Global Emergency Medicine: A Review of the Literature From 2017.

OBJECTIVES: The 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 global audience of academics and clinical practitioners. METHODS: This year, 17,722 articles written in three languages were identified by our electronic search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Another two reviewers searched the gray literature, yielding an additional 11 articles. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles. RESULTS: A total of 848 articles met our inclusion criteria and underwent full review. Sixty-three percent were categorized as emergency care in resource-limited settings, 23% as disaster and humanitarian response, and 14% as EM development. Twenty-one articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed a Cohen's kappa of 0.344. CONCLUSIONS: In 2017, the total number of articles identified by our search continued to increase. Studies and reviews with a focus on infectious diseases, pediatrics, and trauma represented the majority of top-scoring articles.

Global Emergency Medicine: A Review of the Literature From 2016.

OBJECTIVES: The 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 global audience of academics and clinical practitioners. METHODS: This year 13,890 articles written in four 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. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles. RESULTS: A total of 716 articles met our inclusion criteria and underwent full review. Fifty-nine percent were categorized as emergency care in resource-limited settings, 17% as EM development, and 24% as disaster and humanitarian response. Nineteen articles received scores of 18.5 or higher out of a maximum score of 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed Cohen's kappa of 0.441. CONCLUSIONS: In 2016, the total number of articles identified by our search continued to increase. The proportion of articles in each of the three categories remained stable. Studies and reviews with a focus on infectious diseases, pediatrics, and the use of ultrasound in resource-limited settings represented the majority of articles selected for final review.

Global Emergency Medicine: A Review of the Literature From 2015.

OBJECTIVES: The 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 global audience of academics and clinical practitioners. METHODS: This year 12,435 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 723 articles were deemed appropriate by at least one reviewer and approved by their editor for formal scoring of overall quality and importance. Two independent reviewers scored all articles. RESULTS: A total of 723 articles met our predetermined inclusion criteria and underwent full review. Sixty percent were categorized as emergency care in resource-limited settings (ECRLS), 17% as EM development (EMD), and 23% as disaster and humanitarian response (DHR). Twenty-four articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability between reviewers gave an intraclass correlation coefficient of 0.71 (95% confidence interval = 0.66 to 0.75). Studies and reviews with a focus 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. CONCLUSIONS: In 2015, there were almost twice as many articles found by our search compared to the 2014 review. The number of EMD articles increased, while the number ECRLS articles decreased. The number of DHR articles remained stable. As in prior years, the majority of articles focused on infectious diseases.

Global emergency medicine: a review of the literature from 2014.

OBJECTIVES: The 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. METHODS: This 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. RESULTS: Of 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. CONCLUSIONS: In 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.

What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?

BACKGROUND: Computed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant. STUDY OBJECTIVES: This study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel. METHODS: Patients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance. RESULTS: Of 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries-primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT. CONCLUSION: Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management.

Associations between breast milk viral load, mastitis, exclusive breast-feeding, and postnatal transmission of HIV.

BACKGROUND: . Exclusive breast-feeding is protective against postnatal transmission of human immunodeficiency virus (HIV), compared with mixed breast-feeding. Accordingly, exclusive breast-feeding for 6 months is the World Health Organization's recommendation to HIV-infected mothers for whom exclusive replacement feeding is not acceptable, feasible, affordable, safe, or sustainable. The mechanism of exclusive breast-feeding protection is unknown but is hypothesized to be mediated through reduced mastitis. METHODS: We compared breast milk and plasma specimens of exclusive breast-feeding and mixed breast-feeding HIV- positive mothers archived from the ZVITAMBO trial in which mixed breast-feeding was associated with a 2-fold increased risk of postnatal transmission at 18 months. Plasma HIV load, breast milk HIV load and sodium/potassium ratio were measured as a proxy for subclinical mastitis. RESULTS: Mixed breast-feeding was not associated with mastitis or breast milk HIV load. Mastitis was associated with breast milk HIV load, and this effect increased with increasing maternal plasma HIV load; mastitis was associated with postnatal transmission only when maternal plasma HIV load was high (>3.7 log(10) copies/mL). Initiation of breast-feeding within an hour of delivery was associated with exclusive breast-feeding (adjusted odds ratio, 1.62; 95% confidence interval, 1.02-2.58). CONCLUSIONS: Exclusive breast-feeding is associated with reduced postnatal transmission of HIV from mother to child, but this protection is not mediated by reduced mastitis or breast milk HIV load. The deleterious effect of mastitis increases as the mother's plasma HIV load increases.

Pediatric stroke: do clinical factors predict delays in presentation?

OBJECTIVE: To explore associations between age, clinical presentation, or predisposing conditions and delayed diagnosis of arterial ischemic stroke. STUDY DESIGN: This was a retrospective chart review of children admitted to tertiary care medical centers in San Diego County between 1995 and 2000. Inpatient charts were screened by ICD-9 codes for stroke, cerebrovascular anomalies, hemiplegia, and migraine. RESULTS: Time of presentation for medical evaluation did not differ by age group, clinical presentation, or risk factors. There was no relationship between time of presentation and Glasgow Outcome Score. Only 24% (9/37) of the patients with ischemic stroke presented for clinical evaluation within 6 hours after onset of symptoms, and an additional 41% (13/37) presented within the first 24 hours. Children who initially presented with altered mental status were more likely to die than those with other initial presentations (odds ratio = 9.94; 95% confidence interval = 2.05 to 47.9), but none of the 16 children who presented with hemiparesis died (P = .01). CONCLUSION: Time of presentation was not related to the clinical factors studied. Early recognition of stroke in children is an important goal for families and health care providers.

