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Abbas S, Chokotho L, Nyamulani N, Oliver VL. The burden of long bone fracture and health system response in Malawi: A scoping review. Injury 2024; 55:111243. [PMID: 38096746 DOI: 10.1016/j.injury.2023.111243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/16/2023] [Accepted: 11/24/2023] [Indexed: 01/29/2024]
Abstract
OBJECTIVES Fractures pose serious health and socioeconomic consequences for individuals, their families, and societies more broadly. In many low-resource settings, case fatality and long-term sequelae after a fracture remain high due to individual- and system-level barriers affecting timely access to care. This scoping review explored the burden of fractures in Malawi using long bone fracture (LBF) as a case study by examining the epidemiology of these injuries, their consequences, and the accessibility of quality healthcare. Our aim is to not only describe the scale of the issue but to identify specific interventions that can help address the challenges faced in settings with limited resources and healthcare budgets. METHODS A scoping review methodology was adopted with a narrative synthesis of results. We searched five databases to identify relevant literature and applied the "Three Delays" model and the WHO's Building Blocks Framework to analyse findings on the accessibility of fracture care. RESULTS Fractures most often occurred among young males, with falls being the leading cause, constituting between 5 and 35 % of the total burden of injuries. Fractures were typically managed without surgery despite consistent local evidence showing surgical treatment was superior to conservative management in terms of length of hospital stay and bone healing. Poor functional, economic, and social outcomes were noted in fracture patients, especially after conservative treatment. A lack of trust in the health system, financial barriers, poor transport, and road infrastructure, and interfacility transfers were identified as barriers to care-seeking. Factors challenging the provision of appropriate care included governance issues, poor health infrastructure, financial constraints, and shortage of supplies and human resources. CONCLUSIONS To the best of our knowledge, this review represents the first comprehensive examination of the state of LBF and the health system's response in Malawi. The findings underscore the pressing need for a national trauma registry to accurately determine the actual burden of injuries and support a tailored approach to fracture care in Malawi. It is further evident that the health system in Malawi must be strengthen across all six building blocks to address obstacles to equitable access to high-quality fracture care.
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Affiliation(s)
- Shazra Abbas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia.
| | - Linda Chokotho
- Malawi University of Science and Technology, Mikolongwe, Malawi
| | | | - Victoria L Oliver
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Australia
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Sabigaba M, Jing L, Mbanjumucyo G, Mumporeze L, Beeman A, Martin KD. Epidemiology and outcomes of geriatric trauma patients consulting at the center hospitalier universitaire de Kigali emergency department. Afr J Emerg Med 2023; 13:221-224. [PMID: 37662070 PMCID: PMC10470277 DOI: 10.1016/j.afjem.2023.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 08/01/2023] [Accepted: 08/07/2023] [Indexed: 09/05/2023] Open
Abstract
Background Life expectancy in low- and middle-income countries (LMIC) continues to rise, resulting in a growing geriatric population. In Rwanda, a sub-Saharan LMIC, traumatic injuries are a common cause of mortality and morbidity. However, little is known about the frequency and type of traumatic injuries among geriatric populations in Rwanda. Objective We explored the epidemiology and outcomes of trauma for geriatric patients presenting to the emergency department (ED) of the center Hospitalier Universitaire de Kigali (CHUK) in Rwanda. Methods This prospective cross-sectional study was conducted from July 2019 to January 2020 at the ED of CHUK. Trauma patients aged 65 and above and alive at the time of evaluation were eligible for inclusion. Demographic characteristics were collected along with triage category, mechanism of injury, transfer status, transport method to CHUK, time spent at the ED, complications, and mortality predictors. Results For the 100 patients enrolled, the most common injury mechanism was falls (63%), followed by road traffic accidents (28%). The majority of patients spent less than 48 h in the ED (63%). The mortality rate was 14%, with most deaths resulting from injury-related complications. Triage category, Kampala Trauma Score, and Glasgow Coma Scale were significant predictors of mortality, with p-values of 0.002, <0.001, and <0.001, respectively. Conclusions The epidemiology of geriatric trauma found in this study can inform public health and clinical guidelines. Interventions targeting falls and road traffic accidents would target the most common geriatric trauma mechanisms, and clinical protocols that take into account predictors of mortality could improve outcomes and increase life expectancy for this population.
