Incidence, causes and factors associated with torso injury in Cameroon: A community-based study.

BACKGROUND: Morbidity and mortality linked to injury has become an increasingly important public health concern worldwide, especially in developing countries. Despite the potentially severe nature of torso injury, little is known about the population-based epidemiology of torso injury in sub-Saharan Africa. OBJECTIVES: To determine the incidence, identify common mechanisms, and assess the socioeconomic consequences of torso injury in Cameroon. METHODS: We performed a torso injury sub-analysis of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months in the Southwest region of Cameroon. Sampling was done using the three-stage cluster sampling technique. The differences between groups were evaluated using χ² and adjusted Wald tests. RESULTS: We identified 39 cases of torso injuries out of 8 065 participants, providing a yearly incidence estimate of 488 (95% confidence interval (CI) 356 - 668) per 100 000 person-years. Road traffic injury was the most common mechanism of torso injury. The median (interquartile range (IQR)) cost of treatment for torso injury was USD58 (10 - 137), over four times the median (IQR) cost for non-torso injury at USD12 (3 - 43) (p=0.0004). About half of affected households (51%) reported being unable to afford necessities such as rent and food after injury v. 33% of households with members with non-torso injuries (p=0.018). CONCLUSION: Torso injuries have an incidence of 488/100 000 person-years, and road traffic injuries account for the majority of the injuries. Road traffic control measures and trauma care strengthening may reduce the impact of torso injuries and injuries in Cameroon.

Survey of surgical training and experience of associate clinicians compared with medical officers to understand task-shifting in a low-income country.

Background: A workforce crisis exists in global surgery. One solution is task-shifting, the delegation of surgical tasks to non-physician clinicians or associate clinicians (ACs). Although several studies have shown that ACs have similar postoperative outcomes compared with physicians, little is known about their surgical training. This study aimed to characterize the surgical training and experience of ACs compared with medical officers (MOs) in Tanzania. Methods: All surgical care providers in Pwani Region, Tanzania, were surveyed. Participants reported demographic data, years of training, and procedures assisted and performed during training. They answered open-ended questions about training and post-training surgical experience. The median number of training cases for commonly performed procedures was compared by cadre using Wilcoxon rank sum and Student's t tests. The researchers performed modified content analysis of participants' answers to open-ended questions on training needs and experiences. Results: A total of 21 ACs and 12 MOs participated. ACs reported higher exposure than MOs to similar procedures before their first independent operation (median 40 versus 17 cases respectively; P = 0·031). There was no difference between ACs and MOs in total training surgical volume across common procedures (median 150 versus 171 cases; P = 0·995). Both groups reflected similarly upon their training. Each cadre relied on the other for support and teaching, but noted insufficient specialist supervision during training and independent practice. Conclusions: ACs report similar training and operative experience compared with their physician colleagues in Tanzania.

Antecedentes: La falta de cirujanos en determinadas áreas geográficas es flagrante. Una posible solución es el intercambio de tareas, es decir, la delegación de tareas quirúrgicas en personal sanitario no médico o en clínicos asociados (associate clinicians, AC). Si bien varios estudios han demostrado que los AC obtienen resultados postoperatorios similares a los de los médicos, hay poco información acerca de su entrenamiento quirúrgico. Este estudio tuvo como objetivo caracterizar la capacitación quirúrgica y la experiencia de los AC en comparación con los médicos titulados (medical officer, MO) en Tanzania. Métodos: En este estudio, se encuestaron todos los proveedores de atención quirúrgica de la Región de Pwani, Tanzania. Los participantes proporcionaron datos demográficos, años de entrenamiento y número y tipo de procedimientos realizados y a los que se había asistido durante el periodo de capacitación. Además, respondieron a preguntas abiertas sobre el entrenamiento y su experiencia quirúrgica posterior al entrenamiento. Se comparó la mediana del número de procedimientos más realizados por cada grupo mediante la suma de rangos de Wilcoxon y la prueba de la t de Student. Los investigadores realizaron un análisis del contenido de las respuestas a las preguntas abiertas sobre las necesidades y la experiencia durante la etapa de entrenamiento. Resultados: En el estudio participaron 21 ACs y 12 MOs. Los CA estuvieron expuestos a un mayor número procedimientos del mismo tipo antes de efectuar su primera operación de forma independiente en comparación con los OM (40 versus 17 casos, P = 0,031). No hubo diferencias en el volumen operatorio total de los procedimientos comunes entre los AC y los MO (150 versus 171 casos, P = 0,995). Las opiniones de los dos grupos sobre el entrenamiento fueron similares. Los dos grupos se dieron soporte entre ellos, pero quedó patente que la supervisión por parte de un especialista durante el entrenamiento y la práctica independiente era insuficiente. Conclusiones: En Tanzania, los asociados clínicos tienen entrenamientos y experiencias quirúrgicas similares a las de sus colegas médicos.

