Pediatric renal tumor epidemiology: Global perspectives, progress, and challenges

Pediatric renal tumors account for 3%–11% of childhood cancers, the most common of which is Wilms tumor or nephroblastoma. Epidemiology plays a key role in cancer prevention and control by describing the distribution of cancer and discovering risk factors for cancer. Large pediatric research consortium trials have led to a clearer understanding of pediatric renal tumors, identification of risk factors, and development of more risk-adapted therapies. These therapies have improved event-free and overall survival for children. However, several challenges remain and not all children have benefited from the improved outcomes. In this article, we review the global epidemiology of pediatric renal tumors, including key consortium and global studies. We identify current knowledge gaps and challenges facing both high and low middle-incomes countries.

The epidemiology and outcomes of prolonged trauma care (EpiC) study: methodology of a prospective multicenter observational study in the Western Cape of South Africa

Deaths due to injuries exceed 4.4 million annually, with over 90% occurring in low-and middle-income countries. A key contributor to high trauma mortality is prolonged trauma-to-treatment time. Earlier receipt of medical care following an injury is critical to better patient outcomes. Trauma epidemiological studies can identify gaps and opportunities to help strengthen emergency care systems globally, especially in lower income countries, and among military personnel wounded in combat. This paper describes the methodology of the “Epidemiology and Outcomes of Prolonged Trauma Care (EpiC)” study, which aims to investigate how the delivery of resuscitative interventions and their timeliness impacts the morbidity and mortality outcomes of patients with critical injuries in South Africa.

The EpiC study is a prospective, multicenter cohort study that will be implemented over a 6-year period in the Western Cape, South Africa. Data collected will link pre- and in-hospital care with mortuary reports through standardized clinical chart abstraction and will provide longitudinal documentation of the patient’s clinical course after injury. The study will enroll an anticipated sample of 14,400 injured adults. Survival and regression analysis will be used to assess the effects of critical early resuscitative interventions (airway, breathing, circulatory, and neurologic) and trauma-to-treatment time on the primary 7-day mortality outcome and secondary mortality (24-h, 30-day) and morbidity outcomes (need for operative interventions, secondary infections, and organ failure).

This study is the first effort in the Western Cape of South Africa to build a standardized, high-quality, multicenter epidemiologic trauma dataset that links pre- and in-hospital care with mortuary data. In high-income countries and the U.S. military, the introduction of trauma databases and registries has led to interventions that significantly reduce post-injury death and disability. The EpiC study will describe epidemiology trends over time, and it will enable assessments of how trauma care and system processes directly impact trauma outcomes to ultimately improve the overall emergency care system.

Trial Registration: Not applicable as this study is not a clinical trial.

Crohn’s Disease Among the Poorest Billion: Burden of Crohn’s Disease in Low- and Lower-Middle-Income Countries

To establish the epidemiology and patterns of care of Crohn’s Disease in low- and lower-middle-income countries.

A cross-sectional survey of gastroenterology providers in countries where the world’s poorest billion live was conducted to learn more about the state of diagnostic and treatment capacity for Crohn’s. Quantitative data were analyzed in R and Excel.

A total of 46 survey responses from 15 countries were received, giving a response rate of 54.8%. All responses collected were from providers practicing in Africa and South Asia. The mean number of patients with Crohn’s cared for in the last year was 89.5 overall but ranged from 0 reported at one facility in Rwanda to 1000 reported at two different facilities in India. Overall, Crohn’s disease made up 20.6% of the inflammatory bowel disease diagnoses reported by survey respondents, with Africa exhibiting a larger proportion of Crohn’s compared to ulcerative colitis than Asia. Most providers reported that patients with Crohn’s have symptoms for 6–24 months prior to diagnosis and that 26–50% of their patients live in rural areas. The most reported diagnostic challenges are differentiating between Crohn’s and intestinal tuberculosis, poor disease awareness, and lack of trained pathologists. The most widely reported challenge in managing Crohn’s disease is patients’ inability to afford biologics, reported by 65% of providers.

Our study suggests there may be a greater burden of Crohn’s disease in low- and lower-middle-income countries than is indicated in prior literature. Respondents reported many challenges in diagnosing and treating Crohn’s disease.

The structure, function and implementation of an outcomes database at a Ugandan secondary hospital: the Mbarara Surgical Services Quality Assurance Database

The Mbarara Surgical Services Quality Assurance Database (Mbarara SQUAD) is an outcomes database of surgical, obstetric and anaesthetic/critical care at Mbarara Regional Referral Hospital, a secondary referral hospital in southwestern Uganda. The primary scope of SQUAD is the assessment of the outcomes of care. The primary outcome is mortality. The aim is to improve the quality of care, guide allocation of resources and provide a platform for research. The target population includes all inpatients admitted for treatment to the surgery service, the obstetrics and gynaecology services, and the intensive care unit (ICU). Data collection was initiated in 2013 and closed in 2018. Data were extracted from patient charts and hospital logbooks. The database has over 50 000 patient encounters, including over 20 000 obstetrics and gynaecology admissions, 15 000 surgical admissions and 16 000 otolaryngology outpatient visits. Entries are coded using the International Classification of Diseases, Tenth Revision (ICD-10) for diagnoses, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for procedures. The completeness and accuracy of the data entry and the coding were validated. Governance of data use is by a local steering committee in Mbarara. The structure, function and implementation of this database may be relevant for similar hospital databases in low-income countries.

