Low-Dose Whole-Body Computed Tomography and Radiation Exposure in Patients with Trauma - Trust, but Verify

In an attempt to minimize missed injury rates, potentially decrease mortality, and enhance rapid patient disposition, standard-dose whole-body computed tomographic (WBCT) imaging has become ubiquitous at trauma centers for the hemodynamically stable patient admitted with trauma. The radiation dose from WBCT ranges from 10 to 20 mGy, which results in an approximately 0.08% estimated lifetime cancer mortality for 45-year-old persons.3 Risk of mortality due to missed injury is therefore higher than the risk of future radiation-induced cancer

An invited commentary on “Impact of the Coronavirus (COVID-19) pandemic on surgical practice-part 1”. Impact of the Coronavirus (COVID-19) pandemic on surgical practice: Time to embrace telehealth in surgery

The COVID‐19 pandemic caused by the novel coronavirus, SARS‐CoV‐2, is disrupting global health and the economy to a degree unparalleled in modern history. In addition to the reduction in visits for routine and preventative health care and decline in emergency room visits, hospital systems are suffering from the collateral damage of near‐universal cancellation of elective surgeries. The mobilization of surgical resources for emergencies, use of operating rooms as intensive care units and anesthesia machines as ventilators, redeployment of operating room personnel for patient and provider safety have com-promised the delivery of necessary surgery

An Invited Commentary on “World Health Organization declares global emergency: A review of the 2019 novel Coronavirus (COVID-19)”: Emergency or new reality?

The onset of the novel Coronavirus Disease 2019 (COVID-19) outbreak in Wuhan, China, suggests animal-to-person spread and later person-to-person spread. The complete clinical picture following COVID-19 infection is not yet fully understood. A recent report on over 72,000 COVID-19 cases by the Chinese Center for Disease Control and Prevention showed the case fatality rate was overall 2.3%. The mortality rises to 8% in patients between 70 and 79-years-old, and spikes to 14.8% in those aged 80 and above. Sorhabi et al. give an informative and comprehensive account of the timeline, etiology, symptoms, supportive treatment, and transmission prevention of COVID-19

The effect of traditional healer intervention prior to allopathic care on pediatric burn mortality in Malawi

Introduction: Burn injury is a significant contributor to mortality, especially in low and middle-income countries (LMICs). Patients in many communities throughout sub-Saharan Africa use traditional health practitioners for burn care prior to seeking evaluation at an allopathic burn center. The World Health Organization defines a traditional health practitioner as “a person who is recognized by the community where he or she lives as someone competent to provide health care by using plant, animal and mineral substances and other methods based on social, cultural and religious practices based on indigenous knowledge and belief system.” The aim of this study is to determine the prevalence of prior traditional health practitioner treatment and assess its effect on burn injury mortality. Methods: A retrospective analysis of the prospectively collected Kamuzu Central Hospital (KCH) Burn Surveillance Registry was performed from January 2009 through July 2017. Pediatric patients (<13 years) who were injured with flame or scald burns were included in the study and we compared groups based on patient or family reported use of traditional health practitioners prior to evaluation at Kamuzu Central Hospital. We used propensity score weighted multivariate logistic regression to identify the association with mortality after visiting a traditional healer prior to hospitalization. Results: 1689 patients were included in the study with a mean age of 3.3 years (SD 2.7) and 55.9% were male. Mean percent total body surface area of burn was 16.4% (SD 12.5%) and most burns were related to scald injuries (72.4%). 184 patients (10.9%) used traditional medicine prior to presentation. Only a delay in presentation was associated with prior traditional health practitioner use. After propensity weighted score matching, the odds ratio of mortality after using a prior traditional health practitioner was 1.91 (95% CI 1.09, 3.33). Conclusion: The use of traditional health practitioners prior to presentation at a tertiary burn center is associated with an increased odds of mortality after burn injury. These effects may be independent of the potential harms associated with a delay in definitive care. Further work is needed to delineate strategies for integrating with local customs and building improved networks for burn care, especially in rural areas

Predictors of change in code status from time of admission to death in critically ill surgical patients

