Global Emergency Medicine: A Review of the Literature From 2013

Objectives The Global Emergency Medicine Literature Review ( GEMLR ) conducts an annual search of peer‐reviewed and grey literature relevant to global emergency medicine ( EM ) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners. Methods This year 8,768 articles written in six languages were identified by our search. These articles were distributed among 22 reviewers for initial screening based on their relevance to the field of global EM . An additional two reviewers searched the grey literature. A total of 434 articles were deemed appropriate by at least one reviewer and approved by an editor for formal scoring of overall quality and importance. Results Of the 434 articles that met our predetermined inclusion criteria, 65% were categorized as emergency care in resource‐limited settings, 18% as EM development, and 17% as disaster and humanitarian response. A total of 24 articles received scores of 18 or higher and were selected for formal summary and critique. Interrater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.63 (95% confidence interval = 0.55 to 0.69). Infectious diseases, trauma, and the diagnosis and treatment of diseases common in resource‐limited settings represented the majority of articles selected for final review. Conclusions In 2013, there were more emergency care in resource‐limited settings articles, while the number of disaster and humanitarian response articles decreased, when compared to the 2012 review. However, the distribution of articles selected for full review did not change significantly. As in prior years, the majority of articles focused on infectious diseases, as well as trauma and injury prevention. Resumen Objetivos El grupo Global Emergency Medicine Literature Review (GEMLR) lleva a cabo una búsqueda anual de revisión por pares y de la literatura gris relevante para la Medicina de Urgencias y Emergencias ( MUE ) Global para identificar, revisar y divulgar las investigaciones recientes más importantes en este campo para la audiencia mundial de profesores universitarios y médicos clínicos. Metodología Se identificaron según nuestra búsqueda 8.768 artículos escritos en seis lenguas en 2013. Estos artículos se distribuyeron entre 22 revisores para un despistaje inicial basado en la relevancia para el área de la MUE Global. Dos revisores adicionales buscaron en la literatura gris. Un total de 434 artículos se consideraron apropiados por al menos un revisor y se aprobaron por un editor mediante una puntación formal de calidad e importancia. Resultados De los 434 artículos que cumplieron los criterios de inclusión predeterminados, un 65% se categorizó como atención urgente en escenarios de recursos limitados, un 18% como desarrollo de la MUE y un 17% como grandes catástrofes y respuesta humanitaria. Un total de 24 artículos recibió puntuaciones de 18 o más y se seleccionaron para el resumen formal y la crítica. La concordancia interobservador para los dos revisores usando nuestro sistema de puntuación fue buena con un coeficiente de correlación intraclase de 0,63 (intervalo de confianza 95% = 0,55 a 0,69). Las enfermedades infecciosas, los traumatismos y el diagnostico y tratamiento de las enfermedades comunes en escenarios de recursos limitados representaron la mayoría de los artículos seleccionados para la revisión final. Conclusiones En 2013, hubo más artículos de atención urgente en escenarios de recursos limitados, mientras que el número de artículos de grandes catástrofes y respuesta humanitaria disminuyó respecto a la revisión de 2012. Sin embargo, la distribución de los artículos seleccionados para la revisión total no cambio significativamente. Como en años anteriores, la mayoría de los artículos se centró en enfermedades infecciosas, así como en la prevención de los traumatismos y las lesiones.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/108313/1/acem12414.pd

Risk factors for seizure recurrence after initial withdrawal of anti-seizure medications in children with epilepsy at Aga Khan University Hospital, Nairobi, Kenya

