Mechanical and surgical interventions for treating primary postpartum haemorrhage

Background: Primary postpartum haemorrhage (PPH) is commonly defined as bleeding from the genital tract of 500 mL or more within 24 hours of birth. It is one of the most common causes of maternal mortality worldwide and causes significant physical and psychological morbidity. An earlier Cochrane Review considering any treatments for the management of primary PPH, has been split into separate reviews. This review considers treatment with mechanical and surgical interventions.

Objectives: To determine the effectiveness and safety of mechanical and surgical interventions used for the treatment of primary PPH.

Search methods: We searched Cochrane Pregnancy and Childbirth’s Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 July 2019) and reference lists of retrieved studies.

Selection criteria: Randomised controlled trials (RCTs) of mechanical/surgical methods for the treatment of primary PPH compared with standard care or another mechanical/surgical method. Interventions could include uterine packing, intrauterine balloon insertion, artery ligation/embolism, or uterine compression (either with sutures or manually). We included studies reported in abstract form if there was sufficient information to permit risk of bias assessment. Trials using a cluster-RCT design were eligible for inclusion, but quasi-RCTs or cross-over studies were not.

Data collection and analysis: Two review authors independently assessed studies for inclusion and risk of bias, independently extracted data and checked data for accuracy. We used GRADE to assess the certainty of the evidence.

Main results: We included nine small trials (944 women) conducted in Pakistan, Turkey, Thailand, Egypt (four trials), Saudi Arabia, Benin and Mali. Overall, included trials were at an unclear risk of bias. Due to substantial differences between the studies, it was not possible to combine any trials in meta-analysis. Many of this review’s important outcomes were not reported. GRADE assessments ranged from very low to low, with the majority of outcome results rated as very low certainty. Downgrading decisions were mainly based on study design limitations and imprecision; one study was also downgraded for indirectness. External uterine compression versus normal care (1 trial, 64 women) Very low-certainty evidence means that we are unclear about the effect on blood transfusion (risk ratio (RR) 2.33, 95% confidence interval (CI) 0.66 to 8.23). Uterine arterial embolisation versus surgical devascularisation plus B-Lynch (1 trial, 23 women) The available evidence for hysterectomy to control bleeding (RR 0.73, 95% CI 0.15 to 3.57) is unclear due to very low-certainty evidence. The available evidence for intervention side effects is also unclear because the evidence was very low certainty (RR 1.09; 95% CI 0.08 to 15.41). Intrauterine Tamponade Studies included various methods of intrauterine tamponade: the commercial Bakri balloon, a fluid-filled condom-loaded latex catheter (‘condom catheter’), an air-filled latex balloon-loaded catheter (‘latex balloon catheter’), or traditional packing with gauze. Balloon tamponade versus normal care (2 trials, 356 women) One study(116 women) used the condom catheter. This study found that it may increase blood loss of 1000 mL or more (RR 1.52, 95% CI 1.15 to 2.00; 113 women), very low-certainty evidence. For other outcomes the results are unclear and graded as very low-certainty evidence: mortality due to bleeding (RR 6.21, 95% CI 0.77 to 49.98); hysterectomy to control bleeding (RR 4.14, 95% CI 0.48 to 35.93); total blood transfusion (RR 1.49, 95% CI 0.88 to 2.51); and side effects. A second study of 240 women used the latex balloon catheter together with cervical cerclage. Very low-certainty evidence means we are unclear about the effect on hysterectomy (RR 0.14, 95% CI 0.01 to 2.74) and additional surgical interventions to control bleeding (RR 0.20, 95% CI 0.01 to 4.12). Bakri balloon tamponade versus haemostatic square suturing of the uterus (1 trial, 13 women) In this small trial there was no mortality due to bleeding, serious maternal morbidity or side effects of the intervention, and the results are unclear for blood transfusion (RR 0.57, 95% CI 0.14 to 2.36; very low certainty). Bakri balloon tamponade may reduce mean ‘intraoperative’ blood loss (mean difference (MD) -426 mL, 95% CI -631.28 to -220.72), very low-certainty evidence. Comparison of intrauterine tamponade methods (3 trials, 328 women) One study (66 women) compared the Bakri balloon and the condom catheter, but it was uncertain whether the Bakri balloon reduces the risk of hysterectomy to control bleeding due to very low-certainty evidence (RR 0.50, 95% CI 0.05 to 5.25). Very low-certainty evidence also means we are unclear about the results for the risk of blood transfusion (RR 0.97, 95% CI 0.88 to 1.06). A second study (50 women) compared Bakri balloon, with and without a traction stitch. Very low-certainty evidence means we are unclear about the results for hysterectomy to control bleeding (RR 0.20, 95% CI 0.01 to 3.97). A third study (212 women) compared the condom catheter to gauze packing and found that it may reduce fever (RR 0.47, 95% CI 0.38 to 0.59), but again the evidence was very low certainty. Modified B-Lynch compression suture versus standard B-Lynch compression suture (1 trial, 160 women) Low-certainty evidence suggests that a modified B-Lynch compression suture may reduce the risk of hysterectomy to control bleeding (RR 0.33, 95% CI 0.11 to 0.99) and postoperative blood loss (MD -244.00 mL, 95% CI -295.25 to -192.75).