Patterns of surgical presentation at an African regional referral hospital: surveillance as a step towards improving access to care.

PURPOSE: Surgical disease is being increasingly recognized as a significant health burden in Africa. Efforts have been made to describe surgical disease and capacity at the district hospital level. Little is known about patterns seen at regional hospitals supporting the district hospital network. METHODS: This retrospective study was conducted at Uganda's Soroti Regional Referral Hospital, serving eight districts. Data were collected from July 2010 to March 2012 using operative and inpatient records as available. Univariate and bivariate analyses were performed to explore patterns of procedures performed and in-patient diagnoses. RESULTS: There were 8511 procedures recorded in the operative log between July 2010 and June 2011, averaging 709 per month. Caesarian sections (41 %), dilation and evacuations (28 %), and laparotomies (19 %) were most frequent. Referrals to Soroti averaged 260 per month, while transfers out averaged 5 patients per month. Inpatient records documented 2949 surgically related diagnoses between July 2010 and May 2011. In patients >4 years old, 21 % of mortality was due to surgical disease, 29 % of which was trauma-related. Women comprised 80 % of violent injury. Common hospital record elements, such as demographic data, important clinical information, and operative notes were absent from these data sources. CONCLUSIONS: The World Health Assembly recently recognized strengthening of first referral hospitals as a crucial element to achieving universal health coverage. Inconsistencies in recordkeeping despite the large volume of surgical disease suggest that sustainable surveillance systems and capacity building at the referral hospital level are potential building blocks to improving access to surgical care.

An estimation of inguinal hernia epidemiology adjusted for population age structure in Tanzania.

PURPOSE: Surgical conditions represent a significant source of global disease burden. Little is known about the epidemiology of inguinal hernia in resource-poor settings. We present a method to estimate inguinal hernia disease burden in Tanzania. METHODS: Using data from the United States National Health and Nutrition Examination Survey (NHANES) prospective cohort study and Tanzanian demographic figures, we calculated inguinal hernia incidence and prevalence in Tanzanian adults under three surgical rate scenarios. Gender-specific incidence figures from NHANES data were adjusted according to Tanzanian population age structure. Hernia duration was adjusted for Tanzanian life expectancy within each age group. RESULTS: The prevalence of inguinal hernia in Tanzanian adults is 5.36% while an estimated 12.09% of men had hernias. Today, 683,904 adults suffer from symptomatic inguinal hernia in Tanzania. The annual incidence of symptomatic hernias in Tanzanian adults is 163 per 100,000 population. At Tanzania's current hernia repair rate, a backlog of 995,874 hernias in need of repair will develop over 10 years. 4.4 million disability-adjusted life-years would be averted with repair of prevalent symptomatic hernias in Tanzania. CONCLUSIONS: Our data indicate the extent of inguinal hernia disease burden in Tanzania. By adjusting our figures for the age structure of Tanzania, we have demonstrated that while the incidence of symptomatic cases may be lower than previously thought, prevalence of inguinal hernia in Tanzania remains high. This approach provides an update to our previously described methodology for calculation of inguinal hernia epidemiology in resource-poor settings that may be used in multiple country contexts.

