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Background We previously derived a Universal Vital Assessment (UVA) score to better risk-stratify hospitalized patients in sub-Saharan Africa, including those with infection. Here, we aimed to externally validate the performance of the UVA score using previously collected data from patients hospitalized with acute infection in Rwanda. Methods We performed a secondary analysis of data collected from adults ≥18 years with acute infection admitted to Gitwe District Hospital in Rwanda from 2016 until 2017. We calculated the UVA score from the time of admission and at 72 hours after admission. We also calculated quick sepsis-related organ failure assessment (qSOFA) and modified early warning scores (MEWS). We calculated amalgamated qSOFA scores by inserting UVA cut-offs into the qSOFA score, and modified UVA scores by removing the HIV criterion. The performance of each score determined by the area under the receiver operator characteristic curve (AUC) was the primary outcome measure. Results We included 573 hospitalized adult patients with acute infection of whom 40 (7%) died in-hospital. The admission AUCs (95% confidence interval [CI]) for the prediction of mortality by the scores were: UVA, 0.77 (0.68–0.85); modified UVA, 0.77 (0.68–0.85); qSOFA, 0.66 (0.56–0.75), amalgamated qSOFA, 0.71 (0.61–0.80); and MEWS, 0.74 (0.64, 0.83). The positive predictive values (95% CI) of the scores at commonly used cut-offs were: UVA >4, 0.35 (0.15–0.59); modified UVA >4, 0.35 (0.15–0.59); qSOFA >1, 0.14 (0.07–0.24); amalgamated qSOFA >1, 0.44 (0.20–0.70); and MEWS >5, 0.14 (0.08–0.22). The 72 hour (N = 236) AUC (95% CI) for the prediction of mortality by UVA was 0.59 (0.43–0.74). The Chi-Square test for linear trend did not identify an association between mortality and delta UVA score at 72 hours (p = 0.82). Conclusions The admission UVA score and amalgamated qSOFA score had good predictive ability for mortality in adult patients admitted to hospital with acute infection in Rwanda. The UVA score could be used to assist with triage decisions and clinical interventions, for baseline risk stratification in clinical studies, and in a clinical definition of sepsis in Africa.

Objective To assess the value of the inability to walk unassisted to predict hospital mortality in patients with suspected infection in a resource-limited setting. Methods This is a post hoc study of a prospective trial performed in rural Rwanda. Patients hospitalized because of a suspected acute infection and who were able to walk unassisted before this disease episode were included. At hospital presentation, the walking status was graded into: 1) can walk unassisted, 2) can walk assisted only, 3) cannot walk. Receiver operating characteristic (ROC) analyses and two-by-two tables were used to determine the sensitivity, specificity, negative and positive predictive values of the inability to walk unassisted to predict in-hospital death. Results One-thousand-sixty-nine patients were included. Two-hundred-one (18.8%), 315 (29.5%), and 553 (51.7%) subjects could walk unassisted, walk assisted or not walk, respectively. Their hospital mortality was 0%, 3.8% and 6.3%, respectively. The inability to walk unassisted had a low specificity (20%) but was 100% sensitive (CI95%, 90–100%) to predict in-hospital death (p = 0.00007). The value of the inability to walk unassisted to predict in-hospital mortality (AUC ROC, 0.636; CI95%, 0.564–0.707) was comparable to that of the qSOFA score (AUC ROC, 0.622; CI95% 0.524–0.728). Fifteen (7.5%), 34 (10.8%) and 167 (30.2%) patients who could walk unassisted, walk assisted or not walk presented with a qSOFA score count ≥2 points, respectively (p

OBJECTIVE To evaluate whether a focused education program and implementation of a treatment bundle increases the rate of early evidence-based interventions in patients with acute infections. DESIGN Single-center, prospective, before-and-after feasibility trial. SETTING Emergency department of a sub-Saharan African district hospital. PATIENTS Patients > 28 days of life admitted to the study hospital for an acute infection. INTERVENTIONS The trial had three phases (each of four months). Interventions took place during the second (educational program followed by implementation of the treatment bundle) and third (provision of resources to implement treatment bundle) phases. MEASUREMENTS AND MAIN RESULTS Demographic, clinical, and laboratory data were collected at study enrollment; 24, 48, and 72 hours after hospital admission; and at discharge. A total of 1,594 patients were enrolled (pre-intervention, n = 661; intervention I, n = 531; intervention II, n = 402). The rate of early evidence-based interventions per patient during Intervention Phase I was greater than during the pre-intervention phase (74 ± 17 vs. 79 ± 15%, p < 0.001). No difference was detected when data were compared between Intervention Phases I and II (79 ± 15 vs. 80 ± 15%, p = 0.58). No differences in the incidence of blood transfusion (pre-intervention, 6%; intervention I, 7%; intervention II, 7%) or severe adverse events in the first 24 hours (allergic reactions: pre-intervention, 0.2%; intervention I, 0%; intervention II, 0%; respiratory failure: pre-intervention, 2%; intervention I, 2%; intervention II, 2%; acute renal failure: pre-intervention, 2%; intervention I, 2%; intervention II, 1%) were observed. CONCLUSIONS Our results indicate that a focused education program and implementation of an infection treatment bundle in clinical practice increased the rate of early evidence-based interventions in patients with acute infections (mostly malaria) admitted to a sub-Saharan African district hospital. Provision of material resources did not further increase this rate. While no safety issues were detected, this could be related to the very low disease severity of the enrolled patient population (www.clinicaltrials.gov: NCT02697513).