Authors’ conclusions: There is currently insufficient evidence from RCTs to determine the relative effectiveness and safety of mechanical and surgical interventions for treating primary PPH. High-quality randomised trials are urgently needed, and new emergency consent pathways should facilitate recruitment. The finding that intrauterine tamponade may increase total blood loss > 1000 mL suggests that introducing condom-balloon tamponade into low-resource settings on its own without multi-system quality improvement does not reduce PPH deaths or morbidity. The suggestion that modified B-Lynch suture may be superior to the original requires further research before the revised technique is adopted. In high-resource settings, uterine artery embolisation has become popular as the equipment and skills become more widely available. However, there is little randomised trial evidence regarding efficacy and this requires further research. We urge new trial authors to adopt PPH core outcomes to facilitate consistency between primary studies and subsequent meta-analysis.

The ratio of shock index to pulse oxygen saturation predicting mortality of emergency trauma patients

Objective: To test the following hypothesis: the ratio of shock index to pulse oxygen saturation can better predict the mortality of emergency trauma patients than shock index.

Methods: 1723 Patients of trauma admitted to the Emergency Department of the First Affiliated Hospital of Soochow University from 1 November 2016 to 30 November 2019 were retrospectively evaluated. We defined SS as the ratio of SI to SPO2, and the mortality of trauma patients in the emergency department as end-point of outcome. We calculated the crude HR of SS and adjusted HR with the adjustment for risk factors including sex, age, revised trauma score (RTS) by Cox regression model. ROC curve analyses were performed to compare the area under the curve (AUC) of SS and SI.

Results: The crude HR of SS was: 4.31, 95%CI (2.89-6.42) and adjusted HR: 3.01, 95%CI(1.86-4.88); ROC curve analyses showed that AUC of SS was higher than that of shock index (SI), and the difference was statistically significant: 0.69, 95%CI(0.55-0.83) vs 0.65, 95%CI (0.51-0.79), P = 0.001.

Conclusion: The ratio of shock index to pulse oxygen saturation is good predictor for emergency trauma patients, which has a better prognostic value than shock index.

Perceptions of Non-Communicable Disease and War Injury Management in the Palestinian Health System: A Qualitative Study of Healthcare Providers Perspectives

Background: Palestine, like other low-income countries, is confronting an increasing epidemic of non-communicable disease (NCD) and trend of war injury. The management of health problems often presents a critical challenge to the Palestinian health system (PHS). Understanding the perceptions of healthcare providers is essential in exploring the gaps in the health system to develop an effective healthcare intervention. Unfortunately, health research on management of NCD and war injury has largely been neglected and received little attention. Therefore, the study aimed to explore the perspectives of healthcare providers regarding NCD and war injury management in the PHS in the Gaza Strip.
Methods: A qualitative study approach was used, based on four focus group discussions (FGDs) involving a purposive sampling strategy of 30 healthcare providers from three main public hospitals in Gaza Strip. A semi-structured topic guide was used, and the focus group interviews data were analyzed using manifest content analysis. The study was approved by the Palestinian Health Research Council (PHRC) for ethics approval.
Results: From the healthcare providers perspective, four main themes and several sub-themes have emerged from the descriptive manifest content analysis: functioning of healthcare system; system-related challenges; patients-related challenges; strategies and actions to navigating the challenges and improving care. Informants frequently discussed that despite some positive aspects in the system, fundamental changes and significant improvements are needed. Some expressed serious concerns that the healthcare system needs complete rebuilding to facilitate the management of NCD and war-related injury. They perceived important barriers to effective management of NCD and war injury such as poor hospital infrastructure and logistics, shortage of micro and sub-specialities and essential resources. Participants also expressed a dilemma and troubles in communication and interactions, especially during emergencies or crises. The informants stressed the unused of updated clinical management guidelines. There was a consensus regarding poor shared-care/task sharing, partnership, and cooperation among healthcare facilities.
Conclusion: Our findings suggest that fundamental changes and significant reforms are needed in the health system to make healthcare services more effective, timely, and efficient. The study disclosed the non-use of clinical guidelines as well as suboptimal sectorial task-sharing among different stakeholders and healthcare providers. A clear and comprehensive healthcare policy considering the gaps in the system must be adopted for the improvement and development of care in the PHS.