Seroprevalence of Leptospira in Rattus Norvegicus in Grenada, West Indies

OBJETIVE: To determine the seroprevalence of Leptospira and the serovars responsible for Leptospira exposure in rats in Grenada in order to assess rats as a reservoir host for human infection. DESIGN AND METHODS: Rattus norvegicus rodents were collected representing each of the six parishes on the island of Grenada. Serum from 237 rats was tested by the microscopic agglutination test (MAT) and an Immunoglobulin G (IgG) Enzyme-Linked Immunosorbent Assay (ELISA). Seroprevalence rates among parishes were compared using a chi-squared test of homogeneity. RESULTS: Of the 237 serum samples tested, 64 were positive by either MAT or ELISA for an overall seroprevalence of 27%. The ELISA identified 24.5 % (57/233) of the rats positive at a titer of > 1:160. The MAT identified 7.1% (13/183) of the rats positive at a titer of > 1:100. Six of the 13 MAT positive samples had antibodies to multiple serovars. The serovars identified by the MAT with the greatest frequency were from the Icterohaemorrhagiae serogroup. Two rats had antibodies for serogroup Cynopteri, the first time this serogroup has been identified on Grenada. CONCLUSIONS: Our results for Leptospira exposure in rats in Grenada support R. norvegicus as an important reservoir host for Leptospira, particularly those from the Icterohaemorrhagiae serogroup. Because this serogroup is the primary serogroup responsible for documented human exposure in Grenada, exposed rats represent a public health threat.

Seroprevalence of Leptospira in rattus norvegicus in Grenada, West Indies.

OBJECTIVE: To determine the seroprevalence of Leptospira and the serovars responsible for Leptospira exposure in rats in Grenada in order to assess rats as a reservoir host for human infection. DESIGN AND METHODS: Rattus norvegicus rodents were collected from each of the six parishes on the island of Grenada. Serum from 237 rats was tested by the microscopic agglutination test (MAT) and an Immunoglobulin G (IgG) Enzyme-Linked Immunosorbent Assay (ELISA). Seroprevalence rates among parishes were compared using a chi-squared test of homogeneity. RESULTS: Of the 237 serum samples tested, 64 were positive by either MAT or ELISA for an overall seroprevalence of 27%. The ELISA identified 24.5% (57/233) of the rats positive at a titer of > or = 1:160. The MAT identified 7.1% (13/183) of the rats positive at a titer of > or = 1:100. Six of the 13 MAT positive samples had antibodies to multiple serovars. The serovars identified by the MAT with the greatest frequency were from the Icterohaemorrhagiae serogroup. Two rats had antibodies for serogroup Cynopteri, the first time this serogroup has been identified in Grenada. CONCLUSIONS: Our results for Leptospira exposure in rats in Grenada support R norvegicus as an important reservoir host for Leptospira, particularly those from the Icterohaemorrhagiae serogroup. Because this serogroup is the primary serogroup responsible for documented human exposure in Grenada, exposed rats represent a public health threat.

Prolonged outbreak of giardiasis with two modes of transmission.

Large outbreaks of giardiasis caused by person-to-person transmission, or a combination of transmission routes, have not previously been reported. A large, prolonged giardiasis outbreak affected families belonging to a country club in a suburb of Boston, Massachusetts, during June-December 2003. We conducted a retrospective cohort study to determine the source of this outbreak. Giardiasis-compatible illness was experienced by 149 (25%) respondents to a questionnaire, and was laboratory confirmed in 97 (65%) of these cases. Of the 30 primary cases, exposure to the children's pool at the country club was significantly associated with illness (risk ratio 3.3, 95% confidence interval 1.7-6.5). In addition, 105 secondary cases probably resulted from person-to-person spread; 14 cases did not report an onset date. This outbreak illustrates the potential for Giardia to spread through multiple modes of transmission, with a common-source outbreak caused by exposure to a contaminated water source resulting in subsequent prolonged propagation through person-to-person transmission in the community. This capacity for a common-source outbreak to continue propagation through secondary person-to-person spread has been reported with Shigella and Cryptosporidium and may also be a feature of other enteric pathogens having low infectious doses.

