries in childhood thus provide insight into factors in the epidemiological triad predisposing children to injury. Objectives: The study objectives were to determine the proportion of children and the factors associated with repeat presentations to Red Cross War Memorial Children’s Hospital Trauma Unit (RCWMCH TU) for all non-transport related injuries in childhood. Methods: This was a retrospective cohort study using data from RCWMCH TU. We included children aged 0-10 years with first presentation from January 1997 to June 2013, and followed up until the earliest of age 13 years or June 2016. We assessed individual and population-level factors associated with repeat injury using multilevel Poisson regression. Child Dependency Ratios were derived from the 2011 national census. Results: Between 1997 and 2013, 72 490 children under 10 years of age (59% male) presented to RCWMCH TU for the first time with injuries. After the initial injury, 9 417 (13%) presented with a repeat injury by 2016 and before age 13 years. After adjusting for health Sub-District, distance from RCWMCH TU and age at first presentation, factors associated with reduced repeat presentation were: injury identified as due to abuse (adjusted incidence rate ratio [aIRR] 0.6; 95% confidence interval [CI]: 0.4 - 0.7), fluid burn (aIRR 0.6; 95% CI: 0.6 - 0.7), foreign body ingestion (aIRR 0.7; 95% CI: 0.7 - 0.9), moderate and severe (vs minor) initial injury (aIRR 0.9; 95% CI: 0.8 - 0.9) and (aIRR 0.7; 95% CI: 0.6 - 0.8 respectively), whilst boys were more likely to have repeat injury presentations (aIRR 1.4; 95% CI: 1.4 - 1.5). Conclusion: Repeat presentations constituted a substantial proportion of disease burden. Factors associated with repeat presentations were identified, strengthening the argument that injuries arise due to sustained exposure to host, agent and environmental risk factors. While it is reassuring that children with initial injuries due to abuse and severe initial injuries are less likely to present again, injury prevention education should not neglect patients with minor and unintentional injuries. The findings of this study suggest that post-injury health promotion activities should not exclude patients who present with minor injuries, and that targeted education and further research is indicated for specific injuries, including those due to non-height falls and injuries sustained whilst playing sport

Analysis of patient flow and barriers to timely discharge from general medical wards at a tertiary academic hospital in Cape Town, South Africa

Abstract Background Movement of patients through a health establishment is a complex activity reliant upon multi-actor co-ordination across departments. The challenge of enhancing service delivery to meet the needs of a growing and aging population, whilst minimizing expense, is a global concern. There is an urgent need to understand and quantify systemic gaps in the efficient delivery of healthcare services. Stagnation of patient flow has negative impacts on both staff and patients by increasing risks of adverse outcomes, staff frustration and job dissatisfaction. An inefficient discharge process can be a significant barrier to timely patient movement. Methods A retrospective cohort study was conducted at a tertiary, academic hospital in the Western Cape, South Africa to assess the journey of medical patients from admission to discharge across the five different medical teams (firms) within the general medicine department. Consecutive sampling was used to capture all eligible adult medical in-patients admitted from the emergency department (ED) to general medicine from the 11th – 20th April 2023 and discharged up until the 30th of April 2023. We reviewed the patient notes (folders) of these individuals using a data-extraction tool to ascertain reasons for admission and barriers to timely discharge. Results Among 86 patient folders reviewed, cumulatively accounting for 596 in-patient days, a difference in the median length of in-patient stay between medical firms (p = 0.042) was noted. The shortest length of stay corresponded to firms with the greatest proportion of daily senior staff oversight (defined as documented patient reviews by a registrar, medical officer and/or consultant independently or in addition to reviews done for the day by interns and/or students). While 52% of patients vacated their beds between 14:00 and 17:00, 66% of patients were admitted after 20:00. Reasons for prolonged admission were variable, and attributable to a range of different disciplines across the multidisciplinary team. Conclusion Whilst this study did not evaluate the appropriateness of chosen medical management but rather systemic drivers affecting patient movement and barriers to timely discharge, the delays in discharge were noted to be multi-factorial including facets across the efficient delivery of medical care, availability of resources and the internal operational frameworks for the institution. Understanding the need to optimize internal process efficiencies with regards to prompt acquisition of investigations, improvement of senior staff oversight and the creation of a standardized discharge process, could enhance efficient patient movement

The assessment of the clinical impact of using a single set of radiotherapy planning data for two kilovoltage therapy units