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Affiliation(s)
- Martin Sabigaba
- Department of Emergency Medicine, University of Rwanda, Kigali, Rwanda
| | - Ling Jing
- Case Western Reserve University School of Medicine, United States
| | - Gabin Mbanjumucyo
- Department of Emergency Medicine, King's College Hospital, London, United Kingdom
| | - Lise Mumporeze
- Department of Emergency Medicine, King Faisal Hospital, Kigali, Rwanda
- School of Medicine, University of Rwanda, Kigali, Rwanda
| | - Aly Beeman
- Department of Emergency Medicine, University of Rwanda, Kigali, Rwanda
| | - Kyle D. Martin
- Department of Emergency Medicine, The Warren Alpert School of Brown University, United States
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Ding K, Sur PJ, Mbianyor MA, Carvalho M, Oke R, Dissak-Delon FN, Signe-Tanjong M, Mfopait FY, Essomba F, Mbuh GE, Etoundi Mballa GA, Christie SA, Juillard C, Chichom Mefire A. Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study. BMJ Open 2022; 12:e056433. [PMID: 35383070 PMCID: PMC8984008 DOI: 10.1136/bmjopen-2021-056433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES In Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death and disability in Cameroonian trauma patients over a 6-month period after hospital discharge. DESIGN Prospective cohort study. SETTING Four hospitals in the Littoral and Southwest regions of Cameroon. PARTICIPANTS A total of 1914 patients entered the study, 1304 were successfully contacted. Inclusion criteria were patients discharged after being treated for traumatic injury at each of four participating hospitals during a 20-month period. Those who did not possess a cellular phone or were unable to provide a phone number were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES The Glasgow Outcome Scale-Extended (GOSE) was administered to trauma patients at 2 weeks, 1 month, 3 months and 6 months post discharge. Median GOSE scores for each timepoint were compared and regression analyses were performed to determine associations with death and disability. RESULTS Of 71 deaths recorded, 90% occurred by 2 weeks post discharge. At 6 months, 22% of patients still experienced severe disability. Median (IQR) GOSE scores at the four timepoints were 4 (3-7), 5 (4-8), 7 (4-8) and 7 (5-8), respectively, (p<0.01). Older age was associated with greater odds of postdischarge disability (OR: 1.23, 95% CI: 1.07 to 1.41) and mortality (OR: 2.15, 95% CI: 1.52 to 3.04), while higher education was associated with decreased odds of disability (OR: 0.65, 95% CI: 0.58 to 0.73) and mortality (OR: 0.38, 95% CI: 0.31 to 0.47). Open fractures (OR: 1.73, 95% CI: 1.38 to 2.18) and closed fractures (OR: 1.83, 95% CI: 1.42 to 2.36) were associated with greater postdischarge disability, while higher Injury Severity Score (OR: 2.44, 95% CI: 2.13 to 2.79) and neurological injuries (OR: 4.40, 95% CI: 3.25 to 5.96) were associated with greater odds of postdischarge mortality. CONCLUSION Mobile follow-up data show significant morbidity and mortality, particularly for orthopaedic and neurologic injuries, up to 6 months following trauma discharge. These results highlight the need for reliable follow-up systems in Cameroon.
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Affiliation(s)
- Kevin Ding
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | - Patrick J Sur
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
- Riverside School of Medicine, University of California, Riverside, California, USA
| | | | - Melissa Carvalho
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | - Rasheedat Oke
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | | | | | - Florentine Y Mfopait
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| | - Frank Essomba
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| | - Golda E Mbuh
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
| | | | - S Ariane Christie
- Department of Trauma and Acute Care Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Catherine Juillard
- Department of Surgery, Program for the Advancement of Surgical Equity, University of California Los Angeles, Los Angeles, California, USA
| | - Alain Chichom Mefire
- Department of Surgery, University of Buea Faculty of Health Sciences, Buea, Cameroon
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Breedt DS, Steyn E. Geriatric Trauma in a High-Volume Trauma Centre in Cape Town: How Do We Compare? World J Surg 2022; 46:582-590. [PMID: 34994839 DOI: 10.1007/s00268-021-06416-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Little is known about the injury profile of older persons from low-and-middle-income countries, such as South Africa, where violence is prevalent. This study aimed to identify common mechanisms of injury (MOI), severity, complications, and outcomes in elderly patients admitted to a referral trauma centre in Cape Town. METHODS A retrospective review was performed of all patients ≥60 years presenting at Tygerberg hospital trauma centre over an eight-month period. Descriptive statistics were computed for all variables of interest, and the relationship between the MOI, injury severity score (ISS), complications, and outcomes were assessed. RESULTS Of the total 7,635 trauma cases admitted, patients ≥60 years accounted for 4% (n = 275). The most frequent MOI was low falls (58%). Of these 11% of injuries were intentionally inflicted. Among them 35% of the patients experienced complications. The ISS was positively associated with the number of complications (p < 0.01). The mortality rate was 6.5%. An ISS of ≥10 was associated with increased mortality (p < 0.01). The number of complications was positively associated with mortality (p < 0.01). CONCLUSIONS In contrast to high-income countries (HICs), the cohort of elderly patients admitted to the trauma centre made up a relatively small portion of the total admissions. Compared to HICs, intentionally inflicted injuries and preventable MOI were common in our sample, underscoring the importance of addressing causative factors. Notably, the ISS was strongly associated with the number of complications and an ISS ≥10 was associated with mortality, highlighting the utility of the ISS in identifying elderly trauma patients most at risk of negative outcomes.
