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Myasthenia gravis is a rare autoimmune disease, which presents with ocular or generalised symptoms. Few publications describe its prevalence in African populations. We describe a young woman who was diagnosed with myasthenia gravis in a Malawian public hospital and outline the challenges encountered in managing this condition in a low-resource setting.

BackgroundGlobally, critical illness causes up to 45 million deaths every year. The burden is highest in low-income countries such as Malawi. Critically ill patients require good quality, essential care in emergency departments and in hospital wards to avoid negative outcomes such as death. Little is known about the quality of care or the availability of necessary resources for emergency and critical care in Malawi. The aim of this study was to assess the availability of resources for emergency and critical care in Malawi using data from the Service Provision Assessment (SPA).MethodsWe conducted a secondary data analysis of the SPA – a nationwide survey of all health facilities. We assessed the availability of resources for emergency and critical care using previously developed standards for hospitals in low-income countries. Each health facility received an availability score, calculated as the proportion of resources that were present. Resource availability was sub-divided into the seven a-priori defined categories of drugs, equipment, support services, emergency guidelines, infrastructure, training and routines.ResultsOf the 254 indicators in the standards necessary for assessing the quality of emergency and critical care, SPA collected data for 102 (40.6%). Hospitals had a median resource availability score of 51.6% IQR (42.2-67.2) and smaller health facilities had a median of 37.5% (IQR 28.1-45.3). For the category of drugs, the hospitals’ median score was 62.0% IQR (52.4-81.0), for equipment 51.9% IQR (40.7-66.7), support services 33.3% IQR (22.2-77.8) and emergency guidelines 33.3% IQR (0-66.7). SPA did not collect any data for resources in the categories of infrastructure, training or routines. ConclusionHospitals in Malawi lack resources for providing emergency and critical care. Increasing data about the availability of resources for emergency and critical care and improving the hospital systems for the care of critically ill patients in Malawi should be prioritized.

An international team of experts in the field of fluid resuscitation was invited by the ESICM to form a task force to systematically review the evidence concerning fluid administration using basic monitoring. The work included a particular emphasis on pre-ICU hospital settings and resource-limited settings. The work focused on four main questions: (1) What is the role of clinical assessment to guide fluid resuscitation in shock? (2) What basic monitoring is required to perform and interpret a fluid challenge? (3) What defines a fluid challenge in terms of fluid type, ranges of volume, and rate of administration? (4) What are the safety endpoints during a fluid challenge? The expert panel found insufficient evidence to provide recommendations according to the GRADE system, and was only able to make recommendations for basic interventions, based on the available evidence and expert opinion. The panel identified significant gaps in the scientific evidence on fluid administration outside the ICU (excluding the operating theater). Globally, scientific communities and health care systems should address these critical gaps in evidence through research on how basic fluid administration in resource-rich and resource-limited settings can be improved for the benefit of patients and societies worldwide.

Introduction The cost-effectiveness of long-acting muscarinic antagonist (LAMA) umeclidinium bromide (UMEC) 62.5 μg as add-on therapy to other maintenance COPD treatments is unknown. Methods This analysis assessed the cost-effectiveness of the following in COPD: UMEC + fluticasone furoate/vilanterol 100/25 μg (FF/VI); UMEC + fluticasone propionate/salmeterol 250/50 μg (FP/SAL); and UMEC + several alternative choices of inhaled corticosteroid/long-acting β2-agonist (ICS/LABA). The model was informed with direct and indirect data from previously published studies, with a UK perspective and a lifetime horizon. Sensitivity analyses were also performed. Results For the lifetime horizon, compared with FF/VI, FP/SAL and ICS/LABAs, addition of UMEC was associated with incremental costs per quality-adjusted life-years (QALY) of £4050, £7210 and £5780, respectively, and incremental costs per life year gain of £3380, £6020 and £4940. All UMEC-containing regimens resulted in numerically lower exacerbation rates versus comparator regimens over a lifetime horizon. Conclusions Addition of UMEC to various ICS/LABA treatments was associated with higher cost than ICS/LABA alone, but was cost-effective in most scenarios.

BackgroundGlobally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and timely treatment of critically ill patients across all medical specialities. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.MethodsA Delphi process was conducted to seek consensus (>90% agreement) in a diverse panel of global clinical experts. The panel was asked to iteratively rate proposed treatments and actions based on previous guidelines and the WHO/ICRC’s Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible EECC package of clinical processes plus a list of hospital resource requirements.ResultsThe 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 hospital readiness requirements. The essential diagnosis-specific care of critically ill COVID-19 patients has an additional 7 clinical processes and 9 hospital readiness requirements.ConclusionThe study has specified the content of the essential emergency and critical care that should be provided to all critically ill patients. Implementation of EECC could be an effective strategy to reduce preventable deaths worldwide. As critically ill patients have high mortality rates, especially where trained staff or resources are limited, even small improvements would have a large impact on survival. EECC has a vital role in the effective scale-up of oxygen and other care for critically ill patients in the COVID-19 pandemic. Policy makers should prioritise EECC, increase its coverage in hospitals, and include EECC as a component of universal health coverage.