To deploy machine learning tools (random forests) to develop a model that reliably predicts hospital mortality in children with acute infections residing in low- and middle-income countries, using age and other variables collected at hospital admission.Post hoc analysis of a single-center, prospective, before-and-after feasibility trial.Rural district hospital in Rwanda, a low-income country in Sub-Sahara Africa.Infants and children greater than 28 days and less than 18 years of life hospitalized because of an acute infection.None.Age, vital signs (heart rate, respiratory rate, and temperature) capillary refill time, altered mental state collected at hospital admission, as well as survival status at hospital discharge were extracted from the trial database. This information was collected for 1,579 adult and pediatric patients admitted to a regional referral hospital with an acute infection in rural Rwanda. Nine-hundred forty-nine children were included in this analysis. We predicted survival in study subjects using random forests, a machine learning algorithm. Five prediction models, all including age plus two to five other variables, were tested. Three distinct optimization criteria of the algorithm were then compared. The in-hospital mortality was 1.5% (n = 14). All five models could predict in-hospital mortality with an area under the receiver operating characteristic curve ranging between 0.69 and 0.8. The model including age, respiratory rate, capillary refill time, altered mental state exhibited the highest predictive value area under the receiver operating characteristic curve 0.8 (95% CI, 0.78-0.8) with the lowest possible number of variables.A machine learning-based algorithm could reliably predict hospital mortality in a Sub-Sahara African population of 949 children with an acute infection using easily collected information at admission which includes age, respiratory rate, capillary refill time, and altered mental state. Future studies need to evaluate and strengthen this algorithm in larger pediatric populations, both in high- and low-/middle-income countries.

Background Our system uses a hub and spoke approach to provide surgical care for our rural population. Patients access care anywhere in the system but are transferred centrally for surgical care. We sought to determine if surgical outcome differed depending on where initial care occurred. We chose acute appendicitis (AA) to investigate our care model. Methods We identified patients admitted with the diagnosis of AA. Patients were divided into 2 groups, Bassett Medical Center presentation and satellite center (SAT) presentation. Demographics were compared and, time from system access to surgery, time of surgery, and clinical information associated with care. Results There were no differences regarding any clinically relevant factor. SAT patients had longer mean surgery times, 60.7 minutes vs 51.5 ( P =.008). Time to surgery, LOS, and complications were similar. Conclusions It is safe to care for AA patients with a hub and spoke approach without putting SAT patients at a disadvantage.

ObjectiveOpen vascular surgical procedures have decreased since the advent of endovascular repair. Advances in spinal fusion techniques and artificial disc replacement have led to an increase in the need for anterior retroperitoneal exposure of the lumbar spine (ARES). Vascular surgeons participate as “exposure surgeons” for these cases due to their unique skills in dealing with retroperitoneal structures. We report a single center experience with this procedure and focus on injury pattern and preservation of open surgical training.MethodsPatients undergoing ARES over an 8-year period were identified from our vascular registry. A two-team approach involving a vascular surgeon and spine surgeon has been routinely employed. ARES was performed for anterior lumbar interbody fusion or total disc replacement. The intraoperative techniques of vascular manipulation were reviewed. The need for suture repair of vascular structures and the incidence and timing of serious vascular injury was recorded.ResultsFour-hundred and five ARES procedures were performed. The levels exposed included L5-S1 alone (128), L4-5 (54), 4-5 and 5-S1 (139), and other combinations in 84 cases. The exposure involved the L4-5 disc in 243 cases (60%). Exposure of L4-5 was accomplished above the left common iliac artery (CIA) in 44%, between the left CIA and common iliac vein (CIV) in 45%, and below the left CIV in 11%. Minor vascular injuries (all venous) needing suture repair occurred in 24% of cases overall. Minor vascular injuries occurred during both exposure (43%) and instrumentation (57%). Minor vascular injuries were significantly more frequent in cases involving the L4-5 disc than in those not involving L4-5 (31.7% vs 11.1%, P < .001). Serious, life-threatening, vascular injuries occurred in 12 patients (3%), all during instrumentation, and included left CIV laceration (seven cases), right CIV laceration (two cases), and inferior vena cava laceration, distal aortic plaque disruption and left CIA laceration in one case each. There was no association between body mass index, prior surgery, or type of instrumentation and the occurrence of minor or major vascular injuries. Postoperative vascular complications included three deep vein thromboses; two of which occurred in patients with CIV laceration.ConclusionVascular expertise is important in anterior retroperitoneal lumbar spine exposure. Minor venous injuries frequently occur during exposure and instrumentation. Significant vascular injuries, while rare, occur during instrumentation, therefore the vascular surgeon should remain present throughout the entire procedure. The vascular manipulations required during exposure of the L4-5 disc offer an excellent opportunity for open vascular surgical experience. Vascular surgeon involvement in these cases allows for prompt repair of vascular injuries and provides opportunities for the vascular surgery resident to augment his/her open surgical training.