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Affiliation(s)
- Danyca Shadé Breedt
- Faculty of Medicine & Health Science, Stellenbosch University, Francie van Zijl Drive, Cape Town, South Africa.
| | - Elmin Steyn
- Division of Surgery, Stellenbosch University & Tygerberg Hospital, Francie van Zijl Drive, Cape Town, South Africa
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Elderly trauma mortality in a resource-limited setting: A benchmark for process improvement. Injury 2021; 52:2651-2656. [PMID: 34272049 PMCID: PMC8429241 DOI: 10.1016/j.injury.2021.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 06/07/2021] [Accepted: 07/01/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION As life expectancy improves globally, the burden of elderly trauma continues to increase. Sub-Saharan Africa is projected to have the most rapid growth in its elderly demographic. Consequently, we sought to examine the trends in characteristics and outcomes of elderly trauma in a tertiary care hospital in Malawi. METHODS We performed a retrospective analysis of adult patients in the trauma registry at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi from 2011-2017. Patients were categorized into elderly (≥ 65 years) and non-elderly (18-64 years). Bivariate analysis compared the characteristics and outcomes of elderly vs. non-elderly patients. The elderly population was then examined over the study period. Poisson regression modeling was used to determine the risk of mortality among elderly patients over time. RESULTS Of 63,699 adult trauma patients, 1,925 (3.0%) were aged ≥ 65 years. Among the elderly, the most common mechanism of injury was falls (n = 725 [37.7%]) whereas vehicle or bike collisions were more common in the non-elderly (n = 15,967 [25.9%]). Fractures and dislocations were more prevalent in the elderly (n = 808 [42.0%] vs. 9,133 [14.8%], p < 0.001). In-hospital crude mortality for the elderly was double the non-elderly group (4.8% vs. 2.4%, p < 0.001). Elderly transfers, surgeries, and length of stay significantly increased over the study period but mortality remained relatively unchanged. When adjusted for injury severity and transfer status, there was no significant difference in risk of in-hospital mortality over time. CONCLUSION At KCH, the proportion of elderly trauma patients is slowly increasing. Although healthcare resource utilization has increased over time, the overall trend in mortality has not improved. As the quality of care for the most vulnerable populations is a benchmark for the success of a trauma program, further work is needed to improve the trend in outcomes of the elderly trauma population in Malawi.
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Gallaher J, Jefferson M, Varela C, Maine R, Cairns B, Charles A. The Malawi trauma score: A model for predicting trauma-associated mortality in a resource-poor setting. Injury 2019; 50:1552-1557. [PMID: 31301812 DOI: 10.1016/j.injury.2019.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 06/20/2019] [Accepted: 07/05/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. Current tools for predicting trauma-associated mortality are often not applicable in low-resource environments due to a lack of diagnostic adjuncts. This study sought to derive and validate a model for predicting mortality that requires only a history and physical exam. METHODS We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi from 2011 through 2014. Using statistical randomization, 80% of patients were used for derivation and 20% were used for validation. Logistic regression modeling was used to derive factors associated with mortality and the Malawi Trauma Score (MTS) was constructed. The model fitness was tested. RESULTS 62,354 patients are included. Patients are young (mean age 23.0, SD 15.9 years) with a male preponderance (72%). Overall mortality is 1.8%. The MTS is tabulated based on initial mental status (alert, responds to voice, responds only to pain or worse), anatomical location of the most severe injury, the presence or absence of a radial pulse on examination, age, and sex. The score range is 2-32. A mental status exam of only responding to pain or worse, head injury, the absence of a radial pulse, extremes of age, and male sex all conferred a higher probability of mortality. The ROC area under the curve for the derivation cohort and validation cohort were 0.83 (95% CI 0.78, 0.87) and 0.83 (95% CI 0.75, 0.92), respectively. A MTS of 25 confers a 50% probability of death. CONCLUSIONS The MTS provides a reliable tool for trauma triage in sub-Saharan Africa and helps risk stratify patient populations. Unlike other models previously developed, its strength is its utility in virtually any environment, while reliably predicting injury- associated mortality.