Objectives To compare injury-profiles of females and males presenting to Emergency Departments (EDs) with an Australian Football injury. Design Prospective observational study. Methods All patients presenting to one of 10 EDs in Victoria, Australia, with an Australian Football injury were included in the study. Data were prospectively collected over a 10 month period, coinciding with a complete Australian Football season, including pre-season training and practice matches. Relevant information was extracted from patient medical records regarding injury-type, body part injured, investigations and treatments required. Female and male data were compared with chi-squared and Fisher’s exact tests. Results 1635 patients were included, of whom 242 (14.8%) were female. Females had a higher proportion of hand/finger injuries (34.3% v 23.4%), neck injuries (6.6% v 2.5%) and patella dislocations (2.9% v 0.6%). Males had a higher proportion of shoulder injuries (11.5% v 5.8%), skin lacerations (8.0% v 1.7%), and thorax/abdominal/pelvic injuries (5.7% v 2.1%). Concussion rates were similar between the genders, occurring in 14.1% of all patients. Anterior cruciate ligament injuries were infrequent (1.0%) and not significantly different between genders. Females received more imaging investigations (83.1% v 74.7%) and analgesia (62.4% v 48.5%). A higher proportion of males required admission to hospital (5.0% v 2.1%), usually for surgery. Conclusion Australian Football injury profiles differed between females and males. Gender-specific injury prevention and management programs would be indicated based on the study findings.

At the beginning of the COVID-19 pandemic, UK national guidance recommended early intubation and ventilation to treat patients with COVID-19. However, multiple Chinese and Italian hospitals were already effectively utilising continuous positive airways pressure (CPAP) and high-flow nasal oxygen (HFNO) to spare ventilator capacity and intensive care resource for the most seriously ill patients, with no obvious risk to their health-care workers from virus aerosolisation. At University College London Hospital (UCLH), London, UK, we thus challenged this guidance in view of the massive anticipated demand that would not be met with existing resources.

Adults admitted to hospital with critical illness are vulnerable and at high risk of morbidity and mortality, especially in sub-Saharan African settings where resources are severely limited. As life expectancy increases, patient demographics and healthcare needs are increasingly complex and require integrated approaches. Patient outcomes could be improved by increased critical care provision that standardises healthcare delivery, provides specialist staff and enhanced patient monitoring and facilitates some treatment modalities for organ support. In Malawi, we established a new high-dependency unit within Queen Elizabeth Central Hospital, a tertiary referral centre serving the country’s Southern region. This unit was designed in partnership with managers, clinicians, nurses and patients to address their needs. In this practice piece, we describe a participatory approach to design and implement a sustainable high-dependency unit for a low-income sub-Saharan African setting. This included: prospective agreement on remit, alignment with existing services, refurbishment of a dedicated physical space, recruitment and training of specialist nurses, development of context-sensitive clinical standard operating procedures, purchase of appropriate and durable equipment and creation of digital clinical information systems. As the global COVID-19 pandemic unfolded, we accelerated unit opening in anticipation of increased clinical requirement and describe how the high-dependency unit responded to this demand.

There are an estimated 19.4 million sepsis cases every year, many of them in low-income countries. The newly adopted definition of sepsis uses Sequential Organ Failure Assessment Score (SOFA), a score which is not feasible in many low-resource settings. A simpler quick-SOFA (qSOFA) based solely on vital signs score has been devised for identification of suspected sepsis. This study aimed to determine in-hospital prevalence and outcomes of sepsis, as defined as suspected infection and a qSOFA score of 2 or more, in two hospitals in Malawi. The secondary aim was to evaluate qSOFA as a predictor of mortality. A cross-sectional study of adult in-patients in two hospitals in Malawi was conducted using prospectively collected single-day point-prevalence data and in-hospital follow-up. Of 1,135 participants, 81 (7.1%) had sepsis. Septic patients had a higher hospital mortality rate (17.5%) than non-septic infected patients (9.0%, p = 0.027, odds ratio 2.1 [1.1-4.3]), although the difference was not statistically significant after adjustment for baseline characteristics. For in-hospital mortality among patients with suspected infection, qSOFA ≥ 2 had a sensitivity of 31.8%, specificity of 82.1%, a positive predictive value of 17.5%, and a negative predictive value of 91.0%. In conclusion, sepsis is common and is associated with a high risk of death in admitted patients in hospitals in Malawi. In low-resource settings, qSOFA score that uses commonly available vital signs data may be a tool that could be used for identifying patients at risk-both for those with and without a suspected infection.

Sepsis and septic shock in the tropics are caused by a wide array of organisms. These infections are encountered mainly in low and middle-income countries (LMIC) where a lack of infrastructure and medical facilities contribute to the high morbidity and mortality. Published sepsis guidelines are based on studies primarily performed in high income countries and as such recommendations may or may not be relevant to practice in the tropics. Failure to adhere to guidelines, particularly among non-intensive care specialists even in high-income countries, is an area of concern for sepsis management. Additionally, inappropriate use of antimicrobials has led to significant antimicrobial resistance. Access to rapid, low-cost, and accurate diagnostic tests is critical in countries where tropical diseases are prevalent to facilitate early diagnosis and treatment. Implementation of performance improvement programs may improve outcomes for patients with sepsis and the addition of resuscitation and treatment bundles may further reduce mortality. Associated co-morbidities such as malnutrition and HIV influence outcomes and must be considered.

Severe malaria is common in tropical countries in Africa, Asia, Oceania and South and Central America. It may also occur in travelers returning from endemic areas. Plasmodium falciparum accounts for most cases, although P vivax is increasingly found to cause severe malaria in Asia. Cerebral malaria is common in children in Africa, manifests as coma and seizures, and has a high morbidity and mortality. In other regions, adults may also develop cerebral malaria but neurological sequelae in survivors are rare. Acute kidney injury, liver dysfunction, thrombocytopenia, disseminated intravascular coagulopathy (DIC) and acute respiratory distress syndrome (ARDS) are also common in severe malaria. Metabolic abnormalities include hypoglycemia, hyponatremia and lactic acidosis. Bacterial infection may coexist in patients presenting with shock or ARDS and this along with a high parasite load has a high mortality. Intravenous artesunate has replaced quinine as the antimalarial agent of choice. Critical care management as per severe sepsis is also applicable to severe malaria. Aggressive fluid boluses may not be appropriate in children. Blood transfusions may be required and treatment of seizures and raised intracranial pressure is important in cerebral malaria in children. Mortality in severe disease ranges from 8 to 30% despite treatment.

