Upper extremity injury management by non-physician emergency practitioners in rural Uganda: a pilot study

Introduction: Improper management of and resultant poor outcomes from upper extremity injuries can be economically devastating to patients who rely on manual labour for survival. This is a pilot study using the Quick DASH Survey (disabilities of arm; shoulder and hand); a validated outcome measurement tool. Our objective was to assess functional outcomes of patients with acute upper extremity injuries who were cared for by non-physician clinicians as part of a task-shifting programme. Methods :This pilot study was performed at the Karoli Lwanga Hospital Emergency Centre (EC) in Uganda. Patients were identified retrospectively by querying the EC quality assurance database. An initial list of all patients who sustained traumatic injury (road traffic accident; assault) between March 2012 and February 2013 was narrowed to patients with upper extremity trauma; those 18 years and older; and those with cellular phone access. This subset of patients was called and administered the Quick DASH. The results were subsequently analysed using the standardised DASH metrics. These outcome measures were further analysed based upon injury type (simple laceration; complex laceration; fracture and subluxation). Results :There were a total of 25 initial candidates; of which only 17 were able to complete the survey. Using the Quick DASH Outcome Measure; our 17 patients had a mean score of 28.86 (range 5.0-56.8). Conclusions : When compared to the standardised Quick DASH outcomes (no work limitation at 27.5 vs. work limited by injury at 52.6) the non-physician clinicians appear to be performing upper extremity repairs with good outcomes. The key variable to successful repair was the initial injury type. Although accommodations needed to be made to the standard Quick DASH protocol; the tool appears to be usable in non-traditional settings

Surgical management of primary breast sarcoma.

Primary sarcoma constitutes less than one per cent of breast malignancies. A retrospective review of this disease at our institution was undertaken to assess the effect of different treatment modalities on outcome. Over a 24-year period 28 patients were identified. Follow-up ranged from one to 228 months. Partial mastectomy was done in seven patients, whereas ten underwent total mastectomy and nine had modified radical mastectomy. Two refused surgery. All margins of resection were negative. In total ten axillary lymph node dissections were done with no positive nodes identified. Pathologic analysis of tumors revealed a variety of sarcomas including high-grade malignant cystosarcoma phyllodes in 13. Recurrence of disease occurred in two women, both with malignant cystosarcoma phyllodes. One was a local recurrence in a patient who had undergone partial mastectomy. This was successfully treated with a total mastectomy. The second recurrence involved a distant metastasis in a patient treated with modified radical mastectomy that eventually led to her death. For the entire group the disease-free survival was 75 per cent at 10 years whereas overall survival was 87.5 per cent. In conclusion an adequate margin of resection is the single most important determinant of long-term survival. Axillary lymph node dissection is not necessary for the treatment of these tumors.