Blair J. Smart

Peritonitis in Rwanda: Epidemiology and risk factors for morbidity and mortality

BACKGROUND Few studies discuss causes and outcomes of peritonitis in low-income settings. This study describes epidemiology of patients with peritonitis at a Rwandan referral hospital. Identification of risk factors associated with mortality and unplanned reoperation could improve management of peritonitis. METHODS Data were collected on demographics, clinical presentation, operative findings, and outcomes for all patients with peritonitis. Multivariate regression analysis identified factors associated with in-hospital mortality and unplanned reoperation. RESULTS A total of 280 patients presented with peritonitis over a 6-month period. Causes of peritonitis were complications of intestinal obstruction (39%) and appendicitis (17%). Thirty-six (13%) patients required unplanned reoperation, and in-hospital mortality was 17%. Factors associated with increased odds of in-hospital mortality were unplanned reoperation (adjusted odds ratio 34.12), vasopressor use (adjusted odds ratio 24.91), abnormal white blood cell count (adjusted odds ratio 12.6), intensive care unit admission (adjusted odds ratio 9.06), and American Society of Anesthesiologist score ≥3 (adjusted odds ratio 7.80). Factors associated with increased odds of unplanned reoperation included typhoid perforation (adjusted odds ratio 5.92) and hypoxia on admission (adjusted odds ratio 3.82). CONCLUSION Peritonitis in Rwanda presents with high morbidity and mortality. Minimizing delays in care is important, as many patients with intestinal obstruction present with features of peritonitis. A better understanding of patient care and management prior to arrival at the referral hospital is needed to identify areas for improvement at the health center and district hospital.

United States trends in thrombolysis for older adults with acute ischemic stroke

OBJECTIVE Thrombolysis for ischemic stroke has been increasing in the United States. We sought to investigate recent trends in thrombolysis use in older adults. METHODS A retrospective, observational analysis of hospitalization data from the Nationwide Inpatient Sample (NIS) in 2005-2010 was performed. Older adults (≥65 years) admitted with a primary diagnosis of acute ischemic stroke were included. Trends in the population-based rates of thrombolysis and outcomes from the NIS were evaluated using the Cochran-Armitage test. RESULTS Thrombolysis in older adult stroke patients increased from 1.7% to 5.4% (2005-2010; trend P<0.001). Large increases were observed among urban patients, urban hospitals, and high volume facilities. Individuals ≥85 years were less likely to receive thrombolysis than younger ages throughout the study period, although there was an increase from an odds ratio of 0.50 (95% CI: 0.44-0.57) to 0.75 (95% CI: 0.69-0.81) from 2005-2006 to 2009-2010 when compared to 65-74 year olds. For those receiving thrombolysis, no change was observed in intracerebral hemorrhage over time. In-hospital mortality rates did not change significantly over the study period for age subgroups and length of stay declined from 2005 to 2010 for the thrombolysis group (7.6 vs 7.0 days; trend P<0.001). CONCLUSIONS Rates of thrombolysis in older adults progressively increased, especially in the oldest old. Increases were largely driven by urban and high volume hospitals.

Critical Care Management of Peritonitis in a Low-Resource Setting

BackgroundManagement of critically ill patients is challenging in a low-resource setting. In Rwanda, peritonitis is a common surgical condition where patients often present late, with advanced disease. We aim to describe critical care management of patients with peritonitis in Rwanda.MethodsData were collected at a tertiary referral hospital in Rwanda on patients undergoing operation for peritonitis over a 6-month period. Data included epidemiology, hospital course and outcomes. Patients requiring admission to the intensive care unit (ICU) were compared with those not requiring ICU admission using Chi-square and Wilcoxon rank-sum test.ResultsOver a 6-month period, 280 patients were operated for peritonitis. Of these, 46 (16.4%) were admitted to the ICU. The most common diagnoses were intestinal obstruction (N = 17, 37.0%) and typhoid intestinal perforation (N = 6, 13.0%). Thirty-nine (89%) patients had sepsis. The median American Society of Anesthesiologist score was 3 (range 2–4), and the median Surgical Apgar Score was 4 (range 0–6). Twenty-four (52.2%) patients required vasopressors, with dopamine and adrenaline being the only vasopressors available. Patients admitted to the ICU, compared with non-critically ill patients, were more likely to have major complications (80.4 vs. 14%, p < 0.001), unplanned reoperation (28 vs. 10%, p < 0.001) and death (72 vs. 8%, p < 0.001).ConclusionPatients with peritonitis admitted to the ICU commonly presented with features of sepsis. Due to limited resources in this setting, interventions are primarily supportive with intravenous fluids, intravenous antibiotics, ventilator support and vasopressors. Morbidity and mortality remain high in this patient population.