Tropical disease results in a great burden of critical illness. The same life-saving and supportive therapies to maintain vital organ functions that comprise critical care are required by these patients as for all other diseases. In low income countries, the little available data points towards high mortality rates and big challenges in the provision of critical care. Improving critical care in low income countries requires a focus on hospital design, training, triage, monitoring & treatment modifications, the basic principles of critical care, hygiene and the involvement of multi-disciplinary teams. As a large proportion of critical illness from tropical disease is in low income countries, the impact and reductions in mortality rates of improved critical care in such settings could be substantial.

Tropical diseases are those that occur primarily or solely in the tropics, and as such include infectious diseases that are particularly prevalent in hot, humid conditions. The incidence of encephalitis in tropical countries is reported to be as high as 6.34/100,000/year. The term encephalitis implies inflammation of the brain and includes the presence of encephalopathy with two and more of the following features: fever, seizures and/or focal neurological findings; a cerebrospinal fluid pleocytosis; electroencephalographic findings or abnormal neuroimaging suggestive of encephalitis. Transverse myelitis (TM) is an inflammation of the spinal cord which has a wide variety of clinical presentations depending on the degree (severity of myelin and neuronal injury) and site of spinal cord involvement. In the present article we discuss the various forms of tropical, viral encephalitides and myelitis and the diagnosis and management.

Viral hemorrhagic fevers (VHFs) are a group of illnesses caused by four families of viruses namely Arenaviruses, Filoviruses, Bunyaviruses, and Flaviviruses. Humans are not the natural reservoir for any of these organisms and acquire the disease through vectors from animal reservoirs. In some conditions human to human transmission is possible increasing the risk to healthy individuals in the vicinity, more so to Health Care Workers (HCW). The pathogenesis of VHF, though poorly understood, varies according to the viruses involved. The resultant microvascular damage leads to increased vascular permeability, organ dysfunction and even death. The management is generally supportive but antiviral agents are of benefit in certain circumstances.

Purpose To estimate the incremental cost-utility ratio of oral semaglutide (14 mg once daily) vs other glucagon-like peptide 1 receptor agonist treatments among adults with type 2 diabetes that was inadequately controlled with 1 to 2 oral antidiabetic drugs from a US payer perspective. Methods A state-transition model with a competing risk approach was developed for diabetic complications and risk of cardiovascular events based on the UK Prospective Diabetes Study Outcomes Model 1 equations. Baseline population characteristics reflect the PIONEER 4 trial (Efficacy and Safety of Oral Semaglutide Versus Liraglutide and Versus Placebo in Subjects With Type 2 Diabetes Mellitus) of oral semaglutide. Model comparators included subcutaneous semaglutide, dulaglutide, and liraglutide. Treatment effects (change in glycosylated hemoglobin, weight, and systolic blood pressure) were estimated by network meta-analysis. Drug, management, and event costs (in 2019 US dollars), survival after nonfatal events, and utilities were obtained from the literature. Costs and quality-adjusted life-year (QALY) outcomes were discounted at 3% annually over a lifetime horizon. Probabilistic and 1-way sensitivity analyses were performed. Findings Total estimated costs and QALYs were $144,065 and 12.98 for oral semaglutide, $145,721 and 12.96 for dulaglutide, $145,833 and 12.99 for SC semaglutide, and $149,428 and 12.97 for liraglutide, respectively. Oral semaglutide was less costly and more effective than dulaglutide and liraglutide but less costly than subcutaneous semaglutide with similar effectiveness. Oral semaglutide was favored versus subcutaneous semaglutide in 52.10% of model replications at a willingness-to-pay of $150,000 per QALY. Implications Oral semaglutide is predicted to offer health benefits similar to subcutaneous semaglutide and ahead of dulaglutide and liraglutide. Oral semaglutide is a cost-effective glucagon-like peptide 1 receptor agonist treatment option.

BackgroundGlobally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19.MethodsIn a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC’s Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements.ResultsThe 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19.ConclusionThe study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

Background. The recent joint International Society for Pharmacoeconomics and Outcomes Research / Society for Medical Decision Making Modeling Good Research Practices Task Force emphasized the importance of conceptualizing and validating models. We report a new model of chronic obstructive pulmonary disease (COPD) (part of the Galaxy project) founded on a conceptual model, implemented using a novel linked-equation approach, and internally validated. Methods. An expert panel developed a conceptual model including causal relationships between disease attributes, progression, and final outcomes. Risk equations describing these relationships were estimated using data from the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study, with costs estimated from the TOwards a Revolution in COPD Health (TORCH) study. Implementation as a linked-equation model enabled direct estimation of health service costs and quality-adjusted life years (QALYs) for COPD patients over their lifetimes. Internal validation compared 3 years of predicted cohort experience with ECLIPSE results. Results. At 3 years, the Galaxy COPD model predictions of annual exacerbation rate and annual decline in forced expiratory volume in 1 second fell within the ECLIPSE data confidence limits, although 3-year overall survival was outside the observed confidence limits. Projections of the risk equations over time permitted extrapolation to patient lifetimes. Averaging the predicted cost/QALY outcomes for the different patients within the ECLIPSE cohort gives an estimated lifetime cost of £25,214 (undiscounted)/£20,318 (discounted) and lifetime QALYs of 6.45 (undiscounted/5.24 [discounted]) per ECLIPSE patient. Conclusions. A new form of model for COPD was conceptualized, implemented, and internally validated, based on a series of linked equations using epidemiological data (ECLIPSE) and cost data (TORCH). This Galaxy model predicts COPD outcomes from treatment effects on disease attributes such as lung function, exacerbations, symptoms, or exercise capacity; further external validation is required.