Objectives: We sought to determine risk factors associated with seizure recurrence following initial withdrawal of anti-seizure medications (ASM) among children with epilepsy. Methods: This was a retrospective observational study of children aged between 2 and 18 years with a diagnosis of epilepsy who underwent withdrawal of anti-seizure medication following remission of seizures. All eligible medical records between January 2011 and December 2019 were included. Demographic, clinical, imaging and electroencephalography data of all eligible patients were analyzed against seizure remission within 24 months after withdrawal of ASM, using appropriate parametric and non-parametric tests. Results: A total of 49 records of children who underwent withdrawal of ASM out of a total of 613 patients on follow up during the same period were included. The median age at ASM withdrawal was 70 months (IQR 52–112 months) and 14 (28.6%) were female. Thirteen patients (26.5%) had seizure recurrence within 24 months following withdrawal of ASM. Focal onset seizure type was associated with significant risk of seizure recurrence (OR 13.7; 95% CI 0.97, 193.54; P value = 0.011). Age at epilepsy diagnosis, abnormal EEG at initiation of treatment and at the time of de-escalation, abnormal MRI findings, first or second degree relative with epilepsy, history of developmental delay, seizure burden, use of 2 or more ASMs and duration of seizure-freedom before de-escalation of ASM were not associated with increased risk of relapse. Conclusion: Focal onset seizure type is associated with increased with risk of seizure recurrence in this cohort

The ethical and validity conundrum in epilepsy research in LMIC settings

In the last few decades, research in epilepsy has significantly improved understanding of risk factors and etiologies associated with epilepsy, promoting greater access to interventions and medications that have improved health-related outcomes for patients. However, these advances and benefits are not being felt evenly on a global scale due to significant inequalities in access to and utilization of research resources and expertise in Low-and Middle-Income Countries (LMICs). To promote effective research output, and advance evidence-based practices; the context, disease burden, and challenges that hinder good research need to be re-defined and addressed. This is key in facilitating implementation of coherent priorities and strategies in epilepsy research in LMICs; and in facilitating the conduct of scientifically and ethically valid research. This paper explores the capacity, ecosystem, and ethical issues that are at play and that need to be addressed to support better evidence generation and utilization in epilepsy care in LMICs

Diagnostic Testing of Pediatric Fevers: Meta-Analysis of 13 National Surveys Assessing Influences of Malaria Endemicity and Source of Care on Test Uptake for Febrile Children under Five Years.

In 2010, the World Health Organization revised guidelines to recommend diagnosis of all suspected malaria cases prior to treatment. There has been no systematic assessment of malaria test uptake for pediatric fevers at the population level as countries start implementing guidelines. We examined test use for pediatric fevers in relation to malaria endemicity and treatment-seeking behavior in multiple sub-Saharan African countries in initial years of implementation. We compiled data from national population-based surveys reporting fever prevalence, care-seeking and diagnostic use for children under five years in 13 sub-Saharan African countries in 2009-2011/12 (n = 105,791). Mixed-effects logistic regression models quantified the influence of source of care and malaria endemicity on test use after adjusting for socioeconomic covariates. Results were stratified by malaria endemicity categories: low (PfPR2-10<5%), moderate (PfPR2-10 5-40%), high (PfPR2-10>40%). Among febrile under-fives surveyed, 16.9% (95% CI: 11.8%-21.9%) were tested. Compared to hospitals, febrile children attending non-hospital sources (OR: 0.62, 95% CI: 0.56-0.69) and community health workers (OR: 0.31, 95% CI: 0.23-0.43) were less often tested. Febrile children in high-risk areas had reduced odds of testing compared to low-risk settings (OR: 0.51, 95% CI: 0.42-0.62). Febrile children in least poor households were more often tested than in poorest (OR: 1.63, 95% CI: 1.39-1.91), as were children with better-educated mothers compared to least educated (OR: 1.33, 95% CI: 1.16-1.54). Diagnostic testing of pediatric fevers was low and inequitable at the outset of new guidelines. Greater testing is needed at lower or less formal sources where pediatric fevers are commonly managed, particularly to reach the poorest. Lower test uptake in high-risk settings merits further investigation given potential implications for diagnostic scale-up in these areas. Findings could inform continued implementation of new guidelines to improve access to and equity in point-of-care diagnostics use for pediatric fevers

Changing trends in incidence and aetiology of childhood acute non-traumatic coma over a period of changing malaria transmission in rural coastal Kenya: a retrospective analysis

