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Objective To describe the characteristics and chief complaints of adults seeking emergency care at two Cambodian provincial referral hospitals. Methods Adults aged 18 years or older who presented without an appointment at two public referral hospitals were enrolled in an observational study. Clinical and demographic data were collected and factors associated with hospital admission were identified. Patients were followed up 48 hours and 14 days after presentation. Findings In total, 1295 hospital presentations were documented. We were able to follow up 85% (1098) of patients at 48 hours and 77% (993) at 14 days. The patients' mean age was 42 years and 64% (823) were females. Most arrived by motorbike (722) or taxi ortuk-tuk (312). Most common chief complaints were abdominal pain (36%; 468), respiratory problems (15%; 196) and headache (13%; 174). Of the 1050 patients with recorded vital signs, 280 had abnormal values, excluding temperature, on arrival. Performed diagnostic tests were recorded for 539 patients: 1.2% (15) of patients had electrocardiography and 14% (175) had diagnostic imaging. Subsequently, 783 (60%) patients were admitted and 166 of these underwent surgery. Significant predictors of admission included symptom onset within 3 days before presentation, abnormal vital signs and fever. By 14-day follow-up, 3.9% (39/993) of patients had died and 19% (192/993) remained functionally impaired. Conclusion In emergency admissions in two public hospitals in Cambodia, there is high admission-to-death ratio and limited application of diagnostic techniques. We identified ways to improve procedures, including better documentation of vital signs and increased use of diagnostic techniques. [TEXT NOT REPRODUCIBLE IN ASCII] [TEXT NOT REPRODUCIBLE IN ASCII] Objectif Decrire les caracteristiques et les principales affections des adultes qui ont recours aux soins d'urgence dans deux hopitaux cambodgiens provinciaux de reference. Methodes Les adultes ages de plus de 18 ans qui se sont presentes sans rendez-vous a deux hopitaux publics de reference, ont ete inscrits a une etude observationnelle. Les donnees cliniques et demographiques ont ete recueillies et les facteurs associes a l'hospitalisation ont ete identifies. Les patients ont ete suivis 48 heures et 14 jours apres leur presentation. Resultats Au total, 1295 presentations a Lhopital ont ete documentees. Nous avons pu suivre 85% (1098) des patients 48 heures et 77% (993) 14 jours apres leur presentation. L'age moyen des patients etait de 42 ans et 64% (823) des patients etaient des femmes. La plupart des patients etaient arrives en moto (722), en taxi ou en tuk-tuk (312). Les principales affections communes etaient en majorite des douleurs abdominales (36%; 468), des problemes respiratoires (15%; 196) et des maux de tete (13%; 174). Parmi les 1050 patients dont les signes vitaux ont ete enregistres, 280 avaient des valeurs anormales, hormis la temperature, lors de leur arrivee. Les tests diagnostiques realises ont ete enregistres pour 539 patients: 1,2% (15) des patients avait beneficie d'une electrocardiographie et 14% (175) des patients avaient beneficie de l'imagerie diagnostique. Par la suite, 783 (60%) patients ont ete hospitalises et 166 d'entre eux ont subi une operation chirurgicale. Les indicateurs significatifs d'hospitalisation comprenaient l'apparition des symptomes dans les 3 jours precedant la presentation, des signes vitaux anormauxet la fievre. A Tissue du suivi des 14 jours, 3,9% (39/993) des patients etaient decedes et 19% (192/993) des patients presentaient des capacites fonctionnelles diminuees. Conclusion Dans les hospitalisations d'urgence dans les deux hopitaux publics au Cambodge, il y a un rapport hospitalisation-deces eleve et une application limitee des techniques de diagnostic. Nous avons identifie des moyens pour ameliorer les procedures, y compris Ia meilleure documentation des signes vitaux et l'utilisation accrue des techniques de diagnostic. Objetivo Describir las caracteristicas y quejas principales de los adultos que solicitan atencion de emergencia en dos hospitals provinciales de remision de Camboya. Metodos Se inscribio a adultos mayores