Assessment of substance use among injured persons seeking emergency care in Nairobi, Kenya

ntroduction: Trauma is a leading cause of morbidity and mortality in Kenya. In many countries, substance use is common among patients presenting with injuries to an emergency center (EC). Objective: To describe the epidemiology of self-reported substance use among adult injured patients seeking ED care in Nairobi, Kenya. Methods: This prospective cross-sectional study, assessed patients presenting with injuries to the Kenyatta Na-tional Hospital ED in Nairobi, Kenya from March through June of 2021. Data on substance use, injury character-istics and ED disposition were collected. Substances of interest were alcohol, stimulants, marijuana, and opiates.The Alcohol Use Disorders Identification Test-Concise (AUDIT-C) tool was used to characterize hazardous alcoholuse. Results: A total of 1,282 patients were screened for participation, of which 646 were enrolled. Among participants,322 (49.8%) reported substance use in the past month (AUDIT-C positive, stimulants, opiates, and/or marijuana). Hazardous alcohol use was reported by 271 (42.0%) patients who screened positive with AUDIT-C. Polysubstance use, (≥2 substances) was reported by 87 participants in the past month. Median time from injury to ED arrival was 13.1 h for all enrolees, and this number was significantly higher among substance users (median 15.4 h, IQR 5.5 - 25.5; p = 0.029). Conclusions: In the population studied, reported substance use was common with a substantial proportion of injured persons screening positive for hazardous alcohol use. Those with substance use had later presentations for injury care. These data suggest that ED programming for substance use disorder screening and care linkagecould be impactful in the study setting.

Evaluation of a modified South African Triage Score as a predictor of patient disposition at a tertiary hospital in Rwanda

Background: Triage is essential for efficient and effective delivery of care in emergency centers (ECs) where numerous patients present simultaneously with varying acuity of conditions. Implementing EC triage systems provides a method of recognizing which patients may require admission and are at higher risks for poor health outcomes. Rwanda is experiencing increased demand for emergency care; however, triage has not been well studied. The University Teaching Hospital of Kigali (UTH-K) is an urban tertiary care health center utilizing a locally modified South African Triage Score (mSATS) that classifies patients into five color categories. Our study evaluated the utility of the mSATS tool at UTH-K. Methods: UTH-K implemented mSATS in April 2013. All patients aged 15 years or older from August 2015 to July 2016 were eligible for inclusion in the database. Variables of interest included demographic information, mSATS category, patient case type (trauma or medical), disposition from the ED and mortality. Results: 1438 cases were randomly sampled; the majority were male (61.9%) and median age was 35 years. Injuries accounted for 56.7% of the cases while medical conditions affected 43.3%. Admission likelihood significantly increased with higher triage color category for medical patients (OR: Yellow=3.61, p<.001 to Red (with alarm)=7.80, p<.01). Likelihood for trauma patients, however, was not significantly increased (OR:Yellow=.84, p=.75 to Red (with alarm)=1.50, p=.65). Mortality rates increased with increasing triage category with the red with alarm category having the highest mortality (7.7%, OR 18.91). Conclusion: The mSATS tool accurately predicted patient disposition and mortality for the overall ED population. The mSATS tool provided useful clinical guidance on the need for hospital admission for medical patients but did not accurately predict patient disposition for injured patients. Further trauma-specific triage studies are needed to improve emergency care in Rwanda

Association between multivitamin supplementation and mortality among patients with Ebola virus disease: an international multisite cohort study