An outbreak of norovirus gastroenteritis associated with wedding cakes.

We sought to determine the source of a norovirus outbreak among attendees of 46 weddings taking place during a single weekend. Norovirus-compatible illness was experienced by 332 (39%) of wedding guests surveyed; the outbreak affected up to 2700 persons. Illness was associated with eating wedding cake provided by a bakery common to the weddings (adjusted RR 4.5, P<0.001). A cake requiring direct hand contact during its preparation accounted for the majority of illness. At least two bakery employees experienced norovirus-compatible illness during the week preceding the weddings. Identical sequence types of norovirus were detected in stool specimens submitted by two wedding guests, a wedding hall employee, and one of the ill bakery employees. It is likely that one or more food workers at the bakery contaminated the wedding cakes through direct and indirect contact. These findings reinforce the necessity of proper food-handling practices and of policies that discourage food handlers from working while ill.

Are temporary inferior vena cava filters really temporary?

BACKGROUND: Despite significant risk for venous thromboembolism, severely injured trauma patients often are not candidates for prophylaxis or treatment with anticoagulation. Long-term inferior vena cava (IVC) filters are associated with increased risk of postphlebitic syndrome. Retrievable IVC filters potentially offer a better solution, but only if the filter is removed; our hypothesis is that the most of them are not. METHODS: This retrospective study queried a level I trauma registry for IVC filter insertion from September 1997 through June 2004. RESULTS: One IVC filter was placed before the availability of retrievable filters in 2001. Since 2001, 27 filters have been placed, indicating a change in practice patterns. Filters were placed for prophylaxis (n = 11) or for therapy in patients with pulmonary embolism or deep vein thrombosis (n = 17). Of 23 temporary filters, only 8 (35%) were removed. CONCLUSIONS: Surgeons must critically evaluate indications for IVC filter insertion, develop standard criteria for placement, and implement protocols to ensure timely removal of temporary IVC filters.

Adjunctive antipsychotic treatment of adolescents with bipolar psychosis.

BACKGROUND: A combination of an antipsychotic medication and a mood stabilizer is often used for initial treatment of acute psychotic mania. However, the optimal duration of this adjunctive antipsychotic medication is unknown. METHOD: As part of a lithium efficacy study, acutely manic adolescents with psychotic features were given open combination treatment with lithium and an adjunctive antipsychotic medication. If the psychosis resolved, the antipsychotic medication dose was gradually tapered and discontinued after 4 weeks of therapeutic lithium levels. The subject was then given a trial of maintenance lithium monotherapy for up to 4 weeks. RESULTS: Significant improvement was seen in 64% of the sample with psychotic features after 4 weeks of combination treatment. However, few maintained their response after discontinuation of the antipsychotic medication. Successful discontinuation of antipsychotic medication in this sample was associated with first episode, shorter duration of psychosis, and the presence of thought disorder at baseline. CONCLUSIONS: Adjunctive antipsychotic medication needs to be maintained for longer than 4 weeks in the vast majority of adolescents with psychotic mania, even though the manic and psychotic symptoms have resolved and lithium treatment is maintained. Future studies to determine the optimal duration of adjunctive antipsychotic medication treatment are warranted.

Adjunctive antipsychotic treatment is necessary for adolescents with psychotic mania.

Adolescents with acute psychotic mania were treated with lithium and adjunctive haloperidol as part of a lithium efficacy study. If the psychosis completely resolved, haloperidol was discontinued after 1 week of therapeutic lithium levels. Our first five subjects experienced a rapid exacerbation of symptoms, which responded to restarting haloperidol. A longer duration of adjunctive antipsychotic treatment is necessary in adolescents with bipolar psychosis.