de 18 anos que acudieron sin cita previa a dos hospitales publicos de remision en un estudio observacional. Se recogieron datos clinicos y demograficos y se identificaron los factores relacionados con el ingreso hospitalario. Se realizo un seguimiento a los pacientes durante 48 horas y 14 dias despues de la visita hospitalaria. Resultados En total, se documentaron 1295 visitas hospitalarias. Se logro realizar un seguimiento del 85 % (1098) y del 77 % (993) de los pacientes a las 48 horas y a los 14 dias, respectivamente. La edad media de los pacientes fue de 42 anos y el 54 % (823) eran mujeres. La mayoria acudio en motocicleta (722), taxi o tuk-tuk (312). Las quejas principales mas comunes fueron dolor abdominal (36 %; 458), problemas respiratorios (15 %; 196) y cefalea (13 %; 174). De los 1050 pacientes con registro de constantes vitales, 280 presentaron valores anomalos, a excepcion de la temperatura corporal, a su llegada. Se registraron las pruebas diagnosticas realizadas en 539 pacientes: se realizo una electrocardiografia al 1,2% (15) e imagenes diagnosticas al 14% (175) de los pacientes. Posteriormente, 783 (60 %) de los pacientes fueron ingresados, de los cuales 166 se sometieron a cirugia. Los predictores significativos para el ingreso incluyeron Ia aparicion de los sintomas 3 dias antes de Ia visita hospitalaria, constantes vitales anomalas yfiebre. Antes de finalizar el seguimiento de 14 dias, el 3,9 % (39/993) de los pacientes habia fallecido y el 19 % (192/993) seguia presentando discapacidades funcionales. Conclusion Las hospitalizaciones de emergencia de dos hospitales publicos de Camboya presentan una elevada relacion entre ingreso y defuncion, asi como un uso limitado de Ias tecnicas de diagnostico. Se identificaron formas de mejorar los procedimientos, como una mejor documentacion de las constantes vitales y un mayor uso de Ias tecnicas de diagnostico., Introduction Emergency medicine is a neglected component of health-care systems in most low- and middle-income countries. Nearly half of deaths and one third of disability adjusted life-years lost in these [...]

We wholeheartedly agree with Paul Farmer and colleagues [1] that it is vitally important to examine social, as well as molecular, causes of disease. Unless we carefully consider the full [...]

Objective: To assess the rates and determinants of mortality, loss to follow-up and immunological failure in a nongovernmental organization-implemented program of access to antiretroviral treatment in Côte d'Ivoire., Methods: In each new treatment center, professionals were trained in HIV care, and a computerized data system was implemented. Individual patient and program level determinants of survival, loss to follow-up and immunological failure were assessed by multivariate analysis., Results: Between May 2004 and February 2007, 10,211 patients started antiretroviral treatment in 19 clinics (median preantiretroviral treatment CD4 cell count, 123 cells/microl; initial regimen zidovudine-lamivudine-efavirenz, 20%; stavudine-lamivudine-efavirenz, 22%; stavudine-lamivudine-nevirapine, 52%). At 18 months on antiretroviral treatment, the median gain in CD4 cell count was +202 cells/microl, the probability of death was 0.15 and the probability of being loss to follow-up was 0.21. In addition to the commonly reported determinants of impaired outcomes (low CD4 cell count, low BMI, low hemoglobin, advanced clinical stage, old age and poor adherence), two factors were also shown to independently jeopardize prognosis: male sex (men vs. women: hazard ratio = 1.52 for death, 1.27 for loss to follow-up, 1.31 for immunological failure); and attending a recently opened clinic (inexperienced vs. experienced centers: hazard ratio = 1.40 for death, 1.58 for loss to follow-up). None of the three outcomes was associated with the drug regimen., Discussion: In this rapidly scaling-up program, survival and immune reconstitution were good; women and patients followed up in centers with longer experience had better outcomes; outcomes were similar in zidovudine/stavudine-based regimens and in efavirenz/nevirapine-based regimens. Decreasing the rate of loss to follow-up should now be the top priority in antiretroviral treatment rollout.