Objective The objective of this study was to investigate the clinical usefulness of d -dimer in excluding a diagnosis of deep vein thrombosis (DVT) in patients with coronavirus disease (COVID-19) infection, potentially limiting the need for venous duplex ultrasound examination. Methods We retrospectively reviewed consecutive patients admitted to our institution with confirmed COVID-19 status by polymerase chain reaction between March 1, 2020, and May 13, 2020, and selected those who underwent both d -dimer and venous duplex ultrasound examination. This cohort was divided into two groups, those with and without DVT based on duplex ultrasound examination. These groups were then compared to determine the value of d -dimer in establishing this diagnosis. Results A total of 1170 patients were admitted with COVID-19, of which 158 were selected for this study. Of the 158, there were 52 patients with DVT and 106 without DVT. There were no differences in sex, age, race, or ethnicity between groups. Diabetes and routine hemodialysis were less commonly seen in the group with DVT. More than 90% of patients in both groups received prophylactic anticoagulation, but the use of low-molecular-weight heparin or subcutaneous heparin prophylaxis was not predictive of DVT. All patients had elevated acute-phase d -dimer levels using conventional criteria, and 154 of the 158 (97.5%) had elevated levels with age-adjusted criteria (mean d -dimer 16,163 ± 5395 ng/mL). Those with DVT had higher acute-phase d -dimer levels than those without DVT (median, 13,602 [interquartile range, 6616-36,543 ng/mL] vs 2880 [interquartile range, 1030-9126 ng/mL], P < .001). An optimal d -dimer cutoff of 6494 ng/mL was determined to differentiate those with and without DVT (sensitivity 80.8%, specificity 68.9%, negative predictive value 88.0%). Wells DVT criteria was not found to be a significant predictor of DVT. Elevated d -dimer as defined by our optimal metric was a statistically significant predictor of DVT in both univariate and multivariable analyses when adjusting for other factors (odds ratio, 6.12; 95% confidence interval, 2.79-13.39; P < .001). Conclusions d -dimer levels are uniformly elevated in patients with COVID-19. Although standard predictive criteria failed to predict DVT, our analysis showed a d -dimer of less than 6494 ng/mL may exclude DVT, potentially limiting the need for venous duplex ultrasound examination.

Background Severe traumatic brain injury (TBI) is a major cause of death and disability worldwide. However, prospective TBI data from sub-Saharan Africa are sparse. This study examines the epidemiology, and explores management of severe TBI patients and adherence to the Brain Trauma Foundation (BTF) Guidelines at a tertiary care referral hospital in Tanzania. Methods Patients with severe TBI hospitalized at Bugando Medical Centre, Mwanza, Tanzania, were recorded in a prospective registry. Epidemiological, clinical, treatment and outcome data were recorded. Results Between September 2013 and October 2015, 371 patients with TBI were admitted. 33% (115/371) had severe TBI. Mean age was 32.0±20.1 years, and the majority were male (80.0%). Vehicular injuries were the most common cause of injury (65.2%). Half of the patients (47.8%) were hospitalized on the same day as their injury. Only 49.6% underwent computed tomography (CT) of the brain, and 58.3% were admitted to the intensive care unit (ICU). Continuous arterial blood pressure (cABP) monitoring and intracranial pressure (ICP) monitoring were not performed on any patient. 38.3% of patients with severe TBI received hyperosmolar therapy and 35.7% underwent craniotomy. Two-week mortality was 34.8%. Conclusion Mortality of patients with severe TBI at Bugando Medical Center, Tanzania, is approximately twice that in high-income countries. ICU care, CT imaging, cABP and ICP monitoring are underutilized or unavailable in the tertiary referral hospital setting. Improving outcomes after severe TBI will require concerted investment in pre-hospital care as well as improvement in availability of ICU resources, CT imaging and expertise in multidisciplinary care.

