Epidemiology of injured patients in rural Uganda: A prospective trauma registry’s first 1000 days

Dennis J. Zheng; Patrick J. Sur; Mary Goretty Ariokot; Catherine Juillard; Mary Margaret Ajiko; Rochelle A. Dicker

doi:10.1371/journal.pone.0245779

Peer Review History

Original SubmissionAugust 24, 2020
2 Nov 2020 Decision Letter - Zsolt J. Balogh, Editor PONE-D-20-26572 Epidemiology of Injured Patients in Rural Uganda: A Prospective Trauma Registry’s First 1000 Days PLOS ONE Dear Dr. Dicker, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Dec 17 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: N/A ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ******** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Dear Rochelle and team You report the establishment of a trauma registry in a regional rural facility in eastern Uganda and detail the injury mechanisms, age and sex differentiation over time, defining the common injury patterns. This is laudable work. I have only some minor technical comments and some suggestions to slightly expand the discussion. 1) As per the recent SABRE guidelines I suggest where you refer to GENDER this is changed to SEX (the former is self-determined and the latter genetically fixed) 2) Some minor expansion of the discussion to include not only the other Ugandan reports on injury burden, but also the other countries around Uganda would be useful (recent work from Botswana and Tanzania published in WJS or AfJEM and from Malawi in various journals would be useful for comparison, not to mention the numerous papers detailing a very different injury pattern from South Africa 3) A discussion around the NSOAP recently completed for Uganda would be useful to contextualize the paper 4) A clear conclusion that is not stated strongly enough as a recommendation would be the establishment of a proper Emergency Department at the hospital. A well written and timely paper on an important aspect of the 4th burden of disease in LMICs Reviewer #2: The authors describe the initiation of a trauma registry in Uganda, after analysis of the first 1000 days. The authors are to be complimented in their effort to set up such a registry and attempt to improve prevention and treatment of trauma victims in their country. Nevertheless, several questions remain: * I understand the reason why the KTS was used, it makes comparison with other international studies difficult. Furthermore, this score mainly contains physiological parameters, parameters which are known to be missing when not collected miticuleously (in the present study 48% missing data). And when they are collected, these parameters are severely influenced by the pre-hospital setting (distance/time, treatment given/not given etc). Is additional information available for (at least a part of) these patients, such as ISS, NISS? The advantage of these scores based on anatomy is they can be collected in hindsight. * A statement is made that the registry influences trauma outcome. Do the authors have data on this statement? Can this be further elaborated? * The number of patients included in the registry declines over time (each period, the number is cut in half). This might be one of the most important findings of this paper. Can there be reasons identified for this phenomenon? How can other centers learn from this experience? ******** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0245779.r001
Revision 1
17 Dec 2020 Author Response RESPONSE TO REVIEWERS The original comments by Reviewer 1 and Reviewer 2 are listed below, followed by our response to each comment: Reviewer 1: 1. As per the recent SABRE guidelines I suggest where you refer to GENDER this is changed to SEX (the former is self-determined and the latter genetically fixed) This has been corrected in each instance. 2. Some minor expansion of the discussion to include not only the other Ugandan reports on injury burden, but also the other countries around Uganda would be useful (recent work from Botswana and Tanzania published in WJS or AfJEM and from Malawi in various journals would be useful for comparison, not to mention the numerous papers detailing a very different injury pattern from South Africa Studies describing findings from other sub-Saharan African trauma registries were added to the discussion in order to better contextualize our work. 3. A discussion around the NSOAP recently completed for Uganda would be useful to contextualize the paper We were unable to discover much about the current status of Uganda’s NSOAP in the literature, nor are our local collaborators involved in its development, but this will undoubtedly be a landmark step in the advancement of care for surgical patients in Uganda. 4. A clear conclusion that is not stated strongly enough as a recommendation would be the establishment of a proper Emergency Department at the hospital. This is a valuable lesson learned from our registry implementation and has been better emphasized in our conclusion. Reviewer 2: 1. I understand the reason why the KTS was used, it makes comparison with other international studies difficult. Furthermore, this score mainly contains physiological parameters, parameters which are known to be missing when not collected miticuleously (in the present study 48% missing data). And when they are collected, these parameters are severely influenced by the pre-hospital setting (distance/time, treatment given/not given etc). Is additional information available for (at least a part of) these patients, such as ISS, NISS? The advantage of these scores based on anatomy is they can be collected in hindsight. Many trade-offs were made in the development of the registry’s instrument, in particular balancing the desire for detailed data collection while maintaining the feasibility of the project. The hospital’s workflow demands and lack of widespread clinical expertise prevented us from reliably establishing an Injury Severity Score for the patients in the registry, whether prospectively or retrospectively. Previously published work from our group has demonstrated the significant predictive value for hospital mortality of physiologic scoring systems such as the Kampala Trauma Score (KTS). We felt this approach would maximize practicality and allow for adequate comparisons with other trauma registries located in low- & middle-income settings. The inability to reliably record all of the elements making up the KTS is a multifactorial problem and represents a focus of ongoing quality improvement measures, in part driven by the trauma registry. 2. A statement is made that the registry influences trauma outcome. Do the authors have data on this statement? Can this be further elaborated? In our discussion we have described in further detail the possible downstream effects of trauma registry implementation. Given the extensive education efforts associated with the establishment and maintenance of the registry, it is not inconceivable that clinical providers could have altered their behaviors to emphasize collection of vital signs, for example. While the Hawthorne effect may influence the practice of clinical care in this way, we would hesitate to say that it may affect patient outcomes. 3. The number of patients included in the registry declines over time (each period, the number is cut in half). This might be one of the most important findings of this paper. Can there be reasons identified for this phenomenon? How can other centers learn from this experience? In our revised discussion we describe in further detail the varied factors contributing to the decline in registry patients over time. They encompass a range of barriers to success in global health, many of which have fatally afflicted trauma registries around the world. Although our data collection is not as robust as it once was, we have successfully adapted our approach to meet the challenge of sustainability, and we consider our currently operational database to serve as an example of the immense capabilities of a locally-run trauma registry. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0245779.r002
8 Jan 2021 Decision Letter - Zsolt J. Balogh, Editor Epidemiology of Injured Patients in Rural Uganda: A Prospective Trauma Registry’s First 1000 Days PONE-D-20-26572R1 Dear Dr. Dicker, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Zsolt J. Balogh, MD, PhD, FRACS Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: (No Response) ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No https://doi.org/10.1371/journal.pone.0245779.r003
Formally Accepted
13 Jan 2021 Acceptance Letter - Zsolt J. Balogh, Editor PONE-D-20-26572R1 Epidemiology of Injured Patients in Rural Uganda: A Prospective Trauma Registry’s First 1000 Days Dear Dr. Dicker: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Zsolt J. Balogh Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0245779.r004

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