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Risman A, Trelles M, Denning DW. Evaluation of multiple open-source deep learning models for detecting and grading COVID-19 on chest radiographs. J Med Imaging (Bellingham) 2022; 8:064502. [PMID: 35005058 PMCID: PMC8734487 DOI: 10.1117/1.jmi.8.6.064502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 12/02/2021] [Indexed: 11/14/2022] Open
Abstract
Purpose: Chest x-rays are complex to report accurately. Viral pneumonia is often subtle in its radiological appearance. In the context of the COVID-19 pandemic, rapid triage of cases and exclusion of other pathologies with artificial intelligence (AI) can assist over-stretched radiology departments. We aim to validate three open-source AI models on an external test set. Approach: We tested three open-source deep learning models, COVID-Net, COVIDNet-S-GEO, and CheXNet for their ability to detect COVID-19 pneumonia and to determine its severity using 129 chest x-rays from two different vendors Phillips and Agfa. Results: All three models detected COVID-19 pneumonia (AUCs from 0.666 to 0.778). Only the COVID Net-S-GEO and CheXNet models performed well on severity scoring (Pearson’s r 0.927 and 0.833, respectively); COVID-Net only performed well at either task on images taken with a Philips machine (AUC 0.735) and not an Agfa machine (AUC 0.598). Conclusions: Chest x-ray triage using existing machine learning models for COVID-19 pneumonia can be successfully implemented using open-source AI models. Evaluation of the model using local x-ray machines and protocols is highly recommended before implementation to avoid vendor or protocol dependent bias.
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Affiliation(s)
| | | | - David W Denning
- The University of Manchester, Manchester Academic Health Science Centre, Manchester Fungal Infection Group, Manchester, United Kingdom
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Daebes HL, Tounsi LL, Nerlander M, Gerdin Wärnberg M, Jaweed M, Mamozai BA, Nasim M, Trelles M, von Schreeb J. Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015. Emerg Med J 2021; 39:628-633. [PMID: 34759014 PMCID: PMC9304096 DOI: 10.1136/emermed-2020-209470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 10/25/2021] [Indexed: 11/22/2022]
Abstract
Background Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF’s standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings Aim This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC. Method and materials This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes. Results Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red. Conclusion The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.
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Affiliation(s)
- Hadjer Latif Daebes
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Linnea Latifa Tounsi
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Maximilian Nerlander
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Martin Gerdin Wärnberg
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Momer Jaweed
- Medical Department, Médecins Sans Frontières, Kunduz, Afghanistan
| | | | - Masood Nasim
- Medical Coordination, Médecins Sans Frontières, Kabul, Afghanistan
| | - Miguel Trelles
- Medical Department, Operational Centre Brussels, Doctors without Borders, Bruxelles, Belgium
| | - Johan von Schreeb
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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Nerlander MP, Pini A, Trelles M, Majanen H, Al-Abbasi O, Maroof M, Ragazzoni L, von Schreeb J. Epidemiology of Patients Treated at the Emergency Department of a Medcins Sans Frontieres Field Hospital During the Mosul Offensive: Iraq, 2017e. J Emerg Med 2021; 61:774-781. [PMID: 34538676 DOI: 10.1016/j.jemermed.2021.07.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/17/2021] [Accepted: 07/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts. OBJECTIVE This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict. METHODS During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant. RESULTS The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately one-third of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED. CONCLUSIONS The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflict-related injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.
