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BackgroundUpper gastrointestinal bleeding (UGIB) is a common emergency department (ED) presentation with high morbidity and mortality. There is a paucity of data on the profile and outcome of patients who present with UGIB to EDs, especially within limited resource settings where emergency medicine is a new specialty. We aim to describe the patient profile, clinical severity and outcomes of the patients who present with UGIB to the ED of tertiary referral hospitals in Tanzania.MethodsThis was a prospective cohort study of consecutive adult (≥18 years) patients presenting to the EDs of Muhimbili National Hospital (ED-MNH) and MUHAS Academic Medical Centre (ED-MAMC), in Tanzania with non-traumatic upper gastrointestinal bleeding (UGIB) from July 2018 to December 2018. Patient demographic data, clinical presentation, and ED and hospital management provided were recorded. We used the clinical Rockall score to assess disease severity. The primary outcome of 7- day mortality was summarized using descriptive statistics. Regression analysis was performed to identify predictors of mortality.ResultsDuring the study period, 123 patients presented to one of the two EDs with an UGIB. The median age was 42 years (Interquartile range (IQR) 32–64 years), and 87 (70.7%) were male. Hematemesis with melena was the most frequently encountered ED complaint 39 (31.7%). Within 7 days, 23 (18.7%) patients died and one-third 8 (34.8%) of these died within 24 h. There were no ED deaths. About 65.1% of the patients had severe anemia but only 60 (48.8%) received blood transfusion in the ED. Amongst those with history of (h/o) esophageal varices 7(41.2%) did not receive octreotide. Upper GI endoscopy, was performed on 46 (37.4%) patients, of whom only 8 (17.4%) received endoscopy within 24 h (early UGI endoscopy). All patients who received early UGI endoscopy had a low or moderate clinical Rockall score i.e. 4 received early UGI endoscopy. Age > 40 years was a significant independent predictor of mortality (OR = 7.00 (95% CI 1.7–29.2). Having a high clinical Rockall score of ≥ 4 was a significant independent predictor of mortality (OR = 6.4 (95% CI 1.8–22.8).ConclusionsIn this urban ED in Sub-Saharan Africa, UGIB carried a high mortality rate. Age > 40 years and clinical Rockall score ≥ 4 were independent predictors of higher mortality. Future studies should focus on evaluating how to improve access to UGI endoscopy so as to improve outcomes.

Background Elevated serum lactate levels have been shown in numerous studies to be associated with serious adverse events, including mortality. Point of care lactate level is increasingly available in resource-limited emergency department (ED) settings. However, little is known about the predictive ability of for serious adverse events. Aim of the study We aimed to describe the utility of serum lactate level as a predictor of 24-h serious adverse events among adult patients presenting at the Emergency Medicine Department (EMD) of Muhimbili National Hospital (MNH) and MUHAS Academic Medical Center (MAMC). Methods This was a prospective observational study involving adult patients presenting to the EMD-MNH and MAMC from 1 September 2018 and 31 October 2018. Eligible patients with at least one lactate level test drawn while in the ED were examined in terms of their demographics, relevant clinical characteristics, and any serious adverse event (SAE) within 24 h of arrival. The sensitivity and specificity of lactate level to predict outcomes of interest were determined using the best cut-off point constructed from AUROC to see how well lactate level could discriminate which patients would have adverse events in the next 24 h. Categorical and continuous variables were compared with the chi-square test and two-sample t test, respectively. Results We screened 2057 (20.9%) out of 9828 patients who presented during study period, and enrolled 387 (18.8%). The overall median age was 54 years (interquartile range 40–68 years) and 206 (53.2%) were male. Using local triaging system, a total of 322 (83.2%) was triaged as an emergency category. The mean lactate level was 3.2 ± 3.6 mmol/L, 65 (16.8%) patients developed at least one SAE, with 42 (11%) who required ICU/HDU, 37 (10%) needed ventilator support, 10 (3%) required inotropes, and 9 (2%) developed cardiac arrest. The overall 24-h mortality was 28 (7%). The AUC of serum lactate level for overall 24-h mortality was 0.801 (95%CI, 0.7–0.9, P ≤ 0.001). At the optimal cutoff value (3.8 mmol/L), lactate level had a sensitivity and specificity for 24-h mortality of 64% and 85%, respectively. Mortality of the high-lactate level group (33.8 mmol/L) was significantly higher than that of the low-lactate level group (p Conclusion The utility of lactate level in predicting mortality was similar to that seen in high-resource settings. A serum lactate level of 33.8 mmol/L predicted 24-h serious adverse events in unselected patients seen in the high-acuity area of our ED. Incorporating serum lactate level in ED in lower- and middle-income countries (LMICs) can help identify patients at risk of developing serious adverse events.

Background : There is a great need for physicians in Tanzania. In 2012, there were approximately 0.31 physicians per 10,000 individuals nationwide, with a lower ratio in the rural areas, where the majority of the population resides. In response, universities across Tanzania have greatly increased the enrollment of medical students. Yet evidence suggests high attrition of medical graduates to other professions and emigration from rural areas where they are most needed. Objective : To estimate the future number of physicians practicing in Tanzania and the potential impact of interventions to improve retention, we built a model that tracks medical students from enrollment through clinical practice, from 1990 to 2025. Design : We designed a Markov process with 92 potential states capturing the movement of 25,000 medical students and physicians from medical training through employment. Work possibilities included clinical practice (divided into rural or urban, public or private), non-clinical work, and emigration. We populated and calibrated the model using a national 2005/2006 physician mapping survey, as well as graduation records, graduate tracking surveys, and other available data. Results : The model projects massive losses to clinical practice between 2016 and 2025, especially in rural areas. Approximately 56% of all medical school students enrolled between 2011 and 2020 will not be practicing medicine in Tanzania in 2025. Even with these losses, the model forecasts an increase in the physician-to-population ratio to 1.4 per 10,000 by 2025. Increasing the absorption of recent graduates into the public sector and/or developing a rural training track would ameliorate physician attrition in the most underserved areas. Conclusions : Tanzania is making significant investments in the training of physicians. Without linking these doctors to employment and ensuring their retention, the majority of this investment in medical education will be jeopardized. Keywords : workforce; modeling; doctor shortage; Tanzania (Published: 27 June 2016) Citation: Glob Health Action 2016, 9 : 31597 - http://dx.doi.org/10.3402/gha.v9.31597