Conscious status is associated with the likelihood of trauma centre care and mortality in patients with moderate-to-severe traumatic brain injury

ABSTRACT Objective: To assess the relationship between The International Classification of Diseases, Ninth Revision, Clinical Modification-derived conscious status and mortality rates in trauma centres (TC) vs. non-trauma centres (NTC). Methods: Patients in the 2006–2011 Nationwide Emergency Department Sample meeting, The Centers for Disease Control and Prevention criteria for traumatic brain injury (TBI), with head/neck Abbreviated Injury Scale (AIS) scores ≥3 were included. Loss of consciousness (LOC) was computed for each patient. Primary outcomes included treatment at a level I/II TC vs. NTC and in-hospital mortality. We compared logistic regression models controlling for patient demographics, injury characteristics, and AIS score with identical models that also included LOC. Results: Of 66,636 patients with isolated TBI identified, 15,761 (23.6%) had missing LOC status. Among the remaining 50,875 patients, 59.0% were male, 54.0% were ≥65 years old, 56.7% were treated in TCs, and 27.3% had extended LOC. Patients with extended LOC were more likely to be treated in TCs vs. those with no/brief LOC (71.1% vs. 51.4%, p < 0.001). Among patients aged <65, TC treatment was associated with increased odds of mortality [Adjusted Odds Ratio (AOR) 1.79]; accounting for LOC substantially mitigated this relationship [AOR 1.27]. Similar findings were observed among older patients, with reduced effect size. Conclusion: Extended LOC was associated with TC treatment and mortality. Accounting for patient LOC reduced the differential odds of mortality comparing TCs vs. NTCs by 60%. Research assessing TBI outcomes using administrative data should include measures of consciousness.

A Faculty-Student Mentoring Program to Enhance Collaboration in Public Health Research in Surgery

procedures among the veteran population, correlating with the previous study. Simple mastectomies and breastconserving operations significantly increased, although a lower overall proportion of partial mastectomies was seen comparatively. Modified radical mastectomies rates showed a decreased trend, although this was not statistically significant. The modest decrease in modified radical mastectomies may represent a lag in progressive treatment or lack of access, associated with delayed treatment requiring more aggressive resection. Systems with multidisciplinary breast cancer programs have shown reconstruction rates of approximately 50% to 60%.5 There are only 7 VA hospitals providing oncologic breast surgery, with reconstruction rates ranging from 26% to 42% since 2007. Although reconstruction rates are increasing, expanding designated breast oncology/surgery programs with multidisciplinary approaches to treatment within the VA may be necessary to meet rising demands and decrease the number of “fee out” services. Free-flap breast reconstructions are also rising in academia, shown by Kadle et al.6 Interestingly, there was an increase in free-flap reconstructions performed in the VA, although the number remained quite low. With the technical difficulty of microsurgical reconstruction, increasing the number of microsurgical trained plastic surgeons in the VA should be considered. As the number of women in the military rises, it will be crucial to improve breast cancer treatment and reconstruction for veterans. Initiatives to expand access to breast oncologic and reconstructive surgeons, enhancing facilities, and improving women’s services will be essential in providing future quality care.

Tackling causes and costs of ED presentation for American football injuries: a population-level study

BACKGROUND American tackle football is the most popular high-energy impact sport in the United States, with approximately 9 million participants competing annually. Previous epidemiologic studies of football-related injuries have generally focused on specific geographic areas or pediatric age groups. Our study sought to examine patient characteristics and outcomes, including hospital charges, among athletes presenting for emergency department (ED) treatment of football-related injury across all age groups in a large nationally representative data set. METHODS Patients presenting for ED treatment of injuries sustained playing American tackle football (identified using International Classification of Diseases, Ninth Revision, Clinical Modification code E007.0) from 2010 to 2011 were studied in the Nationwide Emergency Department Sample. Patient-specific injuries were identified using the primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code and categorized by type and anatomical region. Standard descriptive methods examined patient demographics, diagnosis categories, and ED and inpatient outcomes and charges. RESULTS During the study period 397363 football players presented for ED treatment, 95.8% of whom were male. Sprains/strains (25.6%), limb fractures (20.7%), and head injuries (including traumatic brain injury; 17.5%) represented the most presenting injuries. Overall, 97.9% of patients underwent routine ED discharge with 1.1% admitted directly and fewer than 11 patients in the 2-year study period dying prior to discharge. The proportion of admitted patients who required surgical interventions was 15.7%, of which 89.9% were orthopedic, 4.7% neurologic, and 2.6% abdominal. Among individuals admitted to inpatient care, mean hospital length of stay was 2.4days (95% confidence interval, 2.2-2.6) and 95.6% underwent routine discharge home. The mean total charge for all patients was

Validation of the Surgical Apgar Score After Laparotomy at a Tertiary Referral Hospital in Rwanda

1941 (95% confidence interval,

Risk of Catastrophic Health Expenditure in Rwandan Surgical Patients with Peritonitis

1890-

Conscious status predicts mortality among patients with isolated traumatic brain injury in administrative data.

1992) with substantial injury type-specific variability. Overall, at the US population, estimated total charges of

Conscious status predicts mortality among patients with isolated traumatic brain injury in administrative data

771299862 were incurred over the 2-year period. CONCLUSION In this nationally representative sample, most ED-treated injuries associated with football were not acutely life threatening and very few required major therapeutic intervention. This study provides a cross-sectional overview of ED presentation for acute football-related injury across age groups at the population level in recent years. Longitudinal studies may be warranted to examine associations between the patterns of injury observed in this study and long-term outcomes among American tackle football players.