Kilovoltage therapy units are used for superficial radiotherapy treatment delivery. Peer reviewed studies for MV linear accelerators describe tolerances to dosimetrically match multiple linear accelerators enabling patient treatment on any matched machine. There is an absence of literature on using a single planning data set for multiple kilovoltage units which have limited ability for beam adjustment. This study reviewed kilovoltage dosimetry and treatment planning scenarios to evaluate the feasibility of using ACPSEM annual QA tolerances to determine whether two units (of the same make and model) were dosimetrically matched. The dosimetric characteristics, such as measured half value layer (HVL), percentage depth dose (PDD), applicator factor and output variation with stand-off distance for each kV unit were compared to assess the agreement. Independent planning data based on the measured HVL for each beam energy from each kV unit was prepared. Monitor unit (MU) calculations were performed using both sets of planning data for approximately 200 clinical scenarios and compared with an overall agreement between units of \u3c 2%. Additionally, a dosimetry measurement comparison was completed at each site for a subset of nine scenarios. All machine characterisation measurements were within the ACPSEM Annual QA tolerances, and dosimetric testing was within 2.5%. This work demonstrates that using a single set of planning data for two kilovoltage units is feasible, resulting in a clinical impact within published uncertainty

Predictors of Recurrent Ischemic Stroke in Patients with Embolic Strokes of Undetermined Source and Effects of Rivaroxaban Versus Aspirin According to Risk Status : The NAVIGATE ESUS Trial

Background: Embolic stroke of undetermined source (ESUS) identifies patients with cryptogenic ischemic stroke presumed due to embolism from several unidentified sources. Among patients with recent ESUS, we sought to determine independent predictors of recurrent ischemic stroke during treatment with aspirin or rivaroxaban and to assess the relative effects of these treatments according to risk. Methods: Exploratory analyses of 7213 participants in the NAVIGATE ESUS international trial who were randomized to aspirin 100 mg/day or rivaroxaban 15 mg/day and followed for a median of 11 months, during which time there were 309 first recurrent ischemic strokes (4.6% per year). Baseline features were correlated with recurrent stroke by multivariate analysis. Results: The 7 independent predictors of recurrent stroke were stroke or transient ischemic attack (TIA) prior to the qualifying stroke (hazard ratio [HR] 2.03 95% confidence internal [CI] 1.58-2.60), current tobacco user (HR 1.62, 95% CI 1.24-2.12), age (HR 1.02 per year increase, 95%CI 1.01-1.03), diabetes (HR 1.28, 95% CI 1.01-1.64), multiple acute infarcts on neuroimaging (HR 1.49, 95% CI 1.09-2.02), aspirin use prior to qualifying stroke (HR 1.34, 95% CI 1.02-1.70), and time from qualifying stroke to randomization (HR .98, 95% CI .97-.99). The rate of recurrent stroke rate was 2.6% per year for participants without any of these risk factors, and increased by an average of 45% for each independent predictor (P < .001). There were no significant interactions between treatment effects and independent stroke predictors or stroke risk status. Conclusions: In this large cohort of ESUS patients, several features including prior stroke or TIA, advanced age, current tobacco user, multiple acute infarcts on neuroimaging, and diabetes independently identified those with an increased risk of ischemic stroke recurrence. The relative effects of rivaroxaban and aspirin were similar across the spectrum of independent stroke predictors and recurrent stroke risk status

Identifying knowledge needed to improve surgical care in Southern Africa using a theory of change approach

Surgical healthcare has been prioritised in the Southern African Development Community (SADC), a regional intergovernmental entity promoting equitable and sustainable economic growth and socioeconomic development. However, challenges remain in translating political prioritisation into effective and equitable surgical healthcare. The AfroSurg Collaborative (AfroSurg) includes clinicians, public health professionals and social scientists from six SADC countries; it was created to identify context-specific, critical areas where research is needed to inform evidence-grounded policy and implementation. In January 2020, 38 AfroSurg members participated in a theory of change (ToC) workshop to agree on a vision: ‘An African-led, regional network to enable evidence-based, context-specific, safe surgical care, which is accessible, timely, and affordable for all, capturing the spirit of Ubuntu[1]’ and to identify necessary policy and service-delivery knowledge needs to achieve this vision. A unified ToC map was created, and a Delphi survey was conducted to rank the top five priority knowledge needs. In total, 45 knowledge needs were identified; the top five priority areas included (1) mapping of available surgical services, resources and providers; (2) quantifying the burden of surgical disease; (3) identifying the appropriate number of trainees; (4) identifying the type of information that should be collected to inform service planning; and (5) identifying effective strategies that encourage geographical retention of practitioners. Of the top five knowledge needs, four were policy-related, suggesting a dearth of much-needed information to develop regional, evidenced-based surgical policies. The findings from this workshop provide a roadmap to drive locally led research and create a collaborative network for implementing research and interventions. This process could inform discussions in other low-resource settings and enable more evidenced-based surgical policy and service delivery across the SADC countries and beyond