Infant injuries treated at Red Cross War Memorial Children’s Hospital, Cape Town, South Africa

Background. Infants are entirely dependent on their caregivers, especially <6 months old when they are not yet mobile. While the epidemiology of injury among children in general has been described, the exact causes of infant injury have never been investigated in South Africa (SA).

Objective. To describe causes of injury in infants aged <12 months, stratified for the four quarters of the first year of life, in order to identify opportunities for targeted prevention strategies based on local data.

Methods. This retrospective audit study used data collected by ChildSafe SA from the Red Cross War Memorial Children’s Hospital in Cape Town, SA, over a 4-year period from January 2013 to December 2016. Infants <1 year of age presenting to the hospital’s trauma casualty department were included. Additionally, mortuary data on traumatic infant deaths in the hospital’s catchment area were collected.

Results. A total of 2 279 injured infants were identified. More than half were male (55%; n=1 250) and the median age was 8 months (interquartile range 5 – 10 months). Leading causes of injury were falls (42%; n=957) and burns (32%; n=736). A significant association between the age group and the cause of injury (p<0.001) was found. From 2014 to 2016, an additional 27 infants were traumatically injured and died before arriving at the hospital.

Conclusion. Falls and burns are a significant contributor to the burden of infant injuries in Cape Town. This underlines the urgent need for targeted prevention strategies to improve safety, taking poverty into account

Patterns of injuries among Children visiting Gondar town public health institutes, Northwest Ethiopia, 2019

Background: Injuries have been recognized as the leading cause of death in children for nearly 40 years. However, most epidemiological studies of injuries have not been community-based and are limited either to a single type of injury, such as head injuries or burnsor to a specific cause of injury, such as consumer products.

Objective: To determine patterns of injuries among children visiting Gondar town public health institutes, Northwest Ethiopia,2019.

Methods: An institutional-based prospective cross-sectional study was conductedamong children visiting Gondar town public health institutes of Amhara region, Northwest Ethiopia from June 25 to September 25, 2019. A total of 385 participants were included in the study. Data were entered into Epi-info version 7.2.1 and exported to SPSS version 21.0 for analysis and descriptive statistics were presented in text, tables, charts, and graphs.

Result: The majority of the pediatric trauma cases were seen in males 61.8%, (n = 238) and females comprised only 38.2% (n = 147). Stone or stick injury (29.1%) was the most common mode of trauma followed by road traffic injuries (21.0%), falls (19.0%), and burns (14.0%). The majority of injuries happened during playing (53%) and around the home (37.9%). In this study the three top most frequent sites of injuries were: lower extremity injury 167 (43.4%), upper extremity127 (33.0%), and head injury 50 (13.0%).

Conclusion and recommendation: The high rate of pediatric trauma from sticks or stones, roadways, and falls highlights the need for increased supervision and identification of specific dangers when playing. In our scenario, a comprehensive trauma registry appears to be critical for developing policies to lessen the burden of pediatric trauma. Further research with large sample size and associated factors for pediatric injuries is recommended.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review

Purpose of Review
Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model.

Recent Findings
A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda.

Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action.

Epidemiological characteristics of injury in Georgia: A one-year retrospective study

Injury is a major health problem worldwide and a leading cause of death and disability. Disability caused by traumatic injury is often severe and long-lasting. Injuries place a large burden on societies and individuals in the community, both in cost and lost quality of life. Progress in developing effective injury prevention programs in developing countries is hindered by the lack of basic epidemiological injury data regarding the prevalence of traumatic injuries. The aim of this research was to describe the epidemiological characteristics of injury in all hospitals in Georgia.

The database of the National Center for Disease Control and Public Health of Georgia for 2018, which includes all hospital admissions, was used to identify injury cases treated in hospitals. Cases were included based on the S and T diagnosis coded of ICD-10.

A total of 25,103 adult patients were admitted for an injury, of whom 14,798 (59%) were males and 10,305 (41%) were females, between the ages of 18 and 108 years old. The highest prevalence was among the age group 25–44 years old (n = 8654; 34%), followed by 45–64 years old (n = 6852; 27%). The main mechanism of injury was falls (n = 13,932; 55%) and exposure to mechanical forces (n = 2701; 11%). Over 1,50% (n = 379) of injuries resulted in death after hospitalization. The median hospital length of stay (LOS) was 2 days. There was a significant association between age, mechanism of injury, type of injury, performed surgical interventions, and longer LOS.