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Affiliation(s)
- Jared Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Malcolm Jefferson
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Rebecca Maine
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Bruce Cairns
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi; North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina School of Medicine, CB# 7600, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi; North Carolina Jaycee Burn Center, Department of Surgery, University of North Carolina School of Medicine, CB# 7600, Chapel Hill, NC, USA.
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Laytin AD, Seyoum N, Azazh A, Zewdie A, Juillard CJ, Dicker RA. Feasibility of telephone-administered interviews to evaluate long-term outcomes of trauma patients in urban Ethiopia. Trauma Surg Acute Care Open 2018; 3:e000256. [PMID: 30588508 PMCID: PMC6280902 DOI: 10.1136/tsaco-2018-000256] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Little is known about long-term functional outcomes of trauma patients in low-income and middle-income countries. In sub-Saharan Africa most studies of injury only collect data through emergency department disposition or hospital discharge, and methods of collecting long-term data are subject to significant bias. With the recent increase in access to mobile telephone technology, we hypothesized that structured, telephone-administered interviews now offer a feasible means to collect data about the long-term functional outcomes of trauma patients in urban Ethiopia. Methods We piloted a telephone-administered interview tool based on the Glasgow Outcome Scale-Extended. Using departmental logbooks, 400 consecutive patients presenting to two public referral hospitals were identified retrospectively. Demographics, injury data, and telephone numbers were collected from medical records. When a telephone number was available, patients or their surrogates were contacted and interviewed 6 months after their injuries. Results We were able to contact 47% of subjects or their surrogates, and 97% of those contacted were able and willing to complete an interview. At 6-month follow-up, 22% of subjects had significant persistent functional disability. Many injuries had an ongoing financial impact, with 17% of subjects losing or changing jobs, 18% earning less than they had before their injuries, and 16% requiring ongoing injury-related medical care. Lack of documented telephone numbers and difficulty contacting subjects at recorded telephone numbers were the major obstacles to data collection. Language barriers and respondents’ refusal to participate in the study were not significant limitations. Discussion In urban Ethiopia, many trauma patients have persistent disability 6 months after their injuries. Telephone-administered interviews offer a promising method of collecting data about the long-term trauma outcomes, including functional status and the financial impact of injury. These data are invaluable for capacity building, quality improvement efforts, and advocacy for injury prevention and trauma care. Level of evidence III, retrospective cohort study.
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Affiliation(s)
- Adam D Laytin
- Center for Global Surgical Studies, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nebyou Seyoum
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Aklilu Azazh
- Department of Emergency Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ayalew Zewdie
- Department of Emergency Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Catherine J Juillard
- Center for Global Surgical Studies, Department of Surgery, University of California San Francisco, San Francisco, California, USA
| | - Rochelle A Dicker
- Center for Global Surgical Studies, Department of Surgery, University of California San Francisco, San Francisco, California, USA
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Jingi AM, Kuate LM, Noubiap JJ. A case management of hypertension in the elderly in sub-Sahara Africa: lessons from Granny. Pan Afr Med J 2017; 26:165. [PMID: 28533886 PMCID: PMC5429443 DOI: 10.11604/pamj.2017.26.165.10660] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 03/04/2017] [Indexed: 11/11/2022] Open
Abstract
Management of chronic disease conditions in the elderly is challenging. They usually have many co-morbidities requiring multiple drug regimens, and memory or cognitive problems that can interfere with management. Also, they sometimes have a degree of social problems as they might often live alone, and thereby cater for their daily activities with minimal assistance. Multiple drug use combined with their fragile health predispose them to adverse drug reactions, drug-drug interactions, and direct drug toxicity from overdosing. We report and discuss the lessons learnt from the case of an elderly woman in an urban setting in sub-Saharan Africa who presented with problems of drug dosing, adverse drug effect, and drug-drug interaction that might prove useful in the future management of hypertension with angiotensin converting enzyme inhibitors.
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Affiliation(s)
- Ahmadou Musa Jingi
- Department of Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Liliane Mfeukeu Kuate
- Department of Medicine and Specialties, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon.,Cardiology Unit, Department of Internal Medicine, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Jean Jacques Noubiap
- Department of Medicine, Groote Schuur Hospital and University of Cape town, Cape Town, South Africa.,Medical Diagnostic Centre, Yaoundé, Cameroon
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