Objectives A small amount of data from rural emergency facilities is collated with large urban datasets, but there are no dedicated rural emergency datasets. Methods A network of 10 rural hospitals provided ongoing detailed emergency presentation data. Results Of 59 044 emergency presentations, 25 237 patients were managed entirely at the small local hospital, including 586 triage category 2 cardiac patients, 5663 paediatric patients and 310 mental health clients. Conclusions The RAHDaR dataset includes high-risk presentations managed entirely at low resource sites and, as further sites are added, will tackle the biases that can misrepresent the performance of small rural hospitals.

In low-resource settings, many children are severely ill at arrival to hospital. The risk factors for mortality among such ill children are not well-known. Understanding which of these patients are at the highest risk could assist in the allocation of limited resources to where they are most needed. A cohort study of severely ill children treated in the resuscitation room of the pediatric emergency department at Queen Elizabeth Central Hospital in Malawi was conducted over a 6-month period in 2017. Data on signs and symptoms, vital signs, blood glucose levels, and nutritional status were collected and linked with in-hospital mortality data. The factors associated with in-hospital mortality were analyzed using multivariable logistic regression. Data for 1,359 patients were analyzed and 118 (8.7%) patients died. The following factors were associated with mortality: presence of any severely deranged vital sign, unadjusted odds ratio (UOR) 2.6 (95% CI 1.7–4.0) and adjusted odds ratio (AOR) 3.2 (95% CI 2.0–5.0); severe dehydration, UOR 2.6 (1.4–5.1) and AOR 2.8 (1.3–6.0); hypoglycemia glycemia (< 5 mmol/L), UOR 3.6 (2.2–5.8) and AOR 2.7 (1.6–4.7); and severe acute malnutrition, UOR 5.8 (3.5–9.6) and AOR 5.7 (3.3–10.0). This study suggests that among severely sick children, increased attention should be given to those with hypo/low glycemia, deranged vital signs, malnutrition, and severe dehydration to avert mortality among these high-risk patients.

Sepsis is a major reason for intensive care unit (ICU) admission, also in resource–poor settings. ICUs in low– and middle–income countries (LMICs) face many challenges that could affect patient outcome. The aim of this review is to describe differences between resource–poor and resource–rich settings regarding the epidemiology, pathophysiology, economics and research aspects of sepsis. We restricted this manuscript to the ICU setting even knowing that many sepsis patients in LMICs are treated outside an ICU. Although many bacterial pathogens causing sepsis in LMICs are similar to those in high–income countries, resistance patterns to antimicrobial drugs can be very different; in addition, causes of sepsis in LMICs often include tropical diseases in which direct damaging effects of pathogens and their products can sometimes be more important than the response of the host. There are substantial and persisting differences in ICU capacities around the world; not surprisingly the lowest capacities are found in LMICs, but with important heterogeneity within individual LMICs. Although many aspects of sepsis management developed in rich countries are applicable in LMICs, implementation requires strong consideration of cost implications and the important differences in resources. Addressing both disease–specific and setting–specific factors is important to improve performance of ICUs in LMICs. Although critical care for severe sepsis is likely cost–effective in LMIC setting, more detailed evaluation at both at a macro– and micro–economy level is necessary. Sepsis management in resource–limited settings is a largely unexplored frontier with important opportunities for research, training, and other initiatives for improvement.

Recommendations for hemodynamic assessment and support in sepsis and septic shock in resource-limited settings are largely lacking. In this chapter, we reviewed the literature and provided recommendations regarding hemodynamic assessment and support, taking into consideration aspects of efficacy and effectiveness, availability and feasibility, and affordability and safety. We suggest using capillary refill time, skin mottling scores, and skin temperature gradients and suggest passive leg raise test to guide fluid resuscitation. We recommend crystalloid solutions as the initial fluid of choice and recommend initial fluid resuscitation with 30 ml/kg in the first 3 h but with extreme caution in settings where there is lack of mechanical ventilation. Patients with severe malaria or severe dengue without hypotension should not receive fluid bolus therapy. We recommend against early start of vasopressors and suggest starting a vasopressor in patients with persistent hypotension after initial fluid resuscitation with at least 30 ml/kg, but earlier when there is lack of access to mechanical ventilation, and recommend using norepinephrine (noradrenaline) as first-line vasopressor. We suggest in patients with suspected bacterial sepsis starting an inotrope with persistence of plasma lactate >2 mmol/l or persistence of skin mottling or prolonged capillary refill time when plasma lactate cannot be measured and only after initial fluid resuscitation. We suggest the use of dobutamine as first-line inotrope, recommend administering vasopressors through a central venous line, and suggest administering vasopressors and inotropes via a central venous line using a syringe or infusion pump when available.

Objective The objective of this present study was to describe the initial destination hospital of paediatric patients transported by Ambulance Victoria paramedics within the South Western area of Victoria to determine the proportion of patients that bypassed their closest hospital. Methods All Ambulance Victoria primary ambulance transports for paediatric patients aged 1 month to 14 years in the Barwon South West region between 1 April 2008 and 28 February 2011 were reviewed. Each case was examined to determine the destination hospital location relative to the case scene location, and the overall nature of each case was grouped into one of seven categories (medical respiratory, medical cardiac, medical neurological, medical other, trauma time critical, and trauma non-time critical). Results There were 1191 cases identified, with 978 (82%) being taken to the closest hospital and 213 (18%) to a more distant facility. The average distance travelled from the scene to the destination hospital was 15.2 km, and almost 90% of patients transported to the nearest hospital were within 15 km of that hospital. Time critical trauma cases and respiratory-related medical cases had higher rates of transport to more distant hospitals as their initial destination (26% to non-closest and 23% to non-closest, respectively). Conclusion The patient's condition and their location relative to the larger medical facilities appear to influence the decision of destination hospital. Uncertainty regarding the availability of 24 h hospital services and staffing details may contribute to longer transfers.