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Affiliation(s)
- Maximilian P Nerlander
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Alessandro Pini
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Miguel Trelles
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Hanna Majanen
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Omar Al-Abbasi
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Mansour Maroof
- Operational Headquarters, Médecins Sans Frontières, Brussels, Belgium
| | - Luca Ragazzoni
- Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Johan von Schreeb
- Center for Research on Health Care in Disasters, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
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4
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Naidoo M, Lee J, Trelles M, Wallis L, Chu KM. Preventing avoidable hospital admissions after emergency care in humanitarian settings: a cross-sectional review of Médecins Sans Frontières emergency departments. BMJ Open 2021; 11:e049785. [PMID: 34257097 PMCID: PMC8278912 DOI: 10.1136/bmjopen-2021-049785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe the types of emergency departments (EDs), and the acuity, types and disposition of conditions managed at Médecins Sans Frontières (MSF)-supported EDs in humanitarian settings. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES This was a multicentre, cross-sectional review of visits to MSF-supported EDs from 1 January 2014 to 31 December 2018. EDs were classified into advanced-level, general-level, paediatric and trauma. Variables analysed included: age group, condition, acuity and ED disposition. Frequencies and percentages stratified by ED type or region were reported. RESULTS MSF supported 26 EDs in 12 countries, with a total of 1 388 698 visits between 2014 and 2018. Most patients were discharged home (n=1 097 456, 79%), with nearly 0% mortality (n=4692). The majority of visits at general-level and paediatric EDs were for medical conditions (n=600 088, 78% and n=45 276, 96%, respectively), while nearly half of advanced-level EDs visits were for surgical conditions (n=201 189, 48%). Almost all visits to trauma EDs were for surgical conditions (n=148 078, 98%). Overall, most surgical conditions were traumatic injuries (n=484 008, 94%), the majority unintentional (n=425 487, 82%). The top three most common classified medical conditions were respiratory infections, malaria and diarrhoea. CONCLUSIONS EDs are critical in improving the agility and access to emergency care (EC) in humanitarian settings. This study demonstrated that EC provision resulted in the majority of patients being discharged from EDs, helping prevent avoidable hospital admissions. These results could help better understand the healthcare needs of vulnerable populations, improve responsiveness to emergency conditions and support programmatic planning in humanitarian settings.
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Affiliation(s)
- Megan Naidoo
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
| | - James Lee
- Medical Department, Médecins Sans Frontières- Operational Centre Brussels, Brussels, Belgium
| | - Miguel Trelles
- Medical Department, Médecins Sans Frontières- Operational Centre Brussels, Brussels, Belgium
| | - Lee Wallis
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Kathryn M Chu
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Cape Town, South Africa
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Rahman AS, Chao TE, Trelles M, Dominguez L, Mupenda J, Kasonga C, Akemani C, Kondo KM, Chu KM. The Effect of Conflict on Obstetric and Non-Obstetric Surgical Needs and Operative Mortality in Fragile States. World J Surg 2021; 45:1400-1408. [PMID: 33560502 DOI: 10.1007/s00268-021-05972-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Médecins Sans Frontières (MSF) provides surgical care in fragile states, which are more vulnerable to conflict. The primary objective of this study was to compare the indications for operative intervention in surgical projects in fragile states during periods of active conflict (CON) and non-conflict (NON-CON). In addition, risk factors for non-obstetric and obstetric operative mortality were identified. METHODS This was a retrospective analysis of MSF surgical projects in fragile states January 1, 2008-December 31, 2017. Variables considered in the analysis include age, gender, American Society of Anesthesiology physical status, emergency status, re-intervention status, indication for surgical intervention, and conflict/non-conflict time period. RESULTS There were 30 surgical projects in 13 fragile states with 87,968 surgical interventions in 68,667 patients. Obstetric needs were the most common indication for surgical intervention (n = 28,060, 31.9%) but were more common during NON-CON (n = 23,142, 35.7%) compared to CON periods (n = 4,918, 21.2%, p < 0.001). Trauma was more common during CON (42.0%) compared to NON-CON (23.0%) periods (p < 0.001). Non-obstetric operative mortality was similar during CON (0.2%) compared to NON-CON (0.2%, p = 0.920), but obstetric operative mortality was higher (0.5%) during CON compared to NON-CON (0.2%, p < 0.001) periods. Risk factors for obstetric and non-obstetric mortality included age ≥ 30 years, ASA greater than 1, and emergency intervention. CONCLUSION Humanitarian surgeons working in fragile states should be prepared to treat a range of surgical needs including trauma and obstetrics during conflict and non-conflict periods. The mortality in obstetric patients was higher during conflict periods, and further research to understand ways to protect this vulnerable group is needed.
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Affiliation(s)
- Arifeen S Rahman
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Tiffany E Chao
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, USA.,Department of Surgery, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Miguel Trelles
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Lynette Dominguez
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Jerome Mupenda
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Cheride Kasonga
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Clemence Akemani
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Kalla Moussa Kondo
- Médecins Sans Frontières, Operational Centre Brussels, Brussels, Belgium
| | - Kathryn M Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Francie Van Zijl Dr, Tygerberg Hospital, Cape Town, 7505, South Africa.
