Epidemiological trends in community acquired acute Kidney Injury in Pakistan: 25 years Experience from a Tertiary Care Renal Unit

Background: Epidemiological studies of community acquired acute kidney injury (AKI) are sparse especially from South Asia and none has published from Pakistan. Reported incidences from different countries vary with use of different criteria of defining AKI. There is also variation found in different class of income countries, hospital based versus community based AKI.

Methods: The current study was carried out in all adult AKI patients developing community acquired AKI and coming to a tertiary care renal institution from January 1990 to December 2014. This is a retrospective data collection from patient’s records and AKI was defined according to KDIGO guidelines. Trends among different groups which are classified in medical, obstetrical and surgical were observed and presented.

Results: In medical AKI there has been found a rise in toxic rhabdomyolysis, vivax malaria and dengue infection during later part of study. In obstetrical AKI observed continuous rise in numbers contributing to total AKI during these years. Surgical AKI included obstructed cases during initial ten years and only surgical trauma during later 15 years. Older age on presentation in medical AKI, and thrombocytopenia, deranged coagulation, deranged liver function, hyperkalemia, requirement of mechanical ventilation and multi organ failure in all groups remained predictors of higher mortality.

Conclusion: From Pakistan epidemiology for community acquired AKI has never been published on a large scale and this study would remain source of great information in this regard over coming years.

Patterns of neurosurgical conditions at a major government hospital in Cambodia

Background: Low- and middle-income countries (LMICs) have a growing and largely unaddressed neurosurgical burden. Cambodia has been an understudied country regarding the neurosurgical pathologies and case volume. Rapid infrastructure development with noncompliance of safety regulations has led to increased numbers of traumatic injuries. This study examines the neurosurgical caseload and pathologies of a single government institution implementing the first residency program in an effort to understand the neurosurgical needs of this population. Methods: This is a longitudinal descriptive study of all neurosurgical admissions at the Department of Neurosurgery at Preah Kossamak Hospital (PKH), a major government hospital, in Phnom Penh, Cambodia, between September 2013 and June 2018. Results: 5490 patients were admitted to PKH requiring neurosurgical evaluation and care. Most of these admissions were cranial injuries related to road traffic accidents primarily involving young men compared to women by approximately 4:1 ratio. Spinal pathologies were more evenly distributed in age and gender, with younger demographics more commonly presenting with traumatic injuries, while the older with degenerative conditions. Conclusions: Despite increased attention and efforts over the past decade, Cambodia’s neurosurgical burden mirrors that of other LMICs, with trauma affecting most patients either on the road or at the workplace. Currently, Cambodia has 34 neurosurgeons to address the growing burden of a country of 15 million with an increasing life expectancy of 69 years of age, stressing the importance of better public health policies and urgency for building capacity for safe and affordable neurosurgical care.

Increases in cholecystectomy for gallstone related disease in South Africa

tudies suggest that the rate gallstone disease in Africa is low. Previous studies suggested an increase in gallstone rates and cholecystectomies related to urbanization and the adoption of Western lifestyle habits. This study examined cholecystectomy rates for gallstone disease in South Africa (SA). An audit of cholecystectomies in SA was done by reviewing gallbladder specimens processed by the SA National Health Laboratory Service (NHLS) from 2004 and 2014. Urbanization rates were obtained from Statistics South Africa and BMI data from previously published studies. Fisher’s exact test, t test’s and Pearson’s R were used for comparisons; cholecystectomy rates were calculated per 100,000 population. 33,467 cholecystectomy specimens were analysed. There was a 92% absolute increase in cholecystectomies during the study period (Pearson r 0.94; p < 0.01) with the overall cholecystectomy rate increasing by 65% from 8.36 to 13.81 per 100,000 population. The data was divided into two equal periods and compared. During the second period there was a 28.8% increase in the number cholecystectomies and patients were significantly younger (46.9 vs 48.2 years; p ≤ 0.0001). The Northern Cape was the only province to show a decline in the cholecystectomy rate in this period and was also the only province to record a decline in urbanization. Population based studies in SA demonstrate increases in BMI and an association with increased urbanization. This nationwide African study demonstrates a sustained increase in cholecystectomies for gallstone disease. Increases in BMI and urbanization may be responsible for this trend.

A review of the epidemiology, post-neurosurgical closure complications and outcomes of neonates with open spina bifida

Background. Spina bifida (SB) is a neural tube defect (NTD) that has an increased risk of fatal and disabling effects if not repaired early, i.e. within the first 24 to 48 hours of life. Its diagnosis holds an increased burden for the patient and the caregiver owing to secondary complications. The effects of the disease are detrimental even with early repair, because of the long-term disabling nature of the disease.

Objective. This retrospective study aimed to assess the effects of demographics, immediate post-surgical complications and impact of time to surgical intervention on the outcome of neonates with open SB (OSB) admitted to the neonatal intensive care unit (NICU) at Inkosi Albert Luthuli Central Hospital (IALCH) in KwaZulu-Natal, South Africa (SA), between January 2011 and December 2015.

