Vascular access complications associated with resuscitative endovascular balloon occlusion of the aorta in adult trauma patients: A systematic review and meta-analysis

BACKGROUND

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is gaining popularity worldwide for managing hypotensive trauma patients. Vascular access complications related to REBOA placement have been reported, with some cases resulting in permanent morbidity. We aim to capitalize on the increase in literature to further describe and estimate the incidence of REBOA-associated vascular access complications in adult trauma patients.

METHODS

We searched Medline, EMBASE, Scopus, and CINAHL for studies reporting vascular access complications of REBOA in adult trauma patients from inception to October 14, 2021. Studies reporting data from adult trauma patients who underwent REBOA insertion were eligible. Exclusion criteria included patients 15 years and younger, nontrauma patients, non-REBOA use, non-vascular access complications and patient duplication. Study data was abstracted using the PRISMA checklist and verified independently by three reviewers. Meta-analysis of proportions was performed using a random effects model with Freeman-Turkey double-arcsine transformation. Post hoc meta-regression by year of publication, sheath-size, and geographic region was also performed. The incidence of vascular access complications from REBOA insertion was the primary outcome of interest. Subgroup analysis was performed by degree of bias, sheath size, technique of vascular access, provider specialty, geographical region, and publication year.

RESULTS

Twenty-four articles were included in the systematic review and the meta-analysis, for a total of 675 trauma patients who underwent REBOA insertion. The incidence of vascular access complications was 8% (95% confidence interval, 5%-13%). In post hoc meta-regression adjusting for year of publication and geographic region, the use of a smaller (7-Fr) sheath was associated with a decreased incidence of vascular access complications (odds ratio, 0.87; 95% confidence interval, 0.75-0.99; p = 0.046; R 2 = 35%; I 2 = 48%).

CONCLUSION

This study provides a benchmark for quality of care in terms of vascular access complications related to REBOA insertion in adult trauma patients. Smaller sheath size may be associated with a decrease in vascular access complications.

LEVEL OF EVIDENCE

Systematic Review and Meta-Analysis; Level III.

Predictors of clinical deterioration and intensive care unit admission in trauma patients transferred from northern Quebec to a level 1 trauma centre: a retrospective cohort study

BACKGROUND

Trauma care in Nunavik, Quebec, is highly challenging. Geographic distances and delays in transport can translate into precarious patient transfers to tertiary trauma care centres. The objective of this study was to identify predictors of clinical deterioration during transport and eventual intensive care unit (ICU) admission for trauma patients transferred from Nunavik to a tertiary trauma care centre.

METHODS

This is a retrospective cohort study using the Montreal General Hospital (MGH) trauma registry. All adult trauma patients transferred from Nunavik and admitted to the MGH from 2010 to 2019 were included. Main outcomes of interest were hemodynamic and neurologic deterioration during transport and ICU admission.

RESULTS

In total, 704 patients were transferred from Nunavik and admitted to the MGH during the study period. The median age was 33 (interquartile range [IQR] 23-47) years and the median Injury Severity Score was 10 (IQR 5-17). On multiple regression analysis, transport time from site of injury to the MGH (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.06), thoracic injuries (OR 1.75, 95% CI 1.03-2.99), and head and neck injuries (OR 3.76, 95% CI 2.10-6.76) predicted clinical deterioration during transfer. Injury Severity Score (OR 1.04, 95% CI 1.01-1.08), abnormal local Glasgow Coma Scale score (OR 2.57, 95% CI 1.34-4.95), clinical deterioration during transfer (OR 4.22, 95% CI 1.99-8.93), traumatic brain injury (OR 2.44, 95% CI 1.05-5.68), and transfusion requirement at the MGH (OR 4.63, 95% CI 2.35-9.09) were independent predictors of ICU admission.

CONCLUSION

Our study identified several predictors of clinical deterioration during transfer and eventual ICU admission for trauma patients transferred from Nunavik. These factors could be used to refine triage criteria in Nunavik for more timely evacuation and higher level care during transport.

Surgical, trauma and telehealth capacity in Indigenous communities in Northern Quebec: a cross-sectional survey

BACKGROUND

Delivering trauma and surgical care to Northern Quebec presents unique challenges owing to the region's remoteness, extreme weather and limited transport; the expansion of telehealth could help address these difficulties. We aimed to evaluate current surgical, trauma and telemedicine capacity in Nunavik, Quebec.

METHODS

We used validated assessment tools, including the Personnel, Infrastructure, Procedures, Equipment and Supplies survey, the International Assessment of Capacity for Trauma index and the Maryland Health Care Commission Telemedicine Readiness tool to evaluate surgical, trauma and telemedicine capacity, respectively. We adapted these tools to the Northern Quebec context through discussions with local leadership. Data were collected in 2 regional hospitals - the Ungava Tulattavik Health Centre (UTHC) and the Inuulitsivik Health Centre (IHC) - and 12 Centres locaux de services communautaires (CLSCs; local community services centres) in 6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast through iterative discussions with 4 chief nurses from each regional hospital and set of CLSCs; resources were confirmed through on-site evaluation by the respondents. We performed a descriptive analysis of the data.