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Traynor MD, Trelles M, Hernandez MC, Dominguez LB, Kushner AL, Rivera M, Zielinski MD, Moir CR. North American pediatric surgery fellows' preparedness for humanitarian surgery. J Pediatr Surg 2020; 55:2088-2093. [PMID: 31839370 DOI: 10.1016/j.jpedsurg.2019.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/16/2019] [Accepted: 11/19/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones. METHODS We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests. RESULTS ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05). CONCLUSION While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | - Miguel Trelles
- Surgical Care Unit, Médecins Sans Frontières, Brussels, Belgium
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7
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Wren SM, Wild HB, Gurney J, Amirtharajah M, Brown ZW, Bulger EM, Burkle FM, Elster EA, Forrester JD, Garber K, Gosselin RA, Groen RS, Hsin G, Joshipura M, Kushner AL, Norton I, Osmers I, Pagano H, Razek T, Sáenz-Terrazas JM, Schussler L, Stewart BT, Traboulsi AAR, Trelles M, Troke J, VanFosson CA, Wise PH. A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare. JAMA Surg 2020; 155:114-121. [PMID: 31722004 PMCID: PMC6865259 DOI: 10.1001/jamasurg.2019.4547] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Question What are consensus components of a framework for humanitarian surgical response in modern conflict zones? Findings This survey study using responses from 35 participants in the Stanford Humanitarian Surgical Response in Conflict Working Group suggests that humanitarian responses include both care of traumatic injury and emergency surgical needs of the population. Lessons from civilian and military trauma systems as well as humanitarian settings were translated into a tiered continuum of response from patient presentation through rehabilitation. Meaning Evidence suggests that modern trauma systems save lives but providing this standard of care in insecure conflict settings places new burdens on humanitarian systems; the framework presented herein integrates advances in surgical care to these environments. Importance Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.
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Affiliation(s)
- Sherry M Wren
- Stanford University School of Medicine, Stanford, California
| | - Hannah B Wild
- Stanford University School of Medicine, Stanford, California
| | - Jennifer Gurney
- US Army Institute of Surgical Research/Joint Trauma System, San Antonio, Texas
| | | | - Zachary W Brown
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | - Eileen M Bulger
- Department of Surgery, University of Washington, Seattle.,Committee on Trauma, American College of Surgeons, Chicago, Illinois
| | - Frederick M Burkle
- Harvard T. H. Chan School of Public Health, Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts
| | - Eric A Elster
- Department of Surgery, Uniformed Services University, Bethesda, Maryland
| | | | - Kent Garber
- Department of Surgery, University of California, Los Angeles
| | | | - Reinou S Groen
- Department of Obstetrics and Gynecology, Alaska Native Medical Center, Anchorage
| | - Gary Hsin
- Stanford University School of Medicine, Stanford, California
| | | | - Adam L Kushner
- Center for Humanitarian Health, Johns Hopkins Bloomberg School of Public health, Baltimore, Maryland
| | - Ian Norton
- Emergency Operations and Partnerships, Emergency Operations, World Health Organization, Geneva, Switzerland
| | - Inga Osmers
- Médecins Sans Frontières, Amsterdam, the Netherlands
| | | | - Tarek Razek
- Centre for Global Surgery, McGill University, Montreal, Quebec, Canada
| | | | | | | | | | | | - John Troke
- Samaritan's Purse, Boone, North Carolina
| | | | - Paul H Wise
- Stanford University School of Medicine, Stanford, California
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Haddara MM, Haberisoni JB, Trelles M, Gohou JP, Christella K, Dominguez L, Ali E. Hippopotamus bite morbidity: a report of 11 cases from Burundi. Oxf Med Case Reports 2020; 2020:omaa061. [PMID: 32793365 PMCID: PMC7416829 DOI: 10.1093/omcr/omaa061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 06/19/2020] [Indexed: 11/29/2022] Open
Abstract
Hippopotamus is one of the most-loved animals in Africa, yet it is aggressive and dangerous. The co-existence of humans in close proximity to their natural habitat increases the probability of human injury. Hippopotamus attacks have long been recognized to cause serious injuries, but its magnitude and burden are still unknown. The medical literature is very scarce when it comes to documenting hippopotamus bite injuries and their outcomes. We present a cohort of 11 patients who suffered hippopotamus bite injuries in Burundi. To our knowledge, this is the largest case series reporting on the clinical presentation, injury patterns and surgical outcomes of hippopotamus bites. The results show a high incidence of wound infections, amputations and permanent disability among other complications. Hippopotamus-inflicted injuries should, therefore, be triaged as major trauma rather than just 'mammalian bites'.
