Emergency and surgery services of primary hospitals in the United Republic of Tanzania.

OBJECTIVE: The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services. DESIGN: Cross-sectional survey. SETTING: First-referral health facilities in the United Republic of Tanzania. PARTICIPANTS: 48 health facilities. MEASURES: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment. RESULTS: The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available. CONCLUSIONS: Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Diagnosis and treatment of craniocervical dissociation in 48 consecutive survivors.

STUDY TYPE: Case series Introduction: Craniocervical dissociation (CCD) is an uncommon and frequently fatal injury with few reports in the literature of survivors. Advances in automobile safety and improved emergency medical services have resulted in increased survival. Timely diagnosis and treatment are imperative for optimal outcome. Regrettably, the presence of multiple life threatening injuries, low clinical suspicion, and lack of familiarity with the upper cervical radiographic anatomy frequently lead to missed or delayed diagnosis. OBJECTIVE: This paper represents the largest series of surgically treated CCD survivors. The goal of this study is to determine if any improvements have been made in the timely diagnosis of CCD while performing a complete patient evaluation. METHODS: Following institutional review board approval, a search of the Harborview Medical Center (HMC) trauma registry was conducted for all surgically treated CCD patients between 1996 and 2008. Forty-eight consecutive cases were identified. A retrospective review of the radiological and clinical results with emphasis on timing of diagnosis, modality used for diagnosis (Figures 1 and 2), clinical effect of delayed diagnosis, potential clinical or imaging warning signs, and response to treatment was performed. Thirty-one patients treated from 2003 to 2008 were compared to 17 patients that were treated from 1996 to 2002 and reported previously.1 Figure 1 Initial lateral C-spine radiograph obtained as part of the initial ATLS survey demonstrating an occiput C1 distractive injury.Figure 2 Sagittal C-spine CT scan obtained as part of the initial ATLS survey demonstrating an occiput C2 distractive injury. All patients sustained high-energy injuries and were evaluated according to standard Advanced Trauma Life Support (ATLS) protocols. Once CCD was identified or suspected, provisional stabilization was applied and MRI evaluation performed (Figure 3). Definitive surgical management with rigid posterior instrumentation and fusion was performed as soon as physiologically possible (Figures 4 and 5). Figure 3a-b Preoperative coronal T2 MRI sequences demonstrating increased signal intensity on the occiput-C1 and C1-2 joints.Figure 4 Postoperative lateral C-spine x-ray showing rigid posterior instrumented fusion from occiput to C2.Figure 5 Postoperative sagittal C-spine x-ray showing rigid posterior instrumented fusion from occiput to C2. RESULTS: Craniocervical dissociation was identified on initial cervical spine imaging in 26 patients (84%). The remaining five patients (16%) were diagnosed by cervical spine MRI. Twenty-three patients (74.2%) were diagnosed within 24 hours of presentation, four (22.6%) were diagnosed between 24 and 48 hours, and one (3.2%) experienced a delay of greater than 48 hours (Table 1). In comparison, four (24%) of the previously treated 17 patients were diagnosed on initial cervical spine imaging. Four patients (24%) were diagnosed within 24 hours of presentation, nine (52%) were diagnosed between 24 and 48 hours, and four (24%) experienced a delay of greater than 48 hours. There were no cases of craniocervical pseudarthrosis or hardware failure during a mean nine-month follow-up period. Four patients expired during their hospital course. The mean American Spinal Injury Association (ASIA) motor score of 47 improved to 60, and the number of patients with useful motor function (ASIA Grade D or E) increased from eight (26%) preoperatively to 17 (55%) postoperatively. CONCLUSIONS: Improvements have been made in time to diagnosis of CCD in recent years. Increased awareness and the routine use of CT scan as part of the initial ATLS evaluation account for this progress. Expedited diagnosis has decreased preoperative neurological deterioration. However, differences in length of follow-up between the two groups preclude conclusions about its effect on long-term neurological outcome. [Table: see text].

Clinical and histologic results related to a low-modulus composite total hip replacement stem.

BACKGROUND: Osteolysis secondary to stress shielding in patients with a total hip arthroplasty has been attributed to greater stiffness of the prosthetic femoral stem compared with the stiffness of the femur. This concern led to the development of a composite femoral stem implant with a structural stiffness similar to that of the native femur. The stem consists of a cobalt-chromium-alloy core surrounded by polyaryletherketone and titanium mesh for bone ingrowth. The purpose of this study was to determine the intermediate-term clinical, radiographic, and histologic results of the use of this stem. METHODS: Twenty-eight patients (nineteen men and nine women) with an average age of 51.3 years underwent primary total hip arthroplasty with the Epoch stem and were followed for an average of 6.2 years. Harris hip scores were determined and radiographic studies were performed preoperatively, postoperatively, and at two-year intervals thereafter. In addition, dual x-ray absorptiometry scans were made up to two years postoperatively to evaluate osseous resorption. Two femora obtained at autopsy thirteen and forty-eight months after surgery were analyzed for bone ingrowth and ongrowth. RESULTS: The Harris hip scores averaged 56 points preoperatively and improved to 97 points at the time of the last follow-up. Dual x-ray absorptiometry scans demonstrated the greatest decrease in mean bone density (27.5%) in Gruen zone 7 at two years. Radiographs demonstrated no instances of migration, and only one hip had osteolysis. All stems had stable osseous fixation. Histologic evaluation of the two femora that had been retrieved at autopsy at thirteen and forty-eight months showed the mean bone ingrowth (and standard deviation) along the entire length of the stem to be 49.62% +/- 13.04% and 73.57% +/- 8.48%, respectively, and the mean bone ongrowth to be 54.18% +/- 7.68% and 80.92% +/- 6.06%, respectively. CONCLUSIONS: Intermediate-term follow-up of hips treated with the Epoch stem indicated excellent clinical success, radiographic evidence of osseous integration, and histologic findings of osseous ingrowth and ongrowth. Although the implant has been associated with excellent results in both the short and the intermediate term, longer follow-up will be necessary to assess the long-term function of the implant.