HIV-positive poor women may stop breast-feeding early to protect their infants from HIV infection although available replacement diets are grossly inadequate.

Little is known about mothers' perspectives and experiences of early breast-feeding cessation as a strategy to reduce postnatal HIV transmission in rural, resource-constrained settings. We conducted in-depth interviews (IDI) with 15 HIV-positive breast-feeding mothers of infants aged 3-5 mo about their plans for feeding their infants after age 6 mo. We also conducted IDI with 12 HIV-positive mothers who intended to stop breast-feeding after receiving their infant's HIV-PCR negative test result at age 6 mo. Twenty-four-hour dietary recalls were conducted with the same 12 mothers and 16 HIV-negative or status unknown mothers who were breast-feeding their 6- to 9-mo-old infants. Of the 12 mothers who intended to stop breast-feeding, 11 did so by 9 mo. Median energy intake (percent requirement) was 1382 kJ (54%) among weaned infants compared with 2234 kJ (87%) among breast-feeding infants. Median intakes were <67% of the recommended levels for 9 and 7 of the 12 micronutrients assessed for weaned and breast-feeding infants, respectively. Factors facilitating early breast-feeding cessation were mothers' knowledge about HIV transmission, family support, and disclosure of their HIV status; food unavailability was the primary barrier. HIV-positive mothers in resource-constrained settings may be so motivated to protect their child from HIV that they stop breast-feeding early even when they cannot provide an adequate replacement diet. As reflected in the new World Health Organization guidance, HIV-positive mothers should continue breastfeeding their infants beyond 6 mo if replacement feeding is still not acceptable, feasible, affordable, sustainable, and safe.

Prescribing patterns and awareness of adverse effects of infliximab: a health survey of gastroenterologists.

We sought to determine prescribing patterns and awareness of adverse drug reactions to infliximab among gastroenterologists. A questionnaire was developed and mailed to all gastroenterologists in Maryland and Washington, D.C. Ninety-six of 336 (28.6%) gastroenterologists responded; 86% of respondents use infliximab often or sometimes and 48% infuse infliximab on-site. Only 48% of respondents use immunomodulators prior to infusing infliximab. Thirty-three percent of respondents do not prescribe maintenance infliximab. Respondents reported that infusion reactions occur in 12.9% of infliximab infusions. Most respondents order a purified protein derivative prior to starting infliximab. Respondents underestimated the risk of serious infection, death, demyelinating diseases, and malignancy and overestimated the risk of congestive heart failure. We conclude that a substantial number of gastroenterologists underutilize immunomodulators and fail to prescribe maintenance infliximab. Further, respondents were unaware of the frequency of major adverse events associated with infliximab. Education regarding treatment algorithms in CD and infliximab-related side effects is needed.

An education and counseling program for preventing breast-feeding-associated HIV transmission in Zimbabwe: design and impact on maternal knowledge and behavior.

International guidance on HIV and infant feeding has evolved over the last decade. In response to these changes, we designed, implemented, and evaluated an education and counseling program for new mothers in Harare, Zimbabwe. The program was implemented within the ZVITAMBO trial, in which 14,110 mother-baby pairs were enrolled within 96 h of delivery and were followed at 6 wk, 3 mo, and 3-mo intervals. Mothers were tested for HIV at delivery but were not required to learn their test results. Infant feeding patterns were determined using data provided up to 3 mo. Formative research was undertaken to guide the design of the program that included group education, individual counseling, videos, and brochures. The program was introduced over a 2-mo period: 11,362, 1311, and 1437 women were enrolled into the trial before, during, and after this period. Exclusive breast-feeding was recommended for mothers of unknown or negative HIV status, and for HIV-positive mothers who chose to breast-feed. A questionnaire assessing HIV knowledge and exposure to the program was administered to 1996 mothers enrolling after the program was initiated. HIV knowledge improved with increasing exposure to the program. Mothers who enrolled when the program was being fully implemented were 70% more likely to learn their HIV status early (<3 mo) and 8.4 times more likely to exclusively breast-feed than mothers who enrolled before the program began. Formative research aided in the design of a culturally sensitive intervention. The intervention increased relevant knowledge and improved feeding practices among women who primarily did not know their HIV status.

Generic evaluation methods for disaster drills in developing countries.

Disaster simulations (drills) are widely used throughout the world and are considered a fundamental tool for evaluation and improvement of local disaster response capacity. Despite this, no generally accepted methodology exists for quantitative evaluation of the medical response to a disaster drill. We therefore set out to develop and prospectively test a comprehensive method to assess both medical provider and organizational performance during a disaster simulation. Because disasters disproportionately affect the populations of developing countries, we designed these methods to be sufficiently flexible to be applicable in both the developed and the developing world. Objective outcome measures were identified for each component of disaster medical response and were incorporated into 3 data collection instruments. The derived methods were applied to a multiagency disaster simulation in Guatemala City, Guatemala. On the basis of this pilot study, suggested modifications and recommendations were made. The ability to objectively identify the specific strengths and weaknesses of an emergency medical services systems' medical response to a disaster is an important step toward optimizing system performance. On the basis of our experience, we recommend the incorporation of objective evaluation methods such as these into every disaster simulation.