OBJECTIVES: Recent changes in malaria transmission have likely altered the aetiology and outcome of childhood coma in sub-Saharan Africa. The authors conducted this study to examine change in incidence, aetiology, clinical presentation, mortality and risk factors for death in childhood non-traumatic coma over a 6-year period. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Secondary level health facility: Kilifi, Coast, Kenya. PARTICIPANTS: Children aged 9 months to 13 years admitted with acute non-traumatic coma (Blantyre Coma Score =2) between January 2004 and December 2009 to Kilifi District Hospital, Kenya. EXCLUSION CRITERIA: delayed development, epilepsy and sickle cell disease. RESULTS: During the study period, 665 children (median age 32 (IQR 20-46) months; 46% were girls) were admitted in coma. The incidence of childhood coma declined from 93/100 000 children in 2004 to 44/100 000 children in 2009. There was a 64% overall drop in annual malaria-positive coma admissions and a 272% overall increase in annual admissions with encephalopathies of undetermined cause over the study period. There was no change in case death of coma. Vomiting, breathing difficulties, bradycardia, profound coma (Blantyre Coma Score=0), bacteraemia and clinical signs of meningitis were associated with increased risk of death. Seizures within 24 h prior to admission, and malaria parasitaemia, were independently associated with survival, unchanging during the study period. CONCLUSION: The decline in the incidence and number of admissions of childhood acute non-traumatic coma is due to decreased malaria transmission. The relative and absolute increase in admissions of encephalopathy of undetermined aetiology could represent aetiologies previously masked by malaria or new aetiologies

The ethical and validity conundrum in epilepsy research in LMIC settings

In the last few decades, research in epilepsy has significantly improved understanding of risk factors and etiologies associated with epilepsy, promoting greater access to interventions and medications that have improved health-related outcomes for patients. However, these advances and benefits are not being felt evenly on a global scale due to significant inequalities in access to and utilization of research resources and expertise in Low-and Middle-Income Countries (LMICs). To promote effective research output, and advance evidence-based practices; the context, disease burden, and challenges that hinder good research need to be re-defined and addressed. This is key in facilitating implementation of coherent priorities and strategies in epilepsy research in LMICs; and in facilitating the conduct of scientifically and ethically valid research. This paper explores the capacity, ecosystem, and ethical issues that are at play and that need to be addressed to support better evidence generation and utilization in epilepsy care in LMICs

Pregnancy Outcomes of Mothers with Sickle Cell Disease: A Retrospective Review of Patients Seeking Delivery Services in a Regional Referral Hospital, Western Kenya

Background: Western Kenya has a high burden of sickle cell disease (SCD) with 4.5% of children born with sickle cell disease. We aimed to describe the demographic characteristics and pregnancy outcomes of women with SCD at Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH). Methods: The hospital records department retrieved all files they could identify of women who were known to have SCD and had delivered at the hospital between October 2017 and December 2022. &nbsp;Data was analyzed using STATA version 16.0. Results: Thirty files were retrieved representing 30 women who delivered in the hospital. The mean age was 26 (18 to 36) years. Most 14 (46.7%) had a term delivery. The maternal mean haemoglobin level was 8.72g/dl (range 5.6-13.5). Twelve (40%) had moderate hemoglobin concentration (8-10g/dl) and only 3 (10%) had severe anemia with HB below 6.5g/dl. A majority (76. %) had normal vaginal delivery. The Caesarean section rate was 23%. There was no maternal mortality; one pregnancy was a multiple birth resulting in 31 babies. Nearly all (93%) of the babies had an APGAR score of more than 7 at five minutes, 5 (16.67%) required NBU admission for various reasons, while one (3.33%) of the babies died within 24 hours of birth. Three of the women used Hydroxyurea at some point in their pregnancies and all had morphologically normal babies.&nbsp; Discussion: Our study findings are comparable with other case series; no maternal death was documented, however, we noted fetal outcomes which are comparable to the regional indices. Conclusion: Though pregnancy in SCD is fraught with adverse outcomes, our series demon strates that good outcomes are feasible