Impact of COVID-19 on Cardiovascular Disease Presentation, Emergency Department Triage and Inpatient Cardiology Services in a Low- to Middle-Income Country – Perspective from a Tertiary Care Hospital of Pakistan

Aims: To identify the changes in cardiovascular disease presentation, emergency room triage and inpatient diagnostic and therapeutic pathways.

Methods: We conducted a retrospective cohort study at the Aga Khan University Hospital, Karachi. We collected data for patients presenting to the emergency department with cardiovascular symptoms between March–July 2019 (pre-COVID period) and March–July 2020 (COVID period). The comparison was made to quantify the differences in demographics, clinical characteristics, admission, diagnostic and therapeutic procedures, and in-hospital mortality between the two periods.

Results: Of 2976 patients presenting with cardiac complaints to the emergency department (ED), 2041(69%) patients presented during the pre-COVID period, and 935 (31%) patients presented during the COVID period. There was significant reduction in acute coronary syndrome (ACS) (8% [95% CI 4–11], p < 0.001) and heart failure (↓6% [95% CI 3–8], p < 0.001). A striking surge was noted in Type II Myocardial injury (↑18% [95% CI 20–15], p < 0.001) during the pandemic. There was reduction in cardiovascular admissions (coronary care unit p < 0.01, coronary step-down unit p = 0.03), cardiovascular imaging (p < 0.001), and procedures (percutaneous coronary intervention p = 0.04 and coronary angiography p = 0.02). No significant difference was noted in mortality (4.7% vs. 3.7%). The percentage of patients presenting from rural areas declined significantly during the COVID period (18% vs. 14%, p = 0.01). In the subgroup analysis of sex, we noticed a falling trend of intervention performed in females during the COVID period (8.2% male vs. 3.3 % female). Conclusions: This study shows a significant decline in patients presenting with Type I myocardial infarction (MI) and a decrease in cardiovascular imaging and procedures during the COVID period. There was a significant increase noted in Type II MI.

Epidemiology and Anatomic Distribution of Colorectal Cancer in South Africa

Background: Colorectal cancer (CRC) is the 5th most common cancer in subSaharan Africa (SSA) and the 3rd most common cancer in Southern Africa. CRC characteristics in SSA, including anatomic distribution, are not well described. Objective: To describe patient characteristics and anatomic location of colorectal adenocarcinoma (CRC-AC) in South Africa. Design: This was a retrospective study of CRC using the South African National Cancer Registry from 2006-2011. Main Outcome Measures: Patient age, gender, racial/ethnic group, province, histology type, and tumour location. Results: 6146 patients were included in the analysis. Among patients with adenocarcinomas, the median age of presentation was 60 (interquartile range, 49-70) years. 1372 (25%) of patients were < 50 years and 2870 (52%) were male. There were 5498 (89%) cases of adenocarcinoma (AC). 1277 (26%) CRC-AC were right colonic lesions, 1214 (25%) were left colonic lesions, and 2404 (49%) lesions were located in the rectum. Patients ≥ 50 years at presentation (OR=1.29. p< 0.001) and from Limpopo province (OR=1.46, p=0.029) were more likely to have left colonic and rectal adenocarcinoma on multivariate analysis. Patients who were black (OR=1.67, p< 0.001), had right colonic lesions (OR=1.25, p=0.007), and were from Mpumalanga (OR=1.67, p=0.007), Limpopo (OR=1.60, p=0.002), or Northwest (OR=1.76, p=0.001), were significantly associated with early onset adenocarcinoma. Conclusion: CRC-AC in South Africa presents at an earlier age than in HICs, such as the US. Early-onset CRC is higher in black South Africans who live in Mpumalanga, Limpopo, and Northwest in comparison with other provinces. The majority of colorectal cancer were leftsided and rectal; thus screening flexible sigmoidoscopy should be considered. Further studies on the age-specific incidence and the genetics and epigenetics of CRC-AC in South Africa are needed.