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Affiliation(s)
- Moustafa M Haddara
- Médecins Sans Frontières, Operational Center Brussels, Belgium, Arche Trauma Centre, Bujumbura, Burundi; Médecins Sans Frontières Canada; Toronto, ON, Canada
| | - Jean Berchmans Haberisoni
- Médecins Sans Frontières, Operational Center Brussels, Arche Trauma Centre, MSF Burundi Mission, Bujumbura, Burundi
| | - Miguel Trelles
- Médecins Sans Frontières, Operational Center Brussels, Medical Department, Brussels, Belgium
| | - Jean-Paul Gohou
- Médecins Sans Frontières, Operational Center Brussels, Arche Trauma Centre, MSF Burundi Mission, Bujumbura, Burundi
| | - Kwizera Christella
- Médecins Sans Frontières, Operational Center Brussels, Arche Trauma Centre, MSF Burundi Mission, Bujumbura, Burundi
| | - Lynette Dominguez
- Médecins Sans Frontières, Operational Center Brussels, Medical Department, Brussels, Belgium
| | - Engy Ali
- Médecins Sans Frontières, Operational Center Brussels, Medical Department, Luxembourg Operational Research Unit (LuxOR), Luxembourg, Luxembourg
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Kudsk-Iversen S, Trelles M, Ngowa Bakebaanitsa E, Hagabimana L, Momen A, Helmand R, Saint Victor C, Shah K, Masu A, Kendell J, Edgcombe H, English M. Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years. BMJ Open 2020; 10:e034891. [PMID: 32139492 PMCID: PMC7059447 DOI: 10.1136/bmjopen-2019-034891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/15/2020] [Accepted: 01/21/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload. DESIGN Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB). SETTING Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres. PARTICIPANTS The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers. PRIMARY OUTCOME MEASURE Volume and nature of surgical workload of different anaesthesia providers. RESULTS Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%. CONCLUSION Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.
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Affiliation(s)
- Søren Kudsk-Iversen
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Miguel Trelles
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
| | - Elie Ngowa Bakebaanitsa
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Masisi Referral Hospital, Masisi-MSF Democratic Republic of the Congo mission, Masisi, The Democratic Republic of the Congo
| | - Longin Hagabimana
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Arche Trauma Hospital, Bujumbura-MSF Burundi mission, Bujumbura, Burundi
| | - Abdul Momen
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Khost Maternity, Khost-MSF Afghanistan mission, Khost, Afghanistan
| | - Rahmatullah Helmand
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Ahmad Shah Baba Hospital, Kabul-MSF Afghanistan mission, Kabul, Afghanistan
| | - Carline Saint Victor
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Tabarre Trauma Hospital, Port-au-Prince-MSF Haiti mission, Port-au-Prince, Haiti
| | - Khalid Shah
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Timurgara District Headquarter Hospital, Timurgara-MSF Pakistan mission, Timurgara, Pakistan
| | - Adolphe Masu
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
- Arche Trauma Hospital, Bujumbura-MSF Burundi mission, Bujumbura, Burundi
- Khost Maternity, Khost-MSF Afghanistan mission, Khost, Afghanistan
- Castors Maternity, Bangui-MSF Central African Republic mission, Bangui, Central African Republic
| | - Judith Kendell
- Operational Centre Brussels, Médecins Sans Frontières, Bruxelles, Belgium
| | - Hilary Edgcombe
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Mike English
- Health Services Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, Oxfordshire, UK
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Coventry CA, Dominguez L, Read DJ, Trelles M, Ivers RQ, Montazerolghaem M, Holland AJA. Comparison of Operative Logbook Experience of Australian General Surgical Trainees With Surgeons Deployed on Humanitarian Missions: What Can Be Learnt for the Future? J Surg Educ 2020; 77:131-137. [PMID: 31451427 DOI: 10.1016/j.jsurg.2019.08.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 07/28/2019] [Accepted: 08/02/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE General surgical training in Australia has undergone considerable change in recent years with less exposure to other areas of surgery. General surgeons from many high-income countries have played important roles in assisting with the provision of surgical care in low- and middle-income countries during sudden-onset disasters (SODs) as part of emergency medical teams (EMTs). It is not known if contemporary Australian general surgeons are receiving the broad surgical training required for work in EMTs. DESIGN Logbook data on the surgical procedures performed by Australian general surgical trainees were obtained from General Surgeons Australia (GSA) for the time period February 2008 to February 2017. Surgical procedures performed by Médecins sans Frontières (MSF) surgeons during 5 projects in 3 SODs (the 2010 Haiti earthquake, the 2013 Philippines typhoon and the 2015 Nepal earthquake) were obtained from previously published data for 6 months following each disaster. SETTING AND PARTICIPANTS This was carried out at the University of Sydney with input from MSF Operational Centre Brussels and GSA. RESULTS Australian