RESULTS

Surgical capacity was highest in the IHC (6.76) and lowest in the Ungava Bay CLSCs (5.52). Personnel (0%-0%) and procedures (13%-33%) were the least available resources. Trauma capacity was highest in the IHC (7.25) and lowest in the Hudson Bay CLSCs (5.58). Although equipment (90%-100%) and supplies (100%-100%) were readily available, personnel (0%-0%) and procedures (25%-56%) were lacking. The UTHC was most prepared for telehealth (67.80%), and the Ungava Bay CLSCs achieved a lower score (51.13%). Underdeveloped telehealth criteria included funding, administrative support, quality improvement and physical spaces (all 33%-67%).

CONCLUSION

Acute care capacity in Nunavik appears heterogeneous, with readily available equipment and supplies, but a lack of personnel capable of performing lifesaving procedures. To address the need for telemedicine, future initiatives should focus on improving funding, administrative support, physical spaces and quality-improvement initiatives.

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

BACKGROUND

Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres.

METHODS

This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low-middle-income countries.

RESULTS

In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of 'single-use' consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low-middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia.

CONCLUSION

This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high- and low-middle-income countries.

Outcomes Among Trauma Patients with Duodenal Leak Following Primary vs Complex Repair of Duodenal Injuries: An EAST Multicenter Trial

BACKGROUND

Duodenal leak is a feared complication of repair and innovative, complex repairs with adjunctive measures(CRAM) were developed to decrease both leak occurrence and severity when leaks occur. Data on the association of CRAM and duodenal leak is sparse and its impact on duodenal leak outcomes nonexistent. We hypothesized primary repair alone (PRA) would be associated with decreased duodenal leak rates, however CRAM would be associated with improved recovery and outcomes when leaks do occur.

METHODS

A retrospective, multicenter analysis from 35 Level-1 trauma centers included patients older than 14 with operative, traumatic duodenal injuries(1/2010-12/2020). The study sample compared duodenal operative repair strategy: primary repair alone(PRA) vs CRAM(any repair plus pyloric exclusion, gastrojejunostomy, triple tube drainage, duodenectomy).

RESULTS

The sample(n = 861) was primarily young(33 years) male(84%) with penetrating injuries(77%); 523 underwent PRA and 338 underwent CRAM. CRAM were more critically injured than PRA and had higher leak rates(CRAM 21% vs PRA 8%, p < 0.001). Adverse outcomes were more common after CRAM with more IR drains, prolonged NPO and LOS, greater mortality, and more readmissions than PRA(all p < 0.05). Importantly, CRAM had no positive impact on leak recovery; there was no difference in number of operations, drain duration, NPO duration, need for IR drainage, HLOS, or mortality between PRA leak vs CRAM leak patients(all p > 0.05). CRAM leaks had longer antibiotic duration, more GI complications, and longer duration until leak resolution(all p < 0.05). PRA was associated with 60% lower odds of leak, whereas injury grade II-IV, damage control, and BMI had higher odds of leak(all p < 0.05). There were no leaks among patients with grade IV-V injuries repaired by PRA.

CONCLUSIONS

CRAM did not prevent duodenal leaks and moreover, did not reduce adverse sequelae when leaks did occur. Our results suggest CRAM is not a protective operative duodenal repair strategy and PRA should be pursued for all injury grades when feasible.

LEVEL OF EVIDENCE

IV, Multicenter retrospective comparative study.

Factors associated with bicycle helmet use and proper fit: a cross-sectional survey of Montreal cyclists during the COVID-19 pandemic

OBJECTIVES

With increased bicycle use during the COVID-19 pandemic and growing availability of bicycle-sharing programs in Montreal, we hypothesize helmet use has decreased. The aim of this study was to evaluate helmet use and proper fit among Montreal cyclists during the pandemic relative to historical data.

METHODS

Nine observers collected data on bike type, gender, helmet use, and ethnicity using the iHelmet© app at 18 locations across the island of Montreal from June to September 2021. Proper helmet wear was assessed at one busy location. Multiple logistic regression was used to identify factors associated with helmet wear and results were compared to a historical study.

RESULTS

Of the 2200 cyclists observed, 1109 (50.4%) wore a helmet. Males (OR = 0.78, 95%CI = 0.65-0.95), young adults (OR = 0.65, 95%CI = 0.51-0.84), visible minorities (OR = 0.38, 95%CI = 0.28-0.53), and bike-share users (OR = 0.21, 95%CI = 0.15-0.28) were less likely to be wearing a helmet, whereas children (OR = 3.92, 95%CI = 2.17-7.08) and cyclists using racing bicycles (OR = 3.84, 95%CI = 2.62-5.62) were more likely to be wearing a helmet. The majority (139/213; 65.3%) of assessed cyclists wore properly fitting helmets. Children had the lowest odds of having a properly fitted helmet (OR = 0.13, 95%CI = 0.04-0.41). Compared to 2011, helmet use during the pandemic increased significantly (1109/2200 (50.4%) vs. 2192/4789 (45.8%); p = 0.032).

CONCLUSION

Helmet use among Montreal cyclists was associated with age, gender, ethnicity, and type of bicycle. Children were least likely to have a properly fitted helmet. The recent increase in popularity of cycling and expansion of bicycle-sharing programs reinforce the need for bicycle helmet awareness initiatives, legislation, and funding prioritization.

High-flow nasal oxygen as first-line therapy for COVID-19-associated hypoxemic respiratory failure: a single-centre historical cohort study

PURPOSE

The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution.