Introduction To compare the cost-effectiveness and patient impact between acute magnetic resonance imaging (MRI) management and conventional management in the diagnosis of occult scaphoid fractures in a rural setting. Methods Consecutive patients presenting to a rural emergency department (ED) with a suspected scaphoid fracture were randomly assigned to either conventional management (6) or acute MRI management (10) (3 patients were excluded from the study analysis). All healthcare costs were compared between the two management groups and potential impacts on the patients’ pain, mobility and lifestyle were also measured. Results There were no significant differences between the two groups at baseline. There was one (10%) scaphoid fracture in the MRI group and none in the conventional group (P = 0.42). A larger proportion of other fractures were diagnosed in the MRI group (20% (2) vs. 16.7% (1), P = 0.87), as well as less clinic attendances (1 (0–2.25) vs. 4 (2.25–5)) and diagnostic services (1 (1–1.25) vs. 2 (1–3)). Median management costs were $485.05 (AUD) (MRI) and $486.90 (AUD) (conventional). The MRI group had better pain and satisfaction scores as well as less time of immobilisation, treatment and time off work. Conclusion MRI dramatically reduces the amount of unnecessary immobilisation, time of treatment and healthcare usage in a rural setting. The two protocols are suggested to be equivalent financially. When potential societal costs, the amount of unnecessary immobilisation, low prevalence of true fractures and patient satisfaction are considered, acute MRI should be the management technique of choice. Further studies are still required to assess the best method for managing bone bruise within the scaphoid.

Background Intensive care is care for critically ill patients with potentially reversible conditions. Patient selection for intensive care should be based on potential benefit but since demand exceeds availability, rationing is needed. In Tanzania, the availability of Intensive Care Units (ICUs) is very limited and the practices for selecting patients for intensive care are not known. The aim of this study was to explore doctors’ experiences and perceptions of ICU referral and admission processes in a university hospital in Tanzania. Methods We performed a qualitative study using semi-structured interviews with fifteen doctors involved in the recent care of critically ill patients in university hospital in Tanzania. Inductive conventional content analysis was applied for the analysis of interview notes to derive categories and sub-categories. Results Two main categories were identified, (i) difficulties with the identification of critically ill patients in the wards and (ii) a lack of structured triaging to the ICU. A lack of critical care knowledge and communication barriers were described as preventing identification of critically ill patients. Triaging to the ICU was affected by a lack of guidelines for admission, diverging ideas about ICU indications and contraindications, the lack of bed capacity in the ICU and non-medical factors such as a fear of repercussions. Conclusion Critically ill patients may not be identified in general wards in a Tanzanian university hospital and the triaging process for the admission of patients to intensive care is convoluted and not explicit. The findings indicate a potential for improved patient selection that could optimize the use of scarce ICU resources, leading to better patient outcomes.

Critical illness results in millions of deaths each year. Care for those with critical illness is often neglected due to a lack of prioritisation, co-ordination, and coverage of timely identification and basic life-saving treatments. To improve care, we propose a new focus on essential emergency and critical care (EECC)—care that all critically ill patients should receive in all hospitals in the world. Essential emergency and critical care should be part of universal health coverage, is appropriate for all countries in the world, and is intended for patients irrespective of age, gender, underlying diagnosis, medical specialty, or location in the hospital. Essential emergency and critical care is pragmatic and low-cost and has the potential to improve care and substantially reduce preventable mortality.

Background Cost-effectiveness of once-daily umeclidinium bromide (UMEC) was compared with once-daily tiotropium (TIO) and once-daily glycopyrronium (GLY) in patients with chronic obstructive pulmonary disease (COPD) from a UK National Health Service (NHS) perspective. Methods A linked-equation model was implemented to estimate COPD progression, associated healthcare costs, exacerbations rates, life years (LY) and quality-adjusted LY (QALYs). Statistical risk equations for endpoints and resource use were derived from the ECLIPSE and TORCH studies, respectively. Treatment effects [mean (standard error)] at 12 weeks on forced expiratory volume in 1 s and St George’s Respiratory Questionnaire score were obtained from the intention-to-treat populations of two head-to-head studies [GSK study identifiers 201316 (NCT02207829) and 201315 (NCT02236611)] which compared UMEC 62.5 mcg with TIO 18 mcg and UMEC 62.5 mcg with GLY 50 mcg, respectively. Treatment costs reflect UK list prices (2016) and NHS unit costs; UMEC and GLY prices being equal and less than TIO. A lifetime horizon, discounted costs and effects at 3.5% were used. Sensitivity analyses were performed to evaluate the robustness of variations in input parameters and assumptions in the model. Results Over a lifetime horizon, UMEC was predicted to increase LYs (+ 0.195; 95% confidence interval [CI]: 0.069, 0.356) and QALYs (+ 0.118; 95% CI: 0.055, 0.191) and reduce the number of annual exacerbations (− 0.053; 95% CI: − 0.171, 0.028) compared with TIO, with incremental cost savings of £460/patient (95% CI: − £645, − £240). Compared with GLY, UMEC increased LYs (+ 0.124; 95% CI: 0.015, 0.281) and QALYs (+ 0.101; 95% CI: 0.043, 0.179) and reduced annual exacerbation (− 0.033; 95% CI: − 0.135, 0.017) at an additional cost of £132/patient (95% CI: £12, £330), resulting in an incremental cost-effectiveness ratio of £1310/QALY (95% CI: £284, £2060). Similar results were observed in alternative time horizons and additional sensitivity analyses. Conclusions For treatment of patients with COPD in the UK over a lifetime horizon, treatment with UMEC dominates treatment with TIO, providing both improved health outcomes and cost savings. In comparison with GLY, treatment with UMEC achieved improved health outcomes but was associated with a higher cost. Trial registration 201316, NCT02207829; 201315, NCT02236611