Methods. A retrospective chart review was conducted at the NICU of IALCH. All neonates diagnosed with SB were identified. The study period was from 1 January 2011 to 31 December 2015. Data were collected from the IALCH electronic database. All neonates with SB admitted to the IALCH NICU were included; any patient who presented beyond the neonatal period (i.e. >28 days) was excluded from the study. Data collected included maternal demographics. Additionally, neonatal history was reviewed and post surgery complications evaluated. Outpatient management post discharge was reviewed.

Results. One hundred and fifty neonates were included (58% male). The mean (standard deviation) maternal age was 26.7 (6.6) years. Only 10% had an antenatal diagnosis of OSB. Seventy-eight percent were born at term and 22% prematurely. The lumbar/sacral region was the most commonly affected. More males (14%) had thoraco/lumbar lesions than females (7.8%). Forty-eight percent presented before 3 days of life (early presentation). In the late-presentation group, there was an association with wound sepsis (p=0.003). Twenty-five percent were repaired between days 0 and 3 of life and 75% after 3 days. Postoperative complications in patients whose open SBs were repaired beyond 3 days of life were not statistically significant compared with those with early repair; all were p>0.05. There was a borderline association of prolonged hospitalisation with wound sepsis (p=0.07). Long-term outcomes showed that 68% had lower limb dysfunction, 18% urological complications, 14% limb deformity, and 11% hydrocephalus. A minority had psychomotor (7%) and developmental (15%) disorders. Ten percent required readmission secondary to shunt complications, and 7% died.

Conclusion. SB remains a significant disease burden that affects outcome and survival of neonates in SA. Lack of good antenatal care, which includes early ultrasound and timely referral to centres, are barriers to good outcomes. Long-term follow-up is also necessary to prevent morbidity.

Epidemiology of surgical valvular heart diseases in a north african tertiary referral hospital

Introduction
The etiology of valvular heart disease (VHD) has changed dramatically in the last five decades. In the western world, the significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of VHD induced the metamorphosis in the etiology of valvular disorders. The aim of this study was to assess the epidemiological profile of the patients undergoing valvular surgery in a north African center of cardiology.

Methods
A retrospective study involving the 246 last patients hospitalized in our department and proposed for valvular surgery from January 2012 to December 2017.

Results
The mean age was 57 years. One hundred twenty-one patients were male (49%). Before surgery mean LVEF is 60% ± 13. Ten percent of the patients were operated with (left ventricular dysfunction LVEF ≤ 40%). Arterial hypertension, diabetes mellitus and smoking are respectively present in 29, 7%, 21, 8% and 27, 7% of the patients. A history of rheumatic fever was present in 60, 8% of rheumatic valvular disease. The rheumatic etiology was the most important (50,5%). A preoperative coronary angiography was performed in 63,4% of the patients and coronary artery disease was associated to the valvular heart disease in 14,9%. Mitral valve replacement, aortic-valve replacement and double valve replacement were respectively performed in 38,7%, 35,4% and 18,7% of the cases. Bioprothesis were implanted in 5,29% of the cases. One eighth of the patients underwent coronary artery bypass graft in addition to the valvular surgery. In 16,8% of the cases it was a redo surgery.

Conclusion
Contemporary epidemiological data show a rise of the degenerative etiology and associated coronary artery disease. Surgery offers good results for patients with significant valvular heart disease. Valve replacement and repair are the main surgical options. Older patients and redo procedures are increasingly frequent.

Incidence of Keratoconus in Refractive Surgery Population of Vojvodina – Single Center Study

Introduction
Keratoconus (KCN) is known to affect all ethnicities but its incidence exhibits geographical variability plausibly due to subclinical forms of the disease, differences in diagnostic methods and criteria, or differences in genetic variations in populations.
Aim
To examine the prevalence of keratoconus among the refractive surgery population of Vojvodina, who underwent refractive surgery screening at Eye Clinic Svjetlost Novi Sad, Serbia from September 2018 to September 2019. This is a single-center study.
Methods
Retrospective analysis of 876 patients who presented for refractive surgery evaluation. Corneal tomographers represent the gold standard in the detection and classification of corneal ectatic diseases and screening is an essential part of the preoperative diagnostics before any refractive surgery. The corneal tomographer used in this study was a Scheimpflug imaging device (Pentacam AXL, Oculus Optikgeräte GmbH, Wetzlar, Germany). The device was realigned before each measurement.
Results
Out of a total number of patients, 619 (70,7%) were candidates for corneal refractive surgery procedure, and 257 patients (29.3%) were not. Out of 257 patients that were not candidates for the procedure 157 (61,0%) patients had thin corneas, high myopia/hypermetropia or had some retinal disease; 75 patients (29,1) were keratoconus suspect and 25 patients (9,7%) had keratoconus. KCN patients had a mean age of 29.5 ± 7.7 years, 18 patients (72.0%) were male and 7 patients were female (28%)
Conclusion
The most cited annual incidence of KCN is 2 approximately 1 per 2,000. Recent data from the biggest Netherland study revealed many different epidemiological results which deprive keratoconus of the community of rare diseases. The incidence of keratoconus in Vojvodina refractive surgery population presented in our Clinic was 2.9%

Comparison of emergency department trauma triage performance of clinicians and clinical prediction models: a cohort study in India

Objective: The aim of this study was to evaluate and compare the abilities of clinicians and clinical prediction models to accurately triage emergency department (ED) trauma patients. We compared the decisions made by clinicians with the Revised Trauma Score (RTS), the Glasgow Coma Scale, Age and Systolic Blood Pressure (GAP) score, the Kampala Trauma Score (KTS) and the Gerdin et al model.