METHODS

We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening.

RESULTS

One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59-73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2-3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94-164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10-14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers.

CONCLUSION

Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.

Trauma in northern Quebec, 2005-2014: epidemiologic features, transfers and patient outcomes

Background:

The Inuit people residing in Nunavik, Quebec, are vulnerable to major trauma owing to environmental and social factors; however, there is no systematic data collection for trauma in Nunavik, and, apart from data regarding patients who are transferred to tertiary care centres, no data enter the Quebec trauma registry directly from Nunavik. We performed a study to characterize the epidemiologic features of trauma in Nunavik, and describe indications for transfer and outcomes of patients referred to the tertiary trauma centre.

Methods:

We collected data retrospectively for all patients with trauma admitted to the Centre de santé Tulattavik de l’Ungava in Kuujjuaq from 2005 to 2014. Sociodemographic, injury and health services data were extracted. The data were analyzed in conjunction with coroners’ reports on death from trauma in Nunavik.

Results:

A total of 797 trauma cases were identified. The most common causes of injury were motor vehicle collisions (258 cases [32.4%]), falls (137 [17.2%]) and blunt assault (95 [11.9%]). One-third of patients (262 [32.9%]) were transferred to the tertiary care centre in Montréal. The incidence rate of major trauma (Injury Severity Score > 12) was 18.1 and 21.7 per 10 000 person-years in the Kuujjuaq region and the Puvirnituq region, respectively, which translates to a relative risk (RR) of 4 compared to the Quebec population. The disparity observed in trauma mortality rate was even greater, with an RR of 47.6 compared to the Quebec population.

Conclusion:

The study showed major disparity in trauma incidence and mortality rate between Nunavik and the province of Quebec. Our findings allow for a better understanding of the burden of injury and regional trauma mortality in Nunavik, and recommendations for optimization of the trauma system in this unique setting.

The Financial Burden of Road Traffic Injuries in Mozambique: A Hospital-Related Cost-of-Illness Study of Maputo Central Hospital

BACKGROUND

Road traffic injuries (RTIs) are increasingly being recognized for their significant economic impact. Mozambique, like other low-income countries, suffers staggering rates of road traffic collisions. To our knowledge, this is the first study to estimate direct hospital costs of RTIs using a bottom-up, micro-costing approach in the Mozambican context. This study aims to calculate the direct, inpatient costs of RTIs in Mozambique and compare it to the financial capacity of the Mozambican public health care system.

METHODS

This was a retrospective, single-centre study. Charts of all patients with RTIs admitted to Maputo Central Hospital over a period of 2 months were reviewed. The costs were recorded and analysed based on direct costs, human resource costs, and overhead costs. Costs were calculated using a micro-costing approach.

RESULTS

In total, 114 patients were admitted and treated for RTIs at Maputo Central Hospital during June-July 2015. On average, the hospital cost per patient was US$ 604.28 (IQR 1033.58). Of this, 44% was related to procedural costs, 23% to diagnostic imaging costs, 17% to length-of-stay costs, 9% to medication costs, and 7% to laboratory test costs. The average annual inpatient cost of RTIs in Mozambique was almost US$ 116 million (0.8% of GDP).

CONCLUSION

The financial burden of RTIs in Mozambique represents approximately 40% of the annual public health care budget. These results help highlight the economic impact of trauma in Mozambique and the importance of an organized trauma system to reduce such costs.

Association of severity of illness and intensive care unit readmission: A systematic review

OBJECTIVES

To determine whether ICU readmission is associated with higher severity of illness scores in adult patients.

BACKGROUND

Readmissions to the intensive care unit (ICU) are associated with increased costs, morbidity, and mortality.

METHODS

We performed searches of MEDLINE, EMBASE, and grey literature databases. We selected studies reporting data from adults who were hospitalized in an ICU, received severity of illness scores, and were discharged from the ICU. Characteristics of readmitted and non-readmitted patients were examined.

RESULTS

We screened 4766 publications and included 31 studies in our analysis. In most studies, severity of illness scores were higher in patients readmitted to the ICU. Readmission was also associated with higher mortality and longer ICU and hospital stays. Excessive heterogeneity precluded the reporting of results in the form of a meta-analysis.

CONCLUSIONS

ICU readmission is associated with higher severity of illness scores during the same hospitalization in adult patients.

Trauma care and referral patterns in Rwanda: implications for trauma system development

BACKGROUND

Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care.

METHODS

We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ² and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns.

RESULTS

Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]).

CONCLUSION

To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions.

Prevalence of surgical conditions in individuals aged more than 50 years: a cluster-based household survey in Sierra Leone

BACKGROUND

With the demographic transition disproportionately affecting developing nations, the healthcare burden associated with the elderly is likely to be compounded by poor baseline surgical capacity in these settings. We sought to assess the prevalence of surgical disease and disability in the elderly population of Sierra Leone to guide future development strategies.

METHODS

A cluster randomized, cross-sectional household survey was carried out countrywide in Sierra Leone from January 9th to February 3rd 2012. Using a standardized questionnaire, household member demographics, deaths occurring during the previous 12 months, and presence of any current surgical condition were elucidated. A retrospective analysis of individuals aged 50 and over was performed.