Background: Acutely sick children in resource-constrained settings who present with hypoglycaemia have poor outcomes. Studies have questioned the current hypoglycaemia treatment cut-off level of 2.5 mmol/l. Improved knowledge about health workers’ attitudes towards and management of hypoglycaemia is needed to understand the potential effects of a raised cut-off level. Objective: This research explored health workers’ perceptions about managing acutely ill children with hypoglycaemia in a Malawian referral hospital. A secondary objective was to explore health workers’ opinions about a potential increase in the hypoglycaemia cut-off level. Methods: We used a qualitative design with semi-structured individual interviews performed with health workers in the Paediatric Accident and Emergency Unit at Queen Elizabeth Central Hospital, Malawi, in October 2016. Data were analysed using latent content analysis. Ethical approval was obtained from the University of Malawi, College of Medicine Research and Ethics Committee P.01/16/1852. Results: Four themes were formed that described the responses. The first, ‘Critical and difficult cases need easy treatment’, showed that health workers perceived hypoglycaemia as a severe condition that was easily manageable. The second, ‘Health system issues’, revealed challenges relating to staffing and resource availability. The third, ‘From parental reluctance to demand’, described a change in parents’ attitudes regarding intravenous treatments. The fourth, ‘Positive about the change but need more information’, exposed health workers’ concerns about potential risks of a raised cut-off level for hypoglycaemia treatment, as well as benefits for the patients. Conclusions: Health workers perceived hypoglycaemia as a severe condition that is easy to manage when the required equipment and supplies are available. Due to the common lack of test equipment and dextrose supplies, health workers have adopted alternative strategies to diagnose and manage hypoglycaemia. A change to the hypoglycaemia treatment cut-off level raised concerns about potential risks, but was also thought to be of benefit for some patients.

Objective There is little evidence that useful electronic data could be collected at Australian small rural emergency services. If in future their funding model changed to the Activity-Based Funding model, then they would need to collect and submit more data. We determine whether it is possible to collect episode-level data at six small rural emergency services and quantify the accuracy of eight fields. Design A prospective cross-sectional study. Setting South-West Victoria, Australia. Participants Six small rural emergency services. Intervention We collected and audited episode-level emergency data from participating services between 1 February 2011 and 31 January 2012. A random sample of these data were audited monthly. Research assistants located at each service supported data entry and audited data accuracy for four hours per week. Main outcome measures Rates for data completeness, accuracy and total accuracy were calculated using audit data. Results Episode-level data were collected for 20 224 presentations across six facilities. The audit dataset consisted of 8.5% (1504/17 627) of presentations from five facilities. For all fields audited, the accuracy of entered data was high (>93%).Triage category was deemed appropriate for 95.9% (95% confidence interval (CI): 94.9–96.9%) of the patient records reviewed. Some procedures were missing (28.7%, 95%CI: 27.2–30.3%). No significant improvement in data accuracy over 12 months was observed. Conclusion All six services collected useful episode-level data for 12-months with four hours per week of assistance. Data entry accuracy was high for all fields audited, and data entry completeness was low for procedures.

Introduction: The cost-effectiveness of treatments for chronic obstructive pulmonary disease (COPD) is needed. Objectives To evaluate the cost effectiveness of once-daily umeclidinium bromide 62.5 µg (UMEC) in combination with inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) versus other long-acting muscarinic antagonists (LAMA)+ICS/LABA triple therapy combinations in the United Kingdom (UK). Methods: A linked-equation model estimated the disease progression, associated health service costs, and impact on quality-adjusted life-years and survival (Briggs et al. Med Decis Making 2016). Statistical risk equations for clinical endpoints and resource use were derived from the ECLIPSE and TORCH studies, respectively. Model baseline inputs and treatment effects were obtained from a network meta-analysis (Chounta et al. ATS 2016). For the base case, a lifetime horizon was used and costs and effects were discounted at 3.5%. Analyses were performed from the UK National Health Service perspective. Results: UMEC+ICS/LABA improved health outcomes versus other LAMA+ICS/LABA combinations with lower costs over the lifetime. Results remained consistent at a 5- or 10-year time horizon. Sensitivity analyses showed that variation in main parameters did not alter the results. Conclusions In COPD, UMEC+ICS/LABA is cost saving and improves health outcomes versus other LAMA+ICS/LABA triple combinations in the UK. Funding GSK (HO-15-8059)

Introduction: Information about the cost effectiveness of add-on treatments for chronic obstructive pulmonary disease (COPD) is needed. Objectives To evaluate the cost effectiveness of once-daily umeclidinium bromide 62.5μg (UMEC) added to inhaled corticosteroids/long-acting β2-agonists (ICS/LABA) versus ICS/LABA in the United Kingdom (UK). Methods: A linked-equation model estimated disease progression, associated health service costs, and impact on quality-adjusted life-years and survival. Statistical risk equations for clinical endpoints and resource use were derived from the ECLIPSE and TORCH studies, respectively. Model baseline inputs and treatment effects were obtained from GSK trials (Siler et al. COPD 2016;13:1–10; Siler et al. Respir Med 2015;109:1155–63) and discontinuation rates from the UPLIFT study. A lifetime horizon was used and costs and effects were discounted at 3.5%. Analyses were performed from the UK National Health Service perspective. Results: Against slightly higher costs, UMEC added to ICS/LABA resulted in improved outcomes. Incremental cost-effectiveness ratios remained within recognised cost-effectiveness thresholds. Sensitivity analyses showed that variation in main parameters did not alter the results including at shorter time horizons of 5 and 10 years. Conclusions Against slightly higher costs, UMEC improves health outcomes when added to ICS/LABA in COPD in the UK. Funding GSK (HO-15-8059)