Identifying the epidemiology of traumatic injury in Benghazi, Libya through the implementation of an electronic trauma registry

Traumatic injury is the leading cause of morbidity and mortality globally, and there is little data in the literature for low middle-income countries (LMIC), although it is slowly growing. Libya has been suffering from low resources that are further strained by an ongoing civil war. Benghazi Medical Centre (BMC) is the only operating trauma public hospital in the country’s eastern region and trauma is on the rise. Currently, there is no system in place to identify the trends of traumatic injuries nor any formal surveillance. The objective of this thesis is to describe the epidemiology of traumatic injuries and identify gaps in the trauma system.Methods: This is a prospective study conducted at BMC’s emergency room through the implementation of an electronic trauma registry, iTrauma application. Data collection occurred during January of 2017 over a 10-day trial period. Upon the traumatic patient’s arrival to the emergency department twenty-five data points were collected and entered into iTrauma. Data points included patient demographics, mechanism of injury and clinical outcomes. Results: A total of 231 patients were evaluated and included into the TR. Males were at higher risk for traumatic injury making up 68% of injured patients. The average age was 31 years old, however, the majority of were in the 0-10 and 31-40 age groups. Falls were the most common cause of injury at 31%, followed closely by motor vehicle collisions at 30%. None of the patients injured in a car collision wore a seatbelt, and half of motorbike collision patients dawned helmets. The most common type of injury was bone fractures at 13% and the most common anatomical region was extremity injuries. The vast majority of trauma patients arrived by private vehicle (57%), whereas 20% arrived by ambulance. In terms of clinical outcome, 36% of patients were either treated and discharged in the ER or discharged by the 2 weeks follow up. However, there was a mortality rate of at least 11%. Conclusion: Traumatic injuries lead to a high mortality rate and carry a large burden to the individual clinically and economically. The implementation of a simple TR was shown to be feasible and has a tremendous value in identifying the epidemiology of traumatic injury, most notably falls and motor vehicle collisions. Advocating for programs that address preventative measures can have remarkable benefits in reducing morbidity and mortality. Furthermore, continued support for TR can evolve with the institution and provide ongoing improvement to quality of car

Epidemiology of Surgical Amputations in Tamale Teaching Hospital, Ghana

The current study aimed to explore the details of surgical amputations in Tamale, Ghana. This was a retrospective descriptive study. We analyzed case files of 112 patients who underwent surgical amputations
between 2011 and 2017. Demographics, site of amputation, indication for amputation, and outcomes were
retrieved from case files. Descriptive statistics were used to report the means and frequencies. Associations
between variables were assessed using Chi-Square, ANOVA, and Student’s t-test. The mean age of the participants was 43.6±23.1 years (range 2 to 86). Most (64.3%) were males. Lower limb amputations accounted for most (78.6%) cases. Diabetic vasculopathy was the most prevalent indication (44.6%), followed by trauma (36.6%). The mean hospital stay was 30.1±22.4 days (range 5 to 120). Surgical site infection (17.9%) was the main complication. In our study setting, there is thus far limited capability for proper management of diabetes mellitus, which needs to be improved. There is also an urgent need for multidisciplinary foot care teams that will help patients receive comprehensive care to reduce complications from diabetes and other vasculopathies

Global Epidemiology of End-Stage Kidney Disease and Disparities in Kidney Replacement Therapy

Background: The global epidemiology of end-stage kidney disease (ESKD) reflects each nation’s unique genetic, environmental, lifestyle, and sociodemographic characteristics. The response to ESKD, particularly regarding kidney replacement therapy (KRT), depends on local disease burden, culture, and socioeconomics. Here, we explore geographic variation and global trends in ESKD incidence and prevalence and examine variations in KRT modality, practice patterns, and mortality. We conclude with a discussion on disparities in access to KRT and strategies to reduce ESKD global burden and to improve access to treatment in low- and middle-income countries (LMICs). Summary: From 2003 to 2016, incidence rates of treated ESKD were relatively stable in many higher income countries but rose substantially predominantly in East and Southeast Asia. The prevalence of treated ESKD has increased worldwide, likely due to improving ESKD survival, population demographic shifts, higher prevalence of ESKD risk factors, and increasing KRT access in countries with growing economies. Unadjusted 5-year survival of ESKD patients on KRT was 41% in the USA, 48% in Europe, and 60% in Japan. Dialysis is the predominant KRT in most countries, with hemodialysis being the most common modality. Variations in dialysis practice patterns account for some of the differences in survival outcomes globally. Worldwide, there is a greater prevalence of KRT at higher income levels, and the number of people who die prematurely because of lack of KRT access is estimated at up to 3 times higher than the number who receive treatment. Key Messages: Many people worldwide in need of KRT as a life-sustaining treatment do not receive it, mostly in LMICs where health care resources are severely limited. This large treatment gap demands a focus on population-based prevention strategies and development of affordable and cost-effective KRT. Achieving global equity in KRT access will require concerted efforts in advocating effective public policy, health care delivery, workforce capacity, education, research, and support from the government, private sector, nongovernmental, and professional organizations.

Epidemiology of injured patients in rural Uganda: A prospective trauma registry’s first 1000 days

Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.