RESULTS

The survey included 1,843 households with a total of 3,645 respondents. Of these, 13.6 % (496/3,645) were aged over 50 years. Of the elderly individuals in our sample, 301 (60.7 %) reported a current surgical condition. Of current surgical disease identified among elderly individuals (n = 530), 349 (65.8 %) described it as disabling, and 223 (42.1 %) sought help from traditional medicine practitioners. Women (odds ratio [OR] 0.60; 95 % confidence interval [CI] 0.40-0.90) and individuals living in urban settings (OR 0.44, 95 % CI 0.26-0.75) were less likely to report a current surgical problem. Of the 230 elderly deaths in the previous year, 83 (36.1 %) reported a surgical condition in the week prior.

CONCLUSIONS

The unmet burden of surgical disease is prevalent in the elderly in low-resource settings. This patient population is expected to grow significantly in the coming years, and more resources should be allocated to address their surgical needs.

Injury prevalence and causality in developing nations: Results from a countrywide population-based survey in Nepal

BACKGROUND

Traumatic injury affects nearly 5.8 million people annually and causes 10% of the world's deaths. In this study we aimed to estimate injury prevalence, to describe risk-factors and mechanisms of injury, and to estimate the number of injury-related deaths in Nepal, a low-income South Asian country.

METHODS

A cluster randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in Nepal in 2014. Questions were structured anatomically and designed around a representative spectrum of operative conditions. Two-stage cluster sampling was performed: 15 of 75 districts were chosen randomly proportional to population; within each district, after stratification for urban and rural populations, 3 clusters were randomly chosen. Injury-related results were analyzed.

RESULTS

A total of 1,350 households and 2,695 individuals were surveyed verbally, with a response rate of 97%. A total of 379 injuries were reported in 354 individuals (13.1%, 95% confidence interval 11.9-14.5%), mean age of 32.6. The most common mechanism of injury was falls (37.5%), road traffic injuries (19.8%), and burns (14.2%). The most commonly affected anatomic site was the upper extremity (42.0%). Of the deaths reported in the previous year, 16.3% were injury-related; 10% of total deaths may have been averted with access to operative care.

CONCLUSION

This study provides baseline data on the epidemiology of traumatic injuries in Nepal and is the first household-based countrywide assessment of injuries in Nepal. These data provide valuable information to help advise policymakers and government officials for allocation of resources toward trauma care.

Acute care surgery in Rwanda: Operative epidemiology and geographic variations in access to care

BACKGROUND

Surgical management of emergent, life-threatening diseases is an important public health priority. The objectives of this study were to (1) describe acute care general surgery procedures performed at the largest referral hospital in Rwanda and (2) understand the geographic distribution of disease presentations and referral patterns.

METHODS

We performed a retrospective review of prospectively collected acute care surgery cases performed at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda between June 1 and December 1, 2011. Using Pearson's χ(2) test and the Fisher exact test, we compared cases originating from within Kigali and transfers from other provinces. Geospatial analyses also were used to further describe transfer patterns.

RESULTS

During the study period, 2,758 surgical interventions were performed, of which 25.6% (707/2,758) were general surgery operations. Of these, 45.4% (321/707) met the definition of acute care surgery. Only about one-third-32.3% (92/285)-of patients resided within Kigali, whereas about two-thirds-67.7% (193/285)-were transferred from other provinces. Most patients transferred from other provinces were younger than 18 years of age (40.4%; 78/193), and 83.0% (39/47) of patients older than 50 years of age originated from outside of Kigali. Specific operative indications and surgical procedures varied substantially between patients from Kigali and patients transferred from other provinces.

CONCLUSION

Emergency surgical conditions remain important contributors to the global burden of disease, particularly in low- and middle-income countries. Geographic variations exist in terms of operative diagnoses and procedures, which implies a need for improved access to surgical care at the district level with defined transfer mechanisms to greater-level care facilities when needed.

Burden of road traffic injuries in Nepal: results of a countrywide population-based survey

BACKGROUND

Road traffic injury has emerged as a leading cause of mortality, contributing to 2·1% of deaths globally and is predicted to be the third highest contributor to the global burden of mortality by 2020. This major public health problem disproportionately affects low-income and middle-income countries, where such incidents are too often underreported. Our study aims to explore the epidemiology of road traffic injurys in Nepal at a population level via a countrywide study.

METHODS

The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a cluster randomised, cross-sectional nationwide survey, was conducted in Nepal between May 25, and June 12, 2014. Two-stage cluster sampling was performed: 15 of 75 districts were chosen randomly proportional to population; within each district, after stratification for urban and rural, and three clusters were randomly chosen. Questions were structured anatomically and designed around a representative spectrum of surgical conditions. Road traffic injury-related results were reported.

FINDINGS

1350 households and 2695 individuals were surveyed with a response rate of 97%. 75 road traffic injuries were reported in 72 individuals (2·67% [95% CI 2·10-3·35] of the study population), with a mean age of 33·2 years (SD 1·85). The most commonly affected age group was 30-44 years, with females showing significantly lower odds of sustaining a road traffic injury than men (crude odds ratio 0·29 [95% CI 0·16-0·52]). Road traffic injuries composed 19·8% of the injuries reported. Motorcycle crashes were the most common road traffic injuries (48·0%), followed by car, truck, or bus crashes (26·7%), and pedestrian or bicycle crashes (25·3%). The extremity was the most common anatomic site injured (74·7%). Of the 80 deaths reported in the previous year, 7·5% (n=6) were due to road traffic injuries.