Objective Examine the range of clinical situations encountered at small rural emergency care services. We hypothesised that over a 12 month period, small rural emergency services would encounter almost the entire range of clinical situations described at designated EDs. Methods We undertook a cross-sectional prospective study observing five small rural emergency care services in South West Victoria. Patients were included if they presented between 1 February 2011 and 31 January 2012, and their type of visit was recorded as an emergency presentation. Main outcome measures are reports that describe clinical activity using the Victorian Emergency Minimum Dataset data collected at the five facilities. Results There were 14 318 emergency presentations to the five emergency care services over 1 year. Almost 6% of patients (5.94%, 851/14 318, 95% CI 5.6–6.3%) were in the two most urgent categories. With a wide spectrum of problems presented, the level 1 facility saw 18 of the possible 27 diagnostic categories, and the level 2 and 3 facilities both saw 25 out of 27 diagnostic categories. There were 26 586 procedures recorded. Of the 62 possible medical procedures, only seven were not performed at least once. Critical care procedures were performed in levels 2 and 3 facilities. Conclusion The five small rural emergency facilities encountered most of the clinical problems seen in full EDs. They saw almost all categories of emergency presentation, saw almost all diagnostic categories, treated critically ill and injured patients, and performed most procedures.

OBJECTIVE: Small rural emergency facilities are an important part of emergency care in many countries. We performed a systematic review of observational studies to determine what is known about the patients these small rural emergency facilities treat, what types of interventions they undertake and how well they perform. METHODS: Pubmed/Medline and Embase databases were systematically reviewed between 1980 and the present. Studies were included if they described hospital-affiliated emergency care facilities which were open 24-hours every day, and described themselves as rural, non-urban or non-metropolitan. Studies were excluded if facilities saw more than 15 000 patients annually. Study quality was assessed using 12 previously described indicators. Key activity and performance data were reported for individual studies but not numerically combined between studies. RESULTS: The search strategy found 19 studies that included quantitative data on activity and performance. Nine studies were from Canada, six were from Australia and four from the United States. The settings and scales used varied widely. Few studies adhered to methodological recommendations. The most common presentation was for injury or poisoning (30-53%). The number of patients requiring attention within 15 min was small (2.5-2.8%). Nurses treated many patients without physician input. CONCLUSIONS: There is only enough evidence in the literature to make the most basic inferences about what small rural emergency departments do. To allow evidence-based improvement, descriptive studies must employ measures and methods validated in the wider emergency medicine literature, and other research techniques should be considered. Language: en

Objective: This pilot study examines the prevalence of cardiac risk factors in a cohort of agricultural workers, assesses their knowledge of local emergency health services and investigates their decision-making abilities with regard to when and how they would seek help when experiencing chest pain. Methods: Farm men and women were recruited from 20 rural Victorian sites and underwent health assessments for total cholesterol, blood glucose, weight, height and blood pressure. Participants completed a survey to determine their knowledge of chest pain treatment, local emergency services and likely response to chest pain. Results: Cardiac risk factors within this cohort of 186 adult farming men and women were common, with 61% of men (58/95, 95% confidence interval [CI] 51–70) and 74% of women (68/91, 95% CI 65–83) either overweight or obese. When asked to name their nearest ED, 10% of participants (19/184, 95% CI 7–16) nominated health services or towns where no ED exists. Furthermore, 67% of respondents (123/185, 95% CI 59–73) believed it was safe to travel to hospital by car while potentially having a myocardial infarction. Conclusions: This cohort of agricultural workers were at considerable risk of experiencing acute coronary events, but many would make decisions about when and how to seek medical help for chest pain that are at odds with published community guidelines. These results highlight the need for education to improve knowledge of local emergency services and address behavioural barriers to accessing care.

The United Nations Millennium Development Goal 4 is to reduce the global under-five mortality rate by two-thirds by 2015. Achieving this goal requires substantial strengthening of health systems in low-income countries. Emergency and critical care services are often one of the weakest parts of the health system and improving such care has the potential to significantly reduce mortality. Introducing effective triage and emergency treatments establishing hospital systems that prioritize the critically ill and ensuring a reliable oxygen delivery system need not be resource intensive. Improving intensive care units training health staff in the fundamentals of critical care concentrating on ABC - airway breathing and circulation - and developing guidelines for the management of common medical emergencies could all improve the quality of inpatient pediatric care. Integration with obstetrics adult medicine and surgery in a combined emergency and critical care service would concentrate resources and expertise.

Background: While there is a need for good quality care for patients with serious reversible disease in all countries in the world, Emergency and Critical Care tends to be one of the weakest parts of health systems in low-income countries. We assessed the structure and availability of resources for Emergency and Critical Care in Tanzania in order to identify the priorities for improving care in this neglected specialty. Methods: Ten hospitals in four regions of Tanzania were assessed using a structured data collection tool. Quality was evaluated with standards developed from the literature and expert opinion. Results: Important deficits were identified in infrastructure, routines and training. Only 30% of the hospitals had an emergency room for adult and paediatric patients. None of the seven district and regional hospitals had a triage area or intensive care unit for adults. Only 40% of the hospitals had formal systems for adult triage and in less than one third were critically ill patients seen by clinicians more than once daily. In 80% of the hospitals there were no staff trained in adult triage or critical care. In contrast, a majority of equipment and drugs necessary for emergency and critical care were available in the hospitals (median 90% and 100% respectively. The referral/private hospitals tended to have a greater overall availability of resources (median 89.7%) than district/regional hospitals (median 70.6). Conclusions: Many of the structures necessary for Emergency and Critical Care are lacking in hospitals in Tanzania. Particular weaknesses are infrastructure, routines and training, whereas the availability of drugs and equipment is generally good. Policies to improve hospital systems for the care of emergency and critically ill patients should be prioritised.