Introduction: Micronutrient supplementation is recommended in Ebola Virus Disease (EVD) care; however, there is limited data on its therapeutic effects. Methods: This retrospective cohort study included patients with EVD admitted to five Ebola Treatment Units (ETU) in Sierra Leone and Liberia during September 2014 to December 2015. A uniform protocol was used to guide ETU care, however, due to supply limitations, only a subset of patients received multivitamins. Data on demographics, clinical characteristics, and laboratory testing was collected. The outcome of interest was facility based mortality and the primary predictor was multivitamin supplementation initiated within 48 h of admission. The multivitamin formulations included: thiamine, riboflavin, niacin and vitamins A, C, and D3. Propensity score models (PSM) were used to match patients based on covariates associated with multivitamin administration and mortality. Mortality between cases treated and untreated within 48 h of admission were compared using generalized estimating equations to calculate relative risk with bootstrap methods employed to assess statistical significance. Results: There were 424 patients with EVD who had sufficient treatment data for analysis, of which 261 (61.6%) had daily multivitamins initiated within 48 h of admission. The mean age of the cohort was 30.5 years and 59.4% were female. In the propensity score matched analysis, mortality was 53.5% among patients receiving multivitamins and 66.2% among patients not receiving multivitamins, resulting in a relative risk for mortality of 0.81 (p=0.03) for patients receiving multivitamins. Conclusion: Early multivitamin supplementation was associated with lower overall mortality. Further research on the impact of micronutrient supplementation in EVD is warranted

Transfusion, mortality and hemoglobin level: associations among emergency department patients in Kigali, Rwanda

Background: Studies from high-income countries (HIC) support restrictive blood transfusion thresholds in medical patients. In low- and middle-income countries (LMIC), the etiologies of anemia and baseline health states differ greatly; optimal transfusion thresholds are unknown. This study evaluated the association of packed red blood cell (PRBC) transfusion with mortality outcomes across hemoglobin levels amongst emergency center (EC) patients presenting with medical pathology in Kigali, Rwanda. Methods: This retrospective cohort study was performed using a random sample of patients presenting to the EC at the University Teaching Hospital of Kigali. Patients ≥15 years of age, treated for medical emergencies during 2013­16, with EC hemoglobin measurements were included. The relationship between EC PRBC transfusion and patient mortality was evaluated using logistic regression, with stratified analyses performed at hemoglobin levels of 7 mg/dL and 5 mg/dL. Results: Of 3609 cases sampled, 1116 met inclusion. The median age was 42 years (IQR 29, 60) and 45.2% were female. Transfusion occurred in 12.1% of patients. Hematologic (24.4%) and gastrointestinal pathologies (20.7%) were the primary diagnoses of those transfused. Proportional mortality was higher amongst those receiving transfusions, although not statistically significant (23.7% vs 17.0%, p=0.06). No significant difference in adjusted odds of overall mortality by PRBC transfusion was found. In stratified analysis, patients receiving EC transfusions with a hemoglobin >5.0 mg/dL, had 2.21 times the odds of mortality (95% CI 1.51­3.21) as compared to those ≤5.0 mg/dL. Conclusions: No association between PRBC transfusion and odds of mortality was observed amongst EC patients in this LMIC setting. An increased mortality association was found for patients receiving PRBC transfusions with an initial hemoglobin >5 mg/dL. Results suggest benefits from PRBC transfusion are limited as compared to HIC. Further research evaluating emergent transfusion thresholds for medical pathologies should be performed in LMICs to guide practice

My Sweetheart Is Broken: Role of Glucose in Diabetic Cardiomyopathy

Despite overall reductions in heart disease prevalence, the risk of developing heart failure has remained 2-fold greater among people with diabetes. Growing evidence has supported that fluctuations in glucose level and uptake contribute to cardiovascular disease (CVD) by modifying proteins, DNA, and gene expression. In the case of glucose, clinical studies have shown that increased dietary sugars for healthy individuals or poor glycemic control in diabetic patients further increased CVD risk. Furthermore, even after decades of maintaining tight glycemic control, susceptibility to disease progression can persist following a period of poor glycemic control through a process termed "glycemic memory." In response to chronically elevated glucose levels, a number of studies have identified molecular targets of the glucose-mediated protein posttranslational modification by the addition of an O-linked N-acetylglucosamine to impair contractility, calcium sensitivity, and mitochondrial protein function. Additionally, elevated glucose contributes to dysfunction in coupling glycolysis to glucose oxidation, pentose phosphate pathway, and polyol pathway. Therefore, in the "sweetened" environment associated with hyperglycemia, there are a number of pathways contributing to increased susceptibly to "breaking" the heart of diabetics. In this review we will discuss the unique contribution of glucose to heart disease and recent advances in defining mechanisms of action.