INTERPRETATION

This study provides the epidemiology of road traffic injuries at a population-based level in the first countrywide surgical needs assessment in Nepal. WHO reported that mortality due to road traffic injuries in Nepal in 2011 was 1·7%, whereas our study reported 7·5%, consistent with the concept of underreporting of deaths in police and hospital level data noted in previous literature. Road traffic injuries continue to be a significant problem in Nepal, probably greater than previously reported; future efforts should focus on addressing this growing epidemic through preventive and mitigating strategies.

FUNDING

The Association for Academic Surgery and Surgeons OverSeas.

Injury assessment in three low-resource settings: a reference for worldwide estimates

BACKGROUND

Trauma has become a worldwide pandemic. Without dedicated public health interventions, fatal injuries will rise 40% and become the 4th leading cause of death by 2030, with the burden highest in low-income and middle-income countries (LMICs). The aim of this study was to estimate the prevalence of traumatic injuries and injury-related deaths in low-resource countries worldwide, using population-based data from the Surgeons OverSeas Assessment of Surgical Need (SOSAS), a validated survey tool.

METHODS

Using data from three resource-poor countries (Nepal, Rwanda, and Sierra Leone), a weighted average of injury prevalence and deaths due to injury was calculated and extrapolated to low-resource countries worldwide. Injuries were defined as wounds from road traffic injuries (bus, car, truck, pedestrian, and bicycle), gunshot or stab or slash wounds, falls, work or home incidents, and burns. The Nepal study included a visual physical examination that confirmed the validity of the self-reported data. Population and annual health expenditure per capita data were obtained from the World Bank. Low-resource countries were defined as those with an annual per capita health expenditure of US$100 or less.

FINDINGS

The overall prevalence of lifetime injury for these three countries was 18·03% (95% CI 18·02-18·04); 11·64% (95% CI 11·53-11·75) of deaths annually were due to injury. An estimated prevalence of lifetime injuries for the total population in 48 low-resource countries is 465·7 million people; about 2·6 million fatal injuries occur in these countries annually.

INTERPRETATION

The limitations of this observational study with self-reported data include possible recall and desirability bias. About 466 million people at a community level (18%) sustain at least one injury during their lifetime and 2·6 million people die annually from trauma in the world's poorest countries. Trauma care capacity should be considered a global health priority; the importance of integrating a coordinated trauma system into any health system should not be underestimated.

FUNDING

None.

Interactions between treatment with 1,25(OH)2D3 and glucocorticoids in uremic patients after kidney transplantation

3 patients undergoing maintenance hemodialysis and receiving 1,25(OH)2D3 for osteomalacic bone disease received cadaveric kidney grafts and concomitant glucocorticoid therapy. The administration of pharmacological doses of glucocorticoids increased the dosage of 1,25(OH)2D3 needed to maintain a normal serum calcium level 7- to 10-fold in 2 patients whose renal grafts failed to function, but there was no decrease in sensitivity to 1,25(OH)2D3 in 1 patient whose renal graft functioned normally. These data suggest that steroids given to a uremic patient may block certain effects normally produced by 1,25(OH)2D3. An end-organ defect due to the combined effects of steroids and uremia is possible.

Recommendations for including surgery on the public health agenda

BACKGROUND

Surgical care has made limited inroads on the public health and global health agendas despite increasing data showing the enormous need. The objective of this study was to survey interested members of a global surgery community to identify patterns of thought regarding barriers to political priority.

MATERIALS AND METHODS

All active members of the nongovernmental organization Surgeons OverSeas were surveyed and asked why surgical care is not receiving recognition and support on the public health and global health agenda. Responses were categorized using the Shiffman framework on determinants of political priority for global initiatives by two independent investigators, and the number of responses for each of the 11 factors was calculated.

RESULTS

Seventy-five Surgeons OverSeas members replied (75 of 176; 42.6% response rate). A total of 248 individual reasons were collected. The most common responses were related to external frame, defined as public portrayals of the issue (60 of 248; 24.2%), and lack of effective interventions (48 of 248; 19.4%). Least cited reasons related to global governance structure (4 of 248; 2.4%) and policy window (4 of 248; 1.6%).

CONCLUSIONS

This survey of a global surgery community identified a number of barriers to the recognition of surgical care on the global health agenda. Recommendations include improving the public portrayal of the problem; developing effective interventions and seeking strong and charismatic leadership.

Promoting quality of care in disaster response: A survey of core surgical competencies

BACKGROUND

Recent humanitarian crises have led to a call for professionalization of the humanitarian field, but core competencies for the delivery of surgical care have yet to be established. The objective of this study was to survey surgeons with experience in disaster response to identify surgical competencies required to be effective in these settings.

METHODS

An online survey elucidating demographic information, scope of practice, and previous experience in global health and disaster response was transmitted to surgeons from a variety of surgical societies and nongovernmental organizations. Participants were provided with a list of 111 operative procedures and were asked to identify those deemed essential to the toolset of a frontline surgeon in disaster response via a Likert scale. Responses from personnel with experience in disaster response were contrasted with those from nonexperienced participants.