Racial and gender disparities in end-of-life decision-making practices have not been well described in surgical patients. We performed an eight-year retrospective analysis of surgical patients within the Cerner Acute Physiology and Chronic Health Evaluation Outcomes database. ICU patients with documented admission code status, and death or ICU discharge code status, respectively, were included. Logistic regression analysis was performed to assess change in code status. Of 468,000 ICU patients, 97,968 (20.9%) were surgical, 63,567 (95%) survived, and 3,343 (5%) died during their hospitalization. Of those, 50,915 (80.1%) and 2,625 (78.5%) had complete code status data on admission and discharge or death, respectively. Women were less likely than men to remain full code at ICU discharge and death (n 5 20,940, 95.6% and n 5 141, 11.9% vs n 5 29,320, 97.4% and n 5 233, 16.3%, P < 0.001). Compared with whites, blacks and other minorities had a 0.46 odds (95% confidence interval [CI]: 0.33–0.64, P < 0.001) and 0.54 odds (95% CI: 0.34–0.85, P 5 0.01) of changing from full code status before death, respectively. Before ICU discharge, blacks and other minorities had a 0.56 odds of changing from full code status when compared with whites (95% CI: 0.40–0.79, P < 0.001 vs 95% CI: 0.36–0.87, P 5 0.01, respectively). Women were more likely to be discharged or die after a change in code status from full code (odds ratio 1.27, 95% CI: 1.06–1.07, P < 0.001 odds ratio 1.39, 95% CI: 1.09–1.79, P 5 0.009). Men and minorities are more likely to be discharged from the ICU or die with a full code status designation

The Inter-Relationship Between Employment Status and Interpersonal Violence in Malawi: A Trauma Center Experience

Introduction: As a proportion of the overall population, sub-Saharan Africa (SSA) has the highest youth demographic, composing 60% of Africa’s unemployed. With the worsening economic crisis in low- and middle-income countries, unengaged youth are susceptible to gang violence and anti-government demonstrations, resulting in political instability. Methods: We performed a retrospective review of the Kamuzu Central Hospital Trauma Registry from 2008–2018. All adult patients (>14 years) injured by interpersonal violence (IPV) were included. Age was categorized as 15–24 (youth), 25–45, and >45 years. A bivariate analysis (IPV versus unintentional injury), and Poisson multivariable analysis were performed to identify factors increasing the risk of IPV. Results: During the study, 87,338 trauma patients presented; 30,532 (35.0%) were injured following IPV. Patients injured following IPV (28 years, IQR 23–34) were younger than those unintentionally injured (30 years, IQR 23–39, p 45 years (RR 1.72, 1.66–1.79), and those injured at night (RR 2.18, 95% CI 2.14–2.23) had increased the risk of being victims of IPV. Conclusion: In Malawi, there is an interrelationship between unemployment and IPV, particularly in the youth population. Given impending demographic realities, government and non-government organizations should prioritize youth employment to help defer political instability in vulnerable nation-states

Access to Operative Intervention Reduces Mortality in Adult Burn Patients in a Resource-Limited Setting in Sub-Saharan Africa

Introduction: Early excision and grafting remains the standard of care after burn injury. However, in a resource-limited setting, operative capacity often limits patient access to surgical intervention. This study sought to describe access to excision and grafting for adult burn patients in a sub-Saharan African burn unit and its relationship with burn-associated mortality. Methods: We analyzed patients recorded in the Kamuzu Central Hospital Burn Registry in Lilongwe, Malawi from 2011–2019. We examined patient characteristics, interventions, and outcomes for adults aged ≥16 years. Modified Poisson regression modeling was used to identify risk factors for mortality. Results: Five hundred and seventy-three patients were included. Median age was 30 years (IQR 23–40) with a male preponderance (63%). Median percent total body surface area burned (%TBSA) was 15% (IQR 8–26) and 68% of burns were caused by flame. 27% (n = 154) had burn excision with skin grafting, with a median time to operation of 18 days (IQR 9–38). When adjusted for age, %TBSA, and time to presentation, operative intervention conferred a survival benefit for patients with flame burns with a RR 0.16 (95% CI 0.06, 0.42). Conclusions: In a resource-limiting setting, access to the operating room is inadequate, and burn patients are not prioritized. While many scald burn patients may be managed with wound care alone, patients with flame burn require surgical intervention to improve clinical outcomes. Burn injury in this region continues to confer a high risk of mortality, and more investment in operative capacity is imperative

Epidemiological Comparisons and Risk Factors for Pre-hospital and In-Hospital Mortality Following Traumatic Injury in Malawi

