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A 62-year-old man presents to the emergency department after an episode of syncope following several weeks of fatigue. He has a history of upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease. His blood pressure is 90/60 mm Hg, pulse of 105/min, and a black, foul-smelling stool is found upon rectal examination. Blood test results show a hemoglobin level of 6.5 g/dL, a creatinine level of 1.0 mg/dL, and a serum urea nitrogen level of 55 mg/dL. Would the results of a nasogastric lavage help determine between an upper endoscopy or a colonoscopy as the test most likely to identify the bleeding source? Case 2A 45-year-old woman presents with 24 hours of diarrhea, nausea, and 2 episodes of vomiting coffee ground material. She takes no prescription medications other than those for hypertension and she takes no over-the-counter medications. Physical examination reveals blood pressure of 145/100 mm Hg, pulse of 70/min, and rectal examination with liquid brown stool. Blood test results reveal a hemoglobin level of 13.7 g/dL, a creatinine level of 1.1 CME available online at www.jamaarchivescme.com and questions on p 1091.

Traumatic brain injury (TBI) is the most common cause of death and disability globally disproportionately affecting low- and middle-income countries where increasing injury rates are compounded by limited quality care. The objective of this study is to describe quality of care for TBI patients who presented to Kilimanjaro Christian Medical Center, Moshi, Tanzania. We evaluated a prospective quality improvement TBI registry that enrolled consecutive patients with acute TBI. Descriptive statistics and qualitative comparative analysis was performed. Overall, 893 TBI patients were enrolled during the study period, with a mean age of 32.1 years and who were mostly (80%) male. 12.9% suffered severe TBI (GCS < 9). Most injuries were road traffic (66%) especially motorcyclists (49%) and 26.8% were alcohol related. One intubation occurred, and 22.9% of hypoxic patients received oxygen. Severe TBI mortality was 47%. TBI affects men 15-45 years old in traffic crashes with high mortality for severe TBI (47%) patients. Care addressing secondary injury, hypoxemia, and hypotension is limited.

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