Design: Prospective cohort study.

Setting: Three hospitals in urban India.

Participants: In total, 7697 adult patients who presented to participating hospitals with a history of trauma were approached for enrolment. The final study sample included 5155 patients. The majority (4023, 78.0%) were male.

Main outcome measure The patient outcome was mortality within 30 days of arrival at the participating hospital. A grid search was used to identify model cut-off values. Clinicians and categorised models were evaluated and compared using the area under the receiver operating characteristics curve (AUROCC) and net reclassification improvement in non-survivors (NRI+) and survivors (NRI−) separately.

Results:The differences in AUROCC between each categorised model and the clinicians were 0.016 (95% CI −0.014 to 0.045) for RTS, 0.019 (95% CI −0.007 to 0.058) for GAP, 0.054 (95% CI 0.033 to 0.077) for KTS and −0.007 (95% CI −0.035 to 0.03) for Gerdin et al. The NRI+ for each model were −0.235 (−0.37 to −0.116), 0.17 (−0.042 to 0.405), 0.55 (0.47 to 0.65) and 0.22 (0.11 to 0.717), respectively. The NRI− were 0.385 (0.348 to 0.4), −0.059 (−0.476 to −0.005), −0.162 (−0.18 to −0.146) and 0.039 (−0.229 to 0.06), respectively.

Conclusion: The findings of this study suggest that there are no substantial differences in discrimination and net reclassification improvement between clinicians and all four clinical prediction models when using 30-day mortality as the outcome of ED trauma triage in adult patients.

The epidemiology and outcome of patients admitted for elective brain tumour surgery at a single neurosurgical centre in South Africa

Introduction
Many countries, including South Africa, do not have a national brain tumour registry. Despite this limitation several institutional studies report age, gender, and histological tumour types that are in-line with the findings of the large established national brain tumour registries from the United States and Europe.

Materials and methods
We conducted a prospective study consecutively enrolling all elective subjects admitted to our Unit with a neoplastic brain tumor from the 01 July 2018–31 March 2020. The data collected included age, gender, admission Glasgow Coma Score, HIV status, admission absolute CD4 count in all patients, radiological tumour diagnosis, pre-operative steroid treatment, length of in-hospital stay prior to surgery, time between prophylactic antibiotic administration and skin incision, intra-operative blood loss, length of surgery, extent of resection, histological diagnosis, post-operative nosocomial infection incidence, and Glasgow Outcome Score.

Results
The mean age of our subjects was 48 (±14.56) years. Significance was demonstrated between age and histological tumour diagnosis (p = 0.031). With regards gender 72/101 (72%) were males and 29/101 (29%) were females. Considering admission HIV status 65/101 (64%) were HIV negative and 36/101 (36%) were HIV positive. Of the 101 subjects enrolled in the study 78/101 (77%) were taken for operative intervention. The mean intra-operative blood loss in our study was 505 (±336) millilitres. The mean length of surgery was 278 (±80.33) minutes. Considering nosocomial infection 30/78 (38%) subjects developed this complication. Considering outcome 29/78 (37%) subjects in our study had a favourable outcome (GOS 4/5), and 49/78 (63%) had an unfavourable outcome (GOS 1–3).

Conclusion
Patients with brain tumours, whether HIV positive or not, show characteristic histological tumour types that are age specific. While being HIV positive does have a detrimental influence, the primary histology of the lesion and the extent of resection are the major determinants of outcome.

The Epidemiology of Traumatic Brain Injury Due to Traffic Accidents in Latin America: A Narrative Review

Objective Traumatic brain injuries (TBIs) are devastating injuries and represent a major cause of morbidity and mortality worldwide. Traffic accidents are one of the main causes, especially in low- and middle-income countries. The epidemiology of TBI due to road traffic in Latin America is not clearly documented.

Methods A narrative review was conducted using PubMed, SCOPUS, and Google Scholar, looking for TBI studies in Latin America published between 2000 and 2018. Seventeen studies were found that met the inclusion and exclusion criteria.

Results  It was found that TBI due to road traffic accidents (RTAs) is more frequent in males between the ages of 15 and 35 years, and patients in motor vehicles accounted for most cases, followed by pedestrians, motorcyclists, and cyclists.

Conclusion Road traffic accidents is a common cause of TBI in Latin America. More studies and registries are needed to properly document the epidemiological profiles of TBI related to RTAs.

Management and outcomes following emergency surgery for traumatic brain injury – A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study).

Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.