RESULTS

A total of 147 surgeons completed the survey. Participants held citizenship in 22 countries, were licensed in 30 countries, and practiced in >20 countries. Most respondents (56%) had previous experience in humanitarian response. The majority agreed or strongly agreed that formal training (54%), past humanitarian response (94%), and past global health experiences (80%) provided adequate preparation. The most commonly deemed important procedures included control of intraabdominal hemorrhage (99%), abdominal packing for trauma (99%), and wound debridement (99%). Procedures deemed important by experienced personnel spanned multiple specialties.

CONCLUSION

This study addressed specifically surgical competencies in disaster response. We provide a list of operative procedures that should set the stage for further structured education programs.

Development of a novel Global Trauma System Evaluation Tool and initial results of implementation in the Republic of South Sudan

INTRODUCTION

Trauma remains a leading cause of death and disability in the world, and trauma systems decrease mortality from trauma. We developed the Global Trauma System Evaluation Tool (G-TSET) specifically for use in low- and middle-income countries (LMICs). The Sudan People's Liberation Army (SPLA) in the Republic of South Sudan (RSS) desires a military trauma system (MTS) which allowed us to pilot the G-TSET.

METHODS

The G-TSET was developed by modifying key components of a trauma system applicable to LMICs. We partnered with the SPLA Medical Corps using clinical collaboration, direct observation, and discussion groups. Benchmarks and indicators were scored with 5 indicating "full capability" and 1 meaning "not present" and were used to develop a SPLA MTS plan.

RESULTS

The overall MTS score was 1.15 indicating an urgent need for system development. The assessment highlighted the need for SPLA Command support. Battlefield care, transport to a trauma facility, and inter-facility communication were identified for improvement. After essential battlefield care, consisting primarily of bandaging and splinting, transport times for injured SPLA soldiers were 12h to 3 days by truck. Based on our findings, we collaborated with SPLA medical leadership to develop a plan to develop a formal MTS.

CONCLUSION

We piloted a novel trauma system assessment tool for the MTS in the RSS. Qualitatively, we identified gaps in the MTS and provided the medical leadership with a plan for improvement. We anticipate a short-term follow-up to quantify improvement, and we seek to validate this tool for use in other countries.

Prioritizing injury care: a review of trauma capacity in low and middle-income countries

BACKGROUND

Trauma is a large contributor to the global burden of disease, particularly in low and middle-income countries (LMICs). This study aimed to summarize the literature assessing surgical capacity in LMICs to provide a current assessment of trauma capacity, which will help guide future efforts.

MATERIALS AND METHODS

The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy, cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank.

RESULTS

Seventeen studies were reviewed, documenting data from 531 hospitals in seventeen countries. None of the countries had access to all twelve trauma criteria in all their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95).

CONCLUSIONS

Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs.

Burn management capacity in low and middle-income countries: a systematic review of 458 hospitals across 14 countries

IMPORTANCE

More than 90% of thermal injury-related deaths occur in low-resource settings. While baseline assessment of burn management capabilities is necessary to guide capacity building strategies, limited data exist from low and middle-income countries (LMICs).

OBJECTIVE

The objective of our review is to assess burn management capacity in LMICs.

EVIDENCE REVIEW

A PubMed literature review was performed based on studies assessing baseline surgical capacity in individual LMICs. Seven criteria were used to assess burn management capabilities: presence of surgeon, presence of anesthesiologist, basic resuscitation capabilities, acute burn management, management of burn complications, endotracheal intubation and skin grafts.

FINDINGS

Fourteen studies were reviewed using data from 458 hospitals in fourteen countries. Of these, 82.3% (284/345) of hospitals had the capacity to provide basic resuscitation and 84.9% (275/324) were capable of providing acute burn management. Endotracheal intubation was only available at 38.3% (51/133) of hospitals. Moreover, only 35.6% (111/312) and 37.9% (120/317) of hospitals were able to provide skin grafts and treat burn complications, respectively.

CONCLUSION

Many hospitals in LMICs are capable of initial burn management and basic resuscitation. However, deficiencies still exist in the capacity to systematically provide advanced burn care. Efforts should be made to better document resources in order to guide burn management resource allocation.

Scarcity of protective items against HIV and other bloodborne infections in 13 low- and middle-income countries

OBJECTIVE

To assess protection of surgical healthcare workers against HIV and other bloodborne infections in low- and middle-income countries (LMICs).

METHODS

Literature review based on recent studies assessing baseline surgical capacity in LMICs using the WHO Situational Analysis of Access to Emergency and Essential Surgical Care, the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey and the Harvard Humanitarian Initiative survey tools. The availability of protective eyewear, sterile gloves and sterilisers was assessed.

RESULTS

Thirteen individual country studies with relevant data were identified documenting items from 399 hospitals. The countries included Afghanistan, Bolivia, Gambia, Ghana, Liberia, Mongolia, Nigeria, Sierra Leone, Solomon Islands, Somalia, Sri Lanka, Tanzania and Zambia. Overall, only 29% (79/270) of hospitals always had eye protection. Sterilisers were only available at 64% (244/383) of facilities. Sterile gloves were the most available item, available at 75% of facilities (256/340).

CONCLUSION

Surgical healthcare worker protection for bloodborne infections continues to be deficient in LMICs. Improved documentation of these items should be incorporated into future surgical capacity studies. Policy makers and clinicians should work together to secure resources and interventions that will protect this vital workforce.