Background: In sub-Saharan Africa, trauma is a leading cause of mortality in people less than 45 years. Injury mechanism and cause of death are difficult to characterize in the absence of pre-hospital care and a trauma surveillance database. Pre-hospital deaths (PHD) and in-hospital deaths (IHD) of trauma patient were compared to elucidate comprehensive injury characteristics associated with mortality. Methods: A retrospective, descriptive analysis of adults (≥ 13 years) presenting to Kamuzu Central Hospital in Lilongwe, Malawi, from February 2008 to May 2018 was performed. Utilizing an emergency department-based trauma surveillance database, univariate and bivariate analysis was performed to compare patient and injury characteristics of pre-hospital and in-hospital deaths. A Poisson multivariate regression was performed, predicting the relative risk of PHD. Results: Between February 2008 and May 2018, 131,020 adult trauma patients presented to KCH, with 2007 fatalities. Of those patients, 1130 (56.3%) and 877 (43.7%) were PHD and IHD, respectively. The majority were men, with a mean age of 33.4 years (SD 12.1) for PHD and 37.4 years (SD 15.5) for IHD, (p < 0.001). Head injuries (n = 545, 49.2% vs. n = 435, 49.7%) due to assaults (n = 255, 24.7% vs. n = 178, 21.8%) and motor vehicle collisions (MVC) (n = 188, 18.2% vs. n = 173, 21.2%) were the leading cause of both groups (PHD vs. IHD). Transportation to the hospital was primarily police (n = 663, 60.1%) for PHD and ambulance (n = 401, 46.4%) for IHD. Patients who were transported to KCH by the police (RR 1.97, 95% 1.52–2.55, p < 0.001) when compared to transport via minibus had an increased relative risk of PHD. Patients with a head or spine (RR 1.32, 95% CI 1.34–1.53, p < 0.001), chest (RR 1.34, 95% CI 1.11–1.62, p = 0.002) or abdomen and pelvis (RR 1.30, 95% CI 1.14–1.53, p = 0.004) when compared to extremity injury had an increased relative risk of PHD. Conclusions: Head injury from assaults and MVC is the leading cause of PHD and IHD in Malawi. The majority of patients are transported via police if PHD. Of IHD patients, the majority are transported by ambulance, most often from outside hospitals. Both are consistent with the absence of a pre-hospital system in Malawi. Improving pre-hospital care, with a particular focus on head injury and strategies for vehicular injury prevention within a trauma system, will reduce adult trauma mortality in Malawi

Diurnal variation in trauma mortality in sub-Saharan Africa: A proxy for health care system maturity

Background: Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. However, trauma centers in these environments have limited resources to manage complex trauma with minimal staffing and diagnostic tools. These limitations may be exacerbated at night. We hypothesized that there is an increase in trauma-associated mortality for patients presenting during nighttime hours. Methods: We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma registry in Lilongwe, Malawi from January 2012 through December 2016. Nighttime was defined as 18:00 until 5:59. Patients brought in dead were excluded. A modified Poisson regression model was used to calculate the relationship between presentation at night and mortality, adjusted for significant confounders. Results: 74,500 patients were included. During the day, crude mortality was 0.8% compared to 1.4% at night (p < 0.001). The risk ratio of mortality following night time presentation compared to day was 1.90 (95% CI 1.48, 2.42) when adjusted for injury severity, assessed by the Malawi Trauma Score (MTS), and transfer status. When stratified by the year of traumatic injury, the risk ratio of death decreased each year from 2012–2014 but increased in 2015. There was no difference in 2016. Conclusions: We report the first description of diurnal variation in trauma-associated mortality in sub-Saharan Africa. Injured patients who presented at night had nearly twice the adjusted risk ratio of death compared to patients that presented during the daytime although there were yearly differences. Diurnal variation in trauma-associated mortality is a simple but important indicator of the maturity of a trauma system and should be tracked for health care system improvement

District General Hospital Surgical Capacity and Mortality Trends in Patients with Acute Abdomen in Malawi

Background: The burden of emergency general surgery conditions is high in sub-Saharan Africa, and poor access to surgical care leads to poor patient outcomes. We examined the trends in mortality in patients presenting with an acute abdomen to a referral hospital. Methods: A retrospective analysis of the prospectively collected Kamuzu Central Hospital Acute Care Surgery database was performed (January 2014 to July 2019). Bivariate analysis was conducted by year of admission. A multivariate Poisson regression was performed to identify predictors of mortality. Results: During the study, 2509 patients with acute abdomen presented. The majority of patients presenting were transferred from outside hospitals (n = 2097, 83.9%). Mortality was highest in patients with preoperative diagnosis of peritonitis (n = 119, 22.2%), bowel obstruction (n = 214, 18.7%), and volvuli (n = 51, 18.6%). There was no difference in mortality by year, p = 0.1. On multivariate Poisson regression, there was an increased relative risk of mortality with being transferred (RR 1.31, 95% CI 1.12–1.55, p = 0.002), as well as undergoing an operation within 1–2 days (RR 1.48, 95% CI 1.16–1.87, p 2 days (RR 1.46, 95% CI 1.17–1.82, p = 0.001) after presentation. Conclusion: The majority of patients in our study who presented with an acute abdomen were transferred from district hospitals, which resulted in high mortality due to delays in surgical care. Therefore, the WHO’s recommendation that the majority of district hospitals perform the Bellwether procedures does not occur in district hospitals in central Malawi. District hospitals require significant resource investment to reduce transfers needs and patient mortality