Are childhood psychiatric histories of bipolar adolescents associated with family history, psychosis, and response to lithium treatment?

OBJECTIVE: To examine if childhood psychiatric diagnoses are associated with family history, psychosis, age, and lithium response. METHOD: Associations among variables, and their contributions to explaining lithium response were examined in 48 bipolar adolescents enrolled in a study of lithium. RESULTS: Presence of a childhood diagnosis was not associated with family psychiatric history or lithium response. Subjects with psychotic features, however, were less likely to have a childhood psychiatric diagnosis, were older, and had a poorer response rate to lithium than subjects without psychosis. DISCUSSION: Heterogeneity within bipolar adolescents may be based on clinical features such as psychosis rather than childhood or family history alone.

Hospitalizing the suicidal adolescent: decision-making criteria of psychiatric residents.

OBJECTIVE: The primary purpose of this research is to investigate the criteria used by general psychiatric residents in determining the appropriateness of hospitalization. METHOD: A questionnaire containing 64 vignettes describing adolescent suicide attempts was completed by a sample of 33 residents from a general psychiatry training program. Six variables known to relate to lethality of attempt were systematically varied within the vignettes: gender, depression, conduct disorder/substance abuse, previous attempts, suicidal relative, and family supports. Respondents were asked to judge the appropriateness of hospitalization for each vignette. RESULTS: Hospitalization preference was significantly predicted by all risk factors except for gender, with the presence of depression emerging as the most important predictor of hospitalization. Residents recommended hospitalization more frequently than did experienced child and adolescent clinicians. In comparison with experienced clinicians, residents placed more importance on depression, and less importance on conduct disorder/substance abuse, in making decisions to hospitalize. CONCLUSIONS: Although psychiatric residents use known risk factors for adolescent suicide in assessing need for hospitalization, there was clear support for further training initiatives for psychiatric residents concerning the assessment of suicidal adolescents.

Lithium treatment of conduct disorders in adolescents.

OBJECTIVE: The authors examined the efficacy of lithium carbonate for treating conduct disorder in adolescents. METHOD: The subjects were 33 inpatients aged 12-17 years. Lithium or placebo was administered in a double-blind fashion for 2 weeks. RESULTS: On several measures of clinical change the groups showed no significant differences. Of the patients who completed the study, 8.3% of those receiving placebo (one of 12) versus 21.4% (three of 14) of those receiving lithium were considered responders. CONCLUSIONS: Lithium does not appear beneficial for this indication.

Thought disorder in adolescent-onset schizophrenia.

The nature of the thinking disturbances found in adolescent-onset psychotic conditions is not as well-characterized as the thought disorders found in adult psychotic patients. We used the Thought Disorder Index to examine whether schizophrenic patients in whom psychotic symptoms appear in adolescence show the same characteristic features of thought disorder as do adult schizophrenics. Quantitative and qualitative features of thought disorder were assessed in psychiatric inpatients with adolescent-onset schizophrenia, psychotic depression, and nonpsychotic conditions compared with normal control adolescents. Elevated thought disorder occurred in all groups of adolescents hospitalized for an acute episode of psychiatric illness. The magnitude of the elevation and the frequency of occurrence of disordered thinking were greatest in the psychotic adolescents. The qualitative features of the thought disturbances found in the schizophrenic adolescents were distinct from those observed in adolescents with psychotic depression. The thinking of the schizophrenic adolescents resembled that of adult schizophrenics. In both conditions thought disorder is characterized by idiosyncratic word usage, illogical reasoning, perceptual confusion, loss of realistic attunement to the task, and loosely related ideas.

Penetrating hepatic trauma in children: operating room or not?

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.

Continuous thoracic epidural infusions for postoperative analgesia after pectus deformity repair.