Burns in Sierra Leone: a population-based assessment

PURPOSE

Burns remain disproportionately prevalent in developing countries. This study aims to describe the epidemiology of burns in Sierra Leone to serve as a baseline for future programs.

METHODS

A cluster randomized, cross-sectional, countrywide survey was conducted in 2012 in Sierra Leone. With a standardized questionnaire demographics and deaths during the previous 12 months of household members were assessed with the household representative. Thereafter, 2 randomly selected household members were interviewed, elucidating whether participants had ever had a burn in six body regions and determining burn mechanisms and patterns of health care seeking behavior.

RESULTS

This study included 1843 households and 3645 individuals. 3.98% (145/3645) of individuals reported at least one burn-injury. The highest proportions of burns were reported in the age groups 0-4 years old (23/426, 5.4%) and 5-14 years old (37/887, 4.17%). The majority of burns (129/145, 89.0%) were caused by a hot liquid/object and the upper, extremities were the most commonly burned body regions, with 36% (53/145) of cases. 21% (30/145) of individuals with burns sought care from a traditional healer.

CONCLUSIONS

Burns are highly prevalent in Sierra Leone. Further research and resources should be allocated to the care and prevention of thermal injuries.

Surgical skills needed for humanitarian missions in resource-limited settings: common operative procedures performed at Médecins Sans Frontières facilities

BACKGROUND

Surgeons in high-income countries increasingly are expressing interest in global surgery and participating in humanitarian missions. Knowledge of the surgical skills required to adequately respond to humanitarian emergencies is essential to prepare such surgeons and plan for interventions.

METHODS

A retrospective review of all surgical procedures performed at Médecins Sans Frontières Brussels facilities from June 2008 to December 2012 was performed. Individual data points included country of project; patient age and sex; and surgical indication and surgical procedure.

RESULTS

Between June 2008 and December 2012, a total of 93,385 procedures were performed on 83,911 patients in 21 different countries. The most common surgical indication was for fetal-maternal pathologies, accounting for 25,548 of 65,373 (39.1%) of all cases. The most common procedure was a Cesarean delivery, accounting for a total of 24,182 or 25.9% of all procedures. Herniorrhaphies (9,873/93,385, 10.6%) and minor surgeries (11,332/93,385, 12.1%), including wound debridement, abscess drainage and circumcision, were also common.

CONCLUSION

A basic skill set that includes the ability to provide surgical care for a wide variety of surgical morbidities is urgently needed to cope with the surgical need of humanitarian emergencies. This review of Médecins Sans Frontières's operative procedures provides valuable insight into the types of operations with which an aspiring volunteer surgeon should be familiar.

The International Assessment of Capacity for Trauma (INTACT): an index for trauma capacity in low-income countries

BACKGROUND

Injury remains a leading cause of death worldwide with a disproportionate impact in the developing world. Capabilities for trauma care remain limited in these settings. We propose the implementation of the International Assessment of Capacity for Trauma (INTACT) index to provide a standardized way of assessing a health care facility's capacity to provide adequate trauma care.

MATERIALS AND METHODS

A retrospective review of the trauma capacity of 10 government hospitals (district, secondary, regional, maternity, and tertiary facilities) in Sierra Leone was performed using data collected during on-site visits in August 2011. The index incorporates 40 key elements, including resuscitation, laparotomy, chest tube insertion, fracture repair, and burn management capabilities. The INTACT index was calculated on a scale of 0-10 and compared with a previously published index of surgical capacity, the personnel, infrastructure, equipment, and supplies (PIPES) index.

RESULTS

Connaught Hospital, the only tertiary referral center, had the highest index (9.0), consistent with it being the best equipped and staffed of the country. The three district hospitals assessed had the lowest scores from 3.5 to 4.3. INTACT and PIPES scores were correlated overall (r = 0.88). The proportionate difference compared with the PIPES survey was 30% for the maternity hospital and 1% for the tertiary center, suggesting that the INTACT index may be specific for trauma. Deficiencies are especially prominent in personnel, imaging, fracture repair, and burn management.

CONCLUSIONS

The INTACT index is a simple tool designed to specifically assess trauma capacity from initial resuscitation to definitive care. Shortcomings in trauma capacity remain prominent and the INTACT index could be used to assess trauma care deficiencies in developing countries.

Multiple-dose study of imipenem/cilastatin in patients with end-stage renal disease undergoing long-term hemodialysis

Multiple doses of imipenem/cilastatin were administered to patients with end-stage renal disease undergoing long-term hemodialysis. Schedules of 250 mg every six hours, 500 mg every six hours, and 500 mg every 12 hours were studied. Five hundred mg every 12 hours was the most efficient schedule that maintained effective trough antibiotic activity. Twelve volunteers including two patients with clinical infections using the dose schedule of 500 mg every 12 hours received imipenem/cilastatin for two to 14 days without any notable clinical side effects. Imipenem peak and trough concentrations averaged 29 +/- 5 micrograms/ml and 10 +/- 3 micrograms/ml, respectively. No accumulation of imipenem occurred during the trial. Cilastatin peak and trough concentrations were 89 +/- 38 micrograms/ml and 70 +/- 27 micrograms/ml, respectively. The plasma concentration of cilastatin increased with each dose until the next hemodialysis session.