Diabetes-Related Cardiac Dysfunction

The proposal that diabetes plays a role in the development of heart failure is supported by the increased risk associated with this disease, even after correcting for all other known risk factors. However, the precise mechanisms contributing to the condition referred to as diabetic cardiomyopathy have remained elusive, as does defining the disease itself. Decades of study have defined numerous potential factors that each contribute to disease susceptibility, progression, and severity. Many recent detailed reviews have been published on mechanisms involving insulin resistance, dysregulation of microRNAs, and increased reactive oxygen species, as well as causes including both modifiable and non-modifiable risk factors. As such, the focus of the current review is to highlight aspects of each of these topics and to provide specific examples of recent advances in each area.

Impact of the prehospital trauma life support programme in Trinidad and Tobago

The impact of the Prehospital Trauma Life Support (PHTLS) programme, introduced in Trinidad and Tobago in 1992, was assessed by questionnaires completed by 26 medical personnel (MP); 71 ambulance personnel (AP); and 50 non ambulance paramedical personnel (NAP). Of the 23 MP, 45 AP and 38 NAP who were aware of the programme, 19 (82.6) MP, 40 (88.9) AP and 25 (65.8) NAP were able to differentiate personnel that had taken the PHTLS programme based on their performance. 32 (71.1) of the AP were PHTLS trained. 24 (53.3) and 4 (9) of the AP identified poor equipment and poor supervision, respectively, as reasons for difficulty in applying PHTLS principles. Improvements observed among those completing the PHTLS programme were: improved resuscitation techniques by 20 (86.9) MP, 38 (84.4) AP and 27 (71.1) NAP; better vital signs recording by 8 (34.8) MP, 27 (60) AP and 8 (21.1) NAP; improved immobilization by 23 (100) MP, 40 (88.9) AP and 33 (86.8) NAP; better haemorrhage control by 22 (95.6) MP, 40 (88.9) AP and 24 (63.2) NAP; appropriate splinting of fractures by 23 (100) MP, 40 (88.9) AP and 32 (84.2) NAP; and increased utilization of oxygen by 15 (65.2) MP, 31 (68.9) AP and 21 (55.3) NAP. 32 (71.1) AP with PHTLS training indicated improvement in their ability to resuscitate and transport trauma victims, with 42 (93.3) reporting improvement in overall prehospital care. Medical, paramedical and ambulance personnel all perceive a significant positive impact of PHTLS training on prehospital trauma care. Although improvements in supervision, documentation and equipment are still required, improved trauma resuscitative techniques after PHTLS training should improve trauma patient outcome in Trinidad and Tobago.

Studies on lophocercous cercariae from Bithynia siamensis goniomphalus (Prosobranchia: Bithyniidae).

Cercariae from Bithynia siamensis goniomphalus were studied in an area endemic for opisthorchiasis. Snails emitted different types of cercariae when shedding was induced by illumination. In addition to two lophocercous cercariae, a monostome cercaria (probably Notocotylus sp), two different furcocercariae and a xiphidiocercaria were found. Two similar types of lophocercous cercariae were distinguishable and one could be identified as Opisthorchis viverrini. To date the cercaria of O. viverrini has been regarded as the only lophocercous cercaria in the endemic area of opisthorchiasis. Therefore, differences between these cercariae were further characterized by scanning electron microscopy to enable us to avoid misinterpretations of O. viverrini in Bithynia.

Studies on metacercariae from naiads in northeast Thailand.

One hundred and eleven naiads from six different dragonfly species were investigated for the presence of metacercariae. Sixty-nine animals (62.2%) were infected with intensities up to more than 150 cysts per animal. The metacercarial cysts were characterized by light and scanning electron microscopy. Two types of metacercariae could be differentiated by morphological features of cyst surface, cyst wall and size.