Barriers and facilitators to implementing trauma registries in low- and middle-income countries: Qualitative experiences from Tanzania

Background
The burden of trauma in low and middle-income countries (LMICs) is disproportionately high: LMICs account for nearly 90% of the global trauma deaths. Lack of trauma data has been identified as one of the major challenges in addressing the quality of trauma care and informing injury-preventing strategies in LMICs. This study aimed to explore the barriers and facilitators of current trauma documentation practices towards the development of a national trauma registry (TR).

Methods
An exploratory qualitative study was conducted at five regional hospitals between August 2018 and December 2018. Five focus group discussions (FGDs) were conducted with 49 participants from five regional hospitals. Participants included specialists, medical doctors, assistant medical officers, clinical officers, nurses, health clerks and information communication and technology officers. Participants came from the emergency units, surgical and orthopaedic inpatient units, and they had permanent placement to work in these units as non-rotating staff. We analysed the gathered information using a hybrid thematic analysis.

Results
Inconsistent documentation and archiving system, the disparity in knowledge and experience of trauma documentation, attitudes towards documentation and limitations of human and infrastructural resources in facilities we found as major barriers to the implementation of trauma registry. Health facilities commitment to standardising care, Ministry of Health and medicolegal data reporting requirements, and insurance reimbursements criteria of documentation were found as major facilitators to implementing trauma registry.

Conclusions
Implementation of a trauma registry in regional hospitals is impacted by multiple barriers related to providers, the volume of documentation, resource availability for care, and facility care flow processes. However, financial, legal and administrative data reporting requirements exist as important facilitators in implementing the trauma registry at these hospitals. Capitalizing in the identified facilitators and investing to address the revealed barriers through contextualized interventions in Tanzania and other LMICs is recommended by this study.

Comprehending the lack of access to maternal and neonatal emergency care: Designing solutions based on a space-time approach

Objective
The objective of this study was to better understand how the lack of emergency child and obstetric care can be related to maternal and neonatal mortality levels.

Methods
We performed spatiotemporal geospatial analyses using data from Brazilian municipalities. An emergency service accessibility index was derived using the two-step floating catchment area (2SFCA) for 951 hospitals. Mortality data from 2000 to 2015 was used to characterize space-time trends. The data was overlapped using a spatial clusters analysis to identify regions with lack of emergency access and high mortality trends.

Results
From 2000 to 2015 Brazil the overall neonatal mortality rate varied from 11,42 to 11,71 by 1000 live births. The maternal mortality presented a slightly decrease from 2,98 to 2,88 by 100 thousand inhabitants. For neonatal mortality the Northeast and North regions presented the highest percentage of up trending. For maternal mortality the North region exhibited the higher volume of up trending. The accessibility index obtained highlighted large portions of the rural areas of the country without any coverage of obstetric or neonatal beds.

Conclusions
The analyses highlighted regions with problems of mortality and access to maternal and newborn emergency services. This sequence of steps can be applied to other low and medium income countries as health situation analysis tool.

Significance statement
Low and middle income countries have greater disparities in access to emergency child and obstetric care. There is a lack of approaches capable to support analysis considering a spatiotemporal perspective for emergency care. Studies using Geographic Information System analysis for maternal and child care, are increasing in frequency. This approach can identify emergency child and obstetric care saturated or deprived regions. The sequence of steps designed here can help researchers, and policy makers to better design strategies aiming to improve emergency child and obstetric care.

Trauma team conformation in a war-influenced middle-income country in South America: is it possible?

Introduction: Trauma teams (TTs) improve outcomes in trauma patients. A multidisciplinary TT was conformed in September 2015 in a tertiary level I trauma university hospital in southwestern Colombia, a middle-income war-influenced country.

Objective: To evaluate the impact of a TT in admission-tomography and admission-surgery times as well as mortality in a tertiary center university hospital in a middle-income country war-influenced country.

Material and methods: Retrospective analytical study. Patients older than 17 years admitted to the emergency room 15 months prior and 15 months after the TT implementation were included. Patients prior to the TT implementation were taken as controls. No exclusion criteria. Four hundred sixty-four patients were included, 220 before the TT implementation (BTT) and 244 after (ATT). Demographic data, trauma characteristics, admission-tomography, and admission-surgery time interval as well as mortality were recorded. Requirement of CT scan or surgery was based on physician decision. The analysis was made on Stata 15.1®. Categorical variables were described as quantities and proportions, and continuous variables as mean and standard deviation or median and interquartile range (IQR). Categorical variables were compared using χ2 or Fisher’s test and continuous variables using Student’s T test or Wilcoxon-Mann-Whitney. A multiple logistic regression model was created to evaluate the impact of being treated in the ATT group on mortality, adjusted by age, trauma severity, and physiological response upon admission.