Injuries are prevalent throughout the life course and cause substantial hospitalization time. This research can help focus prevention efforts can focus on the demographic and injury causes that are most prevalent.

Estimated incidence and case fatality rate of traumatic brain injury among children (0–18 years) in Sub-Saharan Africa. A systematic review and meta-analysis

Studies from Sub-Saharan Africa (SSA) countries have reported on the incidence and case fatality rate of children with Traumatic Brain Injury (TBI). However, there is lack of a general epidemiologic description of the phenomenon in this sub-region underpinning the need for an accurate and reliable estimate of incidence and outcome of children (0–18 years) with TBI. This study therefore, extensively reviewed data to reliably estimate incidence, case fatality rate of children with TBI and its mechanism of injury in SSA.

Electronic databases were systematically searched in English via Medline (PubMed), Google Scholar, and Africa Journal Online (AJOL). Two independent authors performed an initial screening of studies based on the details found in their titles and abstracts. Studies were assessed for quality/risk of bias using the modified Newcastle-Ottawa Scale (NOS). The pooled case fatality rate and incidence were estimated using DerSimonian and Laird random-effects model (REM). A sub-group and sensitivity analyses were performed. Publication bias was checked by the funnel plot and Egger’s test. Furthermore, trim and fill analysis was used to adjust for publication bias using Duval and Tweedie’s method.

Thirteen (13) hospital-based articles involving a total of 40685 participants met the inclusion criteria. The pooled case fatality rate for all the included studies in SSA was 8.0%; [95% CI: 3.0%-13.0%], and the approximate case fatality rate was adjusted to 8.2%, [95% CI:3.4%-13.0%], after the trim-and-fill analysis was used to correct for publication bias. A sub-group analysis of sub-region revealed that case fatality rate was 8% [95% CI: 2.0%-13.0%] in East Africa, 1.0% [95% CI: 0.1% -3.0%] in Southern Africa and 18.0% [95% CI: 6.0%-29.0%] in west Africa. The pooled incidence proportion of TBI was 18% [95% CI: 2.0%-33.0%]. The current review showed that Road Traffic Accident (RTA) was the predominant cause of children’s TBI in SSA. It ranged from 19.1% in South Africa to 79.1% in Togo.

TBI affects 18% of children aged 0 to 18 years, with almost one-tenth dying in SSA. The most common causes of TBI among this population in SSA were RTA and falls. TBI incidence and case fatality rate of people aged 0–18 years could be significantly reduced if novel policies focusing on reducing RTA and falls are introduced and implemented in SSA.

Protocol for a prospective cohort study of open tibia fractures in Malawi with a nested implementation of open fracture guidelines

Background: Road traffic injury (RTI) is the largest cause of death amongst 15–39-year-old people worldwide, and the burden of injuries such as open tibia fractures are rapidly increasing in Malawi. This study aims to investigate disability and economic outcomes of people with open tibia fractures in Malawi and improve these with locally delivered implementation of open fracture guidelines.
Methods: This is a prospective cohort study describing function, quality of life and economic burden of open tibia fractures in Malawi. In total, 160 participants will be recruited across six centres and will be followed-up with face-to-face interviews at six weeks, three months, six months and one year following injury. The primary outcome will be function at one year measured by the short musculoskeletal functional assessment (SMFA) score. Secondary outcomes will include quality of life measured by EuroQol EQ-5D-3L, catastrophic loss of income and implementation outcomes (acceptability, adoption, appropriateness, costs, feasibility, fidelity, penetration, and sustainability) at one year. A nested pilot pre-post implementation study of an interventional bundle for all open fractures will be developed based on other implementation studies from low- and middle-income countries (LMICs). Regression analysis will be used to model and investigate associations between SMFA score and fracture severity, infection and the pre- and post-training course period.
Outcome: This prospective cohort study will report patient reported outcomes from open tibia fractures in low-resource settings. Subsequent detailed evaluation of both the clinical and implementation components of the study will promote sustainability of improved open fractures management in the study sites and further scale-up of open fracture management guidelines.
Ethics: Ethics approval has been obtained from the Liverpool School of Tropical Medicine and College of Medicine Research and Ethics committee.