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Diarrhea remains a significant cause of morbidity and mortality among children in developing countries. Water, sanitation, and hygiene practices (WASH) have demonstrated improved diarrhea-related outcomes but may have limited implementation in certain communities. This study analyzes the adoption and effect of WASH-based practices on diarrhea in children under age five in the rural Busiya chiefdom in northwestern Tanzania. In a cross-sectional analysis spanning July-September 2019, 779 households representing 1338 under-five children were surveyed. Among households, 250 (32.1%) reported at least one child with diarrhea over a two-week interval. Diarrhea prevalence in under-five children was 25.6%. In per-household and per-child analyses, the strongest protective factors against childhood diarrhea included dedicated drinking water storage (OR 0.25, 95% CI 0.18–0.36; p < 0.001), improved waste management (OR 0.37, 95% CI 0.27–0.51; p < 0.001), and separation of drinking water (OR 0.38, 95% CI 0.24–0.59; p < 0.001). Improved water sources were associated with decreased risk of childhood diarrhea in per-household analysis (OR 0.72, 95% CI 0.52–0.99, p = 0.04), but not per-child analysis (OR 0.83, 95% CI 0.65–1.05, p = 0.13). Diarrhea was widely treated (87.5%), mostly with antibiotics (44.0%) and oral rehydration solution (27.3%). Targeting water transportation, storage, and sanitation is key to reducing diarrhea in rural populations with limited water access.

OBJECTIVEGiven the high burden of neurotrauma in low- and middle-income countries (LMICs), in this observational study, the authors evaluated the treatment and outcomes of patients with severe traumatic brain injury (TBI) accessing care at the national neurosurgical institute in Tanzania.METHODSA neurotrauma registry was established at Muhimbili Orthopaedic Institute, Dar-es-Salaam, and patients with severe TBI admitted within 24 hours of injury were included. Detailed emergency department and subsequent medical and surgical management of patients was recorded. Two-week mortality was measured and compared with estimates of predicted mortality computed with admission clinical variables using the Corticoid Randomisation After Significant Head Injury (CRASH) core model.RESULTSIn total, 462 patients (mean age 33.9 years) with severe TBI were enrolled over 4.5 years; 89% of patients were male. The mean time to arrival to the hospital after injury was 8 hours; 48.7% of patients had advanced airway management in the emergency department, 55% underwent cranial CT scanning, and 19.9% underwent surgical intervention. Tiered medical therapies for intracranial hypertension were used in less than 50% of patients. The observed 2-week mortality was 67%, which was 24% higher than expected based on the CRASH core model.CONCLUSIONSThe 2-week mortality from severe TBI at a tertiary referral center in Tanzania was 67%, which was significantly higher than the predicted estimates. The higher mortality was related to gaps in the continuum of care of patients with severe TBI, including cardiorespiratory monitoring, resuscitation, neuroimaging, and surgical rates, along with lower rates of utilization of available medical therapies. In ongoing work, the authors are attempting to identify reasons associated with the gaps in care to implement programmatic improvements. Capacity building by twinning provides an avenue for acquiring data to accurately estimate local needs and direct programmatic education and interventions to reduce excess in-hospital mortality from TBI.

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Closed suction drains (CSD) are commonly used in ventral hernia repair (VHR), with or without prolonged postoperative prophylactic antibiotics (PPA) for the duration of their use. We examine the evidence that PPA with CSD reduce surgical site infection (SSI) in patients undergoing VHR. We also examine the evidence assessing the association between SSI and CSD in VHR. A systematic review of PubMed, CIHNL, and Cochrane databases was performed to identify studies analyzing rates of SSI with CSD in patients undergoing abdominal VHR and related procedures with or without the concomitant use of PPA. The primary outcome was the rate of SSI. Five studies totaling 772 patients were identified, 525 patients were confirmed to have CSD, and 434 patients received prolonged antibiotics while drains were in place. PPA had no significant effect on SSI in two studies and were associated with decreased SSI in one study (Odds ratio 0.235, 95% confidence interval 0.090–0.617, P = 0.003). Two studies documented a higher rate of SSI in patients with CSD (79% vs 49% and 19% vs 10%) on univariate analysis. One study demonstrated a very low risk of SSI despite CSD (4.2%) and another demonstrated no increased risk with or without CSD. The use of drains is not clearly associated with an increased risk of SSI in VHR, and there is limited evidence to support antibiotic use while the drains are in place to decrease the potential risk. Prospective randomized studies are needed to more clearly assess these associations.