Results: The admission-tomography time interval was 56 min (IQR 39-100) in the BTT group and 40 min (IQR 24-76) in the ATT group, p < 0.001. The admission-surgery time interval was 116 min (IQR 63-214) in the BTT group and 52 min (IQR 24-76) in the ATT group, p < 0.001. Mortality in the BTT group was 18.1% and 13.1% in the ATT group. Adjusted OR was 0.406 (0.215-0.789) p = 0.006 CONCLUSIONS: A trauma team conformation in a war-influenced middle-income country is feasible and reduces mortality as well as admission-surgery and admission-tomography time intervals in trauma patients.

Aetiologies and Outcomes of Patients With Abdominal Pain Presenting to an Emergency Department of a Tertiary Hospital in Tanzania: A Prospective Cohort Study

Background: Abdominal pain in adults represents a wide range of illnesses, often warranting immediate intervention. This study is to fill the gap in the knowledge about incidence, presentation, causes and mortality from abdominal pain in an established emergency department of a tertiary hospital in Tanzania.

Methods: This was a prospective cohort study of adult (age ≥ 18 years) patients presenting to the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH) in Dar Es Salaam, Tanzania with non-traumatic abdominal pain from September 2017 to October 2017. A case report form was used to record data on demographics, clinical presentation, management, diagnosis, outcomes and patient follow-up. The primary outcome of mortality was summarized using descriptive statistics; secondary outcome was, risks for mortality.

Results: Among 3381 adult patients present during the study period, 288 (8.5%) presented with abdominal pain, and of these 199 (69%) patients were enrolled in our study. Median age was 47 years (IQR 35-60 years), 126 (63%) were female, and 118 (59%) were referred from another hospital. Most common final diagnoses were malignancies 71 (36%), intestinal obstruction 11 (6%) and peptic ulcer disease 9 (5%). Most common EMD interventions given were intravenous fluids 57 (21%), analgesia 49 (25%) and antibiotics 40 (20%). 160 (80%) were admitted of which 15 (8%) underwent surgery directly from EMD. 24-h and 7-day mortality were 4 (2%) and 7 (4%) respectively, while overall in hospital-mortality was 16 (8%). Among the risk factors for mortality were male sex Relative Risk (RR) 2.88 (p = 0.03), hypoglycemia (RR) 5.7 (p = 0.004), ICU admission (RR) 14 (p < 0.0001), receipt of IV fluids (RR) 3.2 (p = 0.0151) and need for surgery (RR) 6.6 (p = 0.0001). Conclusion: Abdominal pain was associated with significant morbidity and mortality as evidenced by a very high admission rate, need for surgical intervention and a high in-hospital mortality rate. Future studies and quality improvement efforts should focus on identifying why such differences exist and how to reduce the mortality.

Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury

Introduction
Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality.

Methods
A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded.

Results
Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6).

Conclusion
Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.

Emergency department management of traumatic brain injuries: A resource tiered review

Introduction
Traumatic brain injury is a leading cause of death and disability globally with an estimated African incidence of approximately 8 million cases annually. A person suffering from a TBI is often aged 20–30, contributing to sustained disability and large negative economic impacts of TBI. Effective emergency care has the potential to decrease morbidity from this multisystem trauma.

Objectives
Identify and summarize key recommendations for emergency care of patients with traumatic brain injuries using a resource tiered framework.

Methods
A literature review was conducted on clinical care of brain-injured patients in resource-limited settings, with a focus on the first 48 h of injury. Using the AfJEM resource tiered review and PRISMA guidelines, articles were identified and used to describe best practice care and management of the brain-injured patient in resource-limited settings.

Key recommendations
Optimal management of the brain-injured patient begins with early and appropriate triage. A complete history and physical can identify high-risk patients who present with mild or moderate TBI. Clinical decision rules can aid in the identification of low-risk patients who require no neuroimaging or only a brief period of observation. The management of the severely brain-injured patient requires a systematic approach focused on the avoidance of secondary injury, including hypotension, hypoxia, and hypoglycaemia. Most interventions to prevent secondary injury can be implemented at all facility levels. Urgent neuroimaging is recommended for patients with severe TBI followed by consultation with a neurosurgeon and transfer to an intensive care unit. The high incidence and poor outcomes of traumatic brain injury in Africa make this subject an important focus for future research and intervention to further guide optimal clinical care.

Cost-effectiveness of Emergency Care Interventions in Low and Middle-Income Countries: A Systematic Review

Objective: To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries.

Methods: Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies.

Results: Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied.

Conclusion: We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.