Assessing barriers to quality trauma care in low and middle-income countries

Most deaths from injury occur in Low and Middle Income Countries (LMICs) with one third potentially avoidable with better health system access. This study aimed to establish consensus on the most important barriers, within a Three Delays framework, to accessing injury care in LMICs that should be considered when evaluating a health system.
A three round electronic Delphi study was conducted with experts in LMIC health systems or injury care. In round one, participants proposed important barriers. These were synthesized into a three delays framework. In round 2 participants scored four components for each barrier. Components measured whether barriers were feasible to assess, likely to delay care for a significant proportion of injured persons, likely to cause avoidable death or disability, and potentially readily changed to improve care. In round 3 participants re-scored each barrier following review of feedback from round 2. Consensus was defined for each component as ≥70% agreement or disagreement.
There were 37 eligible responses in round 1, 30 in round 2, and 27 in round 3, with 21 countries represented in all rounds. Of the twenty conceptual barriers identified, consensus was reached on all four components for 11 barriers. This included 2 barriers to seeking care, 5 barriers to reaching care and 4 barriers to receiving care. The ability to modify a barrier most frequently failed to achieve consensus.
11 barriers were agreed to be feasible to assess, delay care for many, cause avoidable death or disability, and be readily modifiable. We recommend these barriers are considered in assessments of LMIC trauma systems.

Abdominal vascular injuries- what general/ trauma surgeons should know

Abdominal vascular injuries are the common cause of death after abdominal trauma. These are challenging injuries to manage due to severe haemodynamic instability, associated injuries and difficulty in accessing and controlling these vessels. Early control of bleeding can decrease the mortality in these patients. Abdominal vasculature is divided in four zones and each zone need different operative strategy for exposure. Principles of proximal and distal control are followed before exploring any haematoma. Endovascular interventions (angioembolization, stent-graft) have shown improved outcomes in patients with blunt abdominal trauma. Resuscitative Endovascular Balloon Occlusion of Aorta is minimal invasive method of achieving aortic occlusion and acts as bridge for definitive intervention or surgery. Updated knowledge is necessary for all those directly involved in managing these patients. The current review discusses relevant anatomy, principles, different surgical approaches and endovascular techniques to deal these injuries.

Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study

Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India.

This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries.

A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived.

In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.

Epidemiological characteristics of child injury in a tertiary paediatric surgical centre in Bangladesh

While high income countries (HICs) have reduced the mortality from child injury, it is increasing in the low- and middle-income countries (LMICs). However, injury registry and reporting are inconsistent and not well developed in the LMICs. This study aims at describing the epidemiology of child injury in a tertiary paediatric surgical centre in Bangladesh. We retrospectively analysed all patients of injury between 0 and 12 years of age admitted in the Department of Paediatric Surgery, Chattogram Medical College Hospital during January 2017 to June 2020. Analysis was done for the hospital prevalence, age and sex distribution, seasonal variations, mechanism of injury, site of involvement, and mortality from injury. There were a total of 538 patients and male to female ratio was 2.01:1. Hospital prevalence was 6.71%. Mean age was 6.60 ± 3.32 years. School age children were affected more (51.7%); and “6-10 years” age group had the highest number injuries (251 patients, 46.65%). The most common mechanisms of injuries were road-traffic accident (RTA, 35.32%), followed by fall (26.39%) and „stab or cut injury‟ (20.63%). Males experienced more abdominal injuries and females had more perineal injuries (P=0.00). RTA was the commonest mechanism in males (37.05%) and falls were the commonest mechanism in females (32.96%). „Stab or cut injury‟ was the commonest mechanism in infants and toddlers, and RTA was commonest among pre-school and school age children. There were no significant seasonal variations (P=0.09). There were 5.76% intentional injuries. Mortality was 2.60% and major causes of mortality were RTA and animal assaults. Injuries were more prevalent during the mid-childhood with an overall increasing trend with age. Mechanism of injury and site of involvement were different among different age groups and between sexes.