Ceftriaxone pharmacokinetics in patients with various degrees of renal impairment

The effects of renal impairment on the pharmacokinetics of ceftriaxone in humans were examined after intravenous infusion of a 1-g dose over 15 min to 30 renally impaired patients. The study included 12 dialysis patients and 18 patients with severe, moderate, or mild renal impairment. Plasma and, where appropriate, urine and dialysate samples were collected at predetermined times and analyzed for ceftriaxone by high-pressure liquid chromatography. The elimination half-life (group mean ranged from 11.7 to 17.3 h) and plasma clearance (group mean ranged from 529 to 705 ml/h) did not correlate linearly with creatinine clearance. The renal clearance and fraction of dose excreted unchanged in urine were related linearly, however weakly, with creatinine clearance. Ceftriaxone was not removed from plasma to a significant extent during hemodialysis. The half-life was prolonged twofold, the plasma clearance was lowered less than 50%, and the volume of distribution was relatively unchanged in renally impaired patients compared with young or elderly healthy subjects with normal renal function at an equivalent dose. Since these changes are moderate, adjustment in the dosage regimen of ceftriaxone for patients with impaired renal function should not be necessary when ceftriaxone dosage is 2 g or less per day (2 g every 24 h or 1 g every 12 h). It was reported that the elimination half-life of ceftriaxone is substantially prolonged in a small percentage of patients with end-stage renal disease maintained on hemodialysis. Therefore, plasma concentrations of ceftriaxone should be monitored in dialysis patients to determine whether dosage adjustments are necessary.

Preliminary trials with 24,25-dihydroxyvitamin D3 in dialysis osteomalacia

Fifteen patients with dialysis osteomalacia were treated with 24,25-dihydroxyvitamin D3 in dosages up to 10 micrograms per day for two to 24 months. All had previously had no improvement during treatment with calcitriol but had been remarkably susceptible to hypercalcemia. When 24,25-dihydroxyvitamin D3 was given with either calcitriol or dihydrotachysterol, serum calcium levels were significantly lower than during treatment with calcitriol or dihydrotachysterol alone. Eight of nine patients who received combined therapy with 24,25-dihydroxyvitamin D3 and calcitriol for longer than two months had clinical improvement; six patients underwent repeated bone biopsy and showed evidence of improved bone mineralization. Patients who received 24,25-dihydroxyvitamin D3 alone did not improve clinically. Since 24,25-dihydroxyvitamin D3 appears to improve calcium homeostasis and bone mineralization in some patients with severe dialysis osteomalacia when administered with 1-hydroxylated vitamin D metabolites, further controlled studies are warranted.

Vitamin-D-resistant osteomalacia in hemodialysis patients lacking secondary hyperparathyroidism

We describe a sporadic, vitamin-D-resistant osteomalacic syndrome in 19 patients undergoing hemodialysis. The syndrome was found in less than 1.5% of patients from referring dialysis centers. All 19 patients had multiple fractures, severe myopathy, and many developed spontaneous hypercalcemia. Severe osteomalacia without evidence of secondary hyperparathyroidism distinguished this syndrome from other forms of renal osteodystrophy. Bone aluminum, measured in six patients, was greatly elevated. Therapy with calcitriol (1 alpha, 25-dihydroxycholecalciferol) lad to clinical improvement in seven patients with reduced pain and myopathy, decreased serum alkaline phosphatase, or both, but no improvement in bone histology. Patients who did not respond clinically to calcitriol developed marked hypercalcemia. The cause of this severe osteomalacia, which occurs despite normal or slightly elevated levels of serum calcium and phosphorus and fails to mineralize with calcitriol, is unclear.

Pharmacokinetics of ceforanide in patients with end stage renal disease on hemodialysis

The pharmacokinetics of ceforanide were evaluated in 11 patients with end stage renal disease (creatinine clearance less than 5 ml/min). A single intravenous dose of 750 mg/m2 produced peak plasma concentrations of 123 +/- 29 microgram/ml. The plasma half-life (T 1/2) of the drug was 19.1 +/- 2.5 h. A 5.5 h hemodialysis session removed 53% of the drug and reduced the T 1/2 to 5 +/- 0.7 h. Plasma concentrations greater than 10 microgram/m2 were maintained without adverse effects with a 1.5-g/m2 dose administered three times a week for 2 weeks.

Pharmacokinetics of cefaclor in patients with end stage renal disease and during hemodialysis

A single 1.0-g dose of cefaclor administered to patients with stable end stage renal disease whose creatinine clearances were <5 ml/min produced a mean peak serum concentration of 48.3 +/- 19.8 mug/ml. The half-life was 2.3 +/- 0.3 h. Hemodialysis shortened the half-life of a similar dose to 1.6 +/- 0.3 h. Approximately one-third (340 mg) of the administered drug was recovered in the dialysate. Multiple doses of 500 mg every 6 h between hemodialysis sessions produced effective serum concentrations and no bioassay evidence of drug accumulation.

Hemodialysis-associated infections: treatment with cephapirin

Large doses of cephapirin (50 mg/kg) administered during the first and last half hours of routine hemodialysis produced effective antimicrobial serum concentrations for 48 h. Repetitive administration during five successive hemodialysis sessions did not result in accumulation or accelerated metabolism of cephapirin. Ten infectious episodes in nine patients were treated in this manner with good clinical results and no toxicity.