Purpose To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis. Methods The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings. Results Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included. Conclusion Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries. Electronic supplementary material The online version of this article (doi:10.1007/s00134-012-2468-5) contains supplementary material, which is available to authorized users.

OBJECTIVE: To assess if secondary and tertiary hospitals in Mongolia have the resources needed to implement the 2008 Surviving Sepsis Campaign (SSC) guidelines. METHODS: To obtain key informant responses, we conducted a nationwide survey by sending a 74-item questionnaire to head physicians of the intensive care unit or department for emergency and critically ill patients of 44 secondary and tertiary hospitals in Mongolia. The questionnaire inquired about the availability of the hospital facilities, equipment, drugs and disposable materials required to implement the SSC guidelines. Descriptive methods were used for statistical analysis. Comparisons between central and peripheral hospitals were performed using non-parametric tests. FINDINGS: The response rate was 86.4% (38/44). No Mongolian hospital had the resources required to consistently implement the SSC guidelines. The median percentage of implementable recommendations and suggestions combined was 52.8% (interquartile range, IQR: 45.8-67.4%); of implementable recommendations only, 68% (IQR: 58.0-80.5%) and of implementable suggestions only, 43.5% (IQR: 34.8-57.6%). These percentages did not differ between hospitals located in the capital city and those located in rural areas. CONCLUSION: The results of this study strongly suggest that the most recent SSC guidelines cannot be implemented in Mongolia due to a dramatic shortage of the required hospital facilities, equipment, drugs and disposable materials. Further studies are needed on current awareness of the problem, development of national reporting systems and guidelines for sepsis care in Mongolia, as well as on the quality of diagnosis and treatment and of the training of health-care professionals.

Following an expert meeting convened in November, 2014, by the UK Chief Medical Officer, Michael Jacobs and colleagues argue there is “no evidence that addition of ventilatory or renal support would result in substantial overall benefit for patients who receive the optimum supportive care” for Ebola. Critical care support for volunteers who treat Ebola will therefore not be routinely provided in Sierra Leone or through repatriation to the UK. This recommendation contradicts our experience and that of colleagues in Germany and the USA who have managed Ebola and provided both ventilation and dialysis to patients who required it. It also goes against expert opinion from the fi eld which suggests many acutely unwell patients, and some recovering from viraemia, become anuric. Much sudden death might be attributed to renal failure and subsequent electrolyte imbalance in addition to respiratory compromise. Though priority should lie on staff safety and immediate basic care, many healthy individuals deteriorate rapidly and might undoubtedly die without organ support. As of December 2014—when we wrote this Correspondence—22 Ebola cases had been treated outside west Africa. To our knowledge where critical care support was provided, fi ve out of eight made a complete recovery. The two US and one German patients who died received late critical care intervention. As Bruce Ribner—who leads the team at Emory University Hospital Atlanta—stated: “[they] can get sick enough to need those interventions and [they] can still walk out of the hospital”. The Centers for Disease Control and Prevention and international nephrologists have produced guidelines for safe provision of haemodialysis in Ebola care. Importantly, no virus was detected in dialysis effl uent. Though ideally we would want critical care to be available for all Ebola patients, we argue that there is no medical reason against providing intensive organ support in Ebola-induced organ failure to all international volunteers whose home countries can provide it.

Background The aim of the study was to investigate the relative effectiveness of four strategies in detecting and preventing tuberculosis: contact tracing of smear-positive pulmonary disease, of smear-negative pulmonary disease and of non-pulmonary disease, and screening new entrants. Methods An analysis of patient records and a TB database was carried out for an NHS Trust-based tuberculosis service in a socio-economically deprived area. Subjects were contacts of all patients treated for TB between 1997 and 1999. New entrants were screened in 1999. Outcomes measured were numbers of cases of active tuberculosis detected and numbers of those screened given chemoprophylaxis. Results A total of 643 contacts of 227 cases of active TB were seen, and 322 new entrants to the United Kingdom. The highest proportion of contacts requiring full treatment or chemoprophylaxis were contacts of smear-positive index cases (33 out of 263 contacts; 12.5 per cent). Tracing contacts of those with smear-negative pulmonary tuberculosis (12 out of 156; 7.7 per cent) and non-pulmonary disease (14 out of 277; 6.2 per cent) was significantly more effective in identifying individuals requiring intervention (full treatment or chemoprophylaxis) than routine screening of new entrants (10 out of 322; 3.1 per cent). Conclusions Screening for TB of new entrants to the United Kingdom is part of the national programme for control and prevention of TB, whereas tracing contacts of those with smear-negative and non-pulmonary disease is not. This study demonstrates that, in our population, the contact-tracing strategy is more effective than new entrant screening. It is not likely that the contacts have caught their disease from the index case, but rather that in high-incidence areas such as ours such tracing selects extended families or communities at particularly high risk.

The difficulty of gaining access to the central skull base has led to the development of many surgical approaches to this area during the past decade. Yet we believe that the Le Fort I technique, which has been used for almost 140 years in orthognathic surgery, is still an excellent approach to treating anterior skull base lesions. This procedure, which entails the horizontal sectioning of the dentoalveolar maxillary segment, seemed to fall out of favor with otolaryngologists after a few reports of complications surfaced during the past 10 to 15 years. In this article, we report a series of seven patients whom we treated with a Le Fort I approach during a 3-year period for a variety of benign and malignant anterior skull base lesions. We have encountered no significant complications of surgery or recurrence of disease at a maximum postoperative followup of 3 years.

It is important to understand how small rural emergency departments work. They are a significant fraction of a state’s medical system. Although they each see only a few thousand patients a year, as a group they are likely to treat more emergency patients than the largest city hospital. It is a myth that they only deal with minor ailments.