PURPOSE: To determine whether continuous epidural analgesia after repair of a pectus deformity is a viable and safe alternative to high-dose narcotics in children. METHODS: Data were collected prospectively for 19 children (4 to 17 years of age; 15 boys, 4 girls) who underwent pectus excavatum (14) or carinatum (5) repair between June 1, 1991 and July 1, 1994. Seventeen had a thoracic epidural catheter placed for postoperative pain control and two did not. The epidural catheter was routinely plead preoperatively by the anesthesiologist at the T3-T8 level, after induction of general anesthesia. Epidural catheters were test-dosed with local anesthesia alone or in combination with fentanyl, and afterward a continuous epidural infusion was maintained on the floor. Postoperative pain was assessed by nursing and house staff on the Wong-Baker scale, with adjustment of the dose rate or analgesic medication as appropriate. RESULTS: All patients had extubation before leaving the operating room and were sent to the general pediatrics ward after leaving the recovery room. The average duration of the epidural was 69 hours (range, 20 to 116 hours). Sixteen patients received their test epidural dose preoperatively, and one patient had his in the recovery room. Fifteen epidural initially were dosed with bupivicaine (1 to 2 mg/kg) alone or in combination with fentanyl (1 to 2 micrograms/kg). Two patients received initial doses of lidocaine (1 to 1.5 micrograms/kg). Ten of 17 patients received fentanyl (1 microgram/kg/h) with bupivicaine (0.5 to 1.0 mg/kg/h) in the epidural as their maintenance medication, and the remainder received bupivicaine alone at the same dosage rate. Eight of 17 patients required additional intermittent supplemental narcotics, with an average of two doses of intravenous morphine per day (0.1 mg/kg) over the first 3 postoperative days. In contrast, the two patients who did not have an epidural catheter for pain control required high-dose intravenous morphine (0.2 mg/kg) every 2 to 3 hours for the first 3 to 4 postoperative days. No catheter-related complications occurred. CONCLUSION: Thoracic epidural analgesia was completely successful in nine (53%) children who underwent repair of pectus deformity, and effectively reduced the intravenous narcotic demand in the other eight. Pain control was excellent, and no catheter-related complications were encountered. The data show that this method of analgesia in children is a safe and attractive alternative to intravenous narcotics, and eliminates the potential disadvantages of sedation and respiratory compromise.

Hospitalizing the suicidal adolescent: an empirical investigation of decision-making criteria.

OBJECTIVE: The primary purpose of this research is to investigate the criteria used by child and adolescent clinicians in determining the appropriateness of hospitalization for suicidal adolescents. METHOD: A questionnaire containing 64 vignettes describing adolescent suicide attempters was completed by a sample of 36 child and adolescent clinicians. Six variables known to relate to lethality of attempt were systematically varied within the vignettes: gender, depression, conduct disorder/substance abuse, previous attempts, suicidal relative, and family supports. Respondents were asked to judge the appropriateness of hospitalization for each vignette. RESULTS: Hospitalization preference was found to be inversely related to professional experience and was significantly predicted by all risk factors except gender. Configural cue utilization added substantially to the efficacy of a linear model in predicting preference to hospitalize. CONCLUSIONS: Experienced clinicians use known risk factors for adolescent suicide in making recommendations to hospitalize, but results also suggest ongoing needs for education and training in adolescent suicidality.

Epi Info: a general-purpose microcomputer program for public health information systems.

Epi Info is a general-purpose set of computer programs for word processing, database management, statistics, and graphics developed over the past five years at the Centers for Disease Control and the World Health Organization. The programs allow rapid questionnaire construction, data entry, and analysis during epidemic investigation. Both data entry and analysis can be programmed to provide customization and automatic operation for more permanent systems, such as those for disease or injury surveillance. Epi Info is in the public domain and copies may be freely distributed. It requires an IBM-compatible micro-computer with at least 512 kilobytes of memory. Translations into French and Spanish are in progress; a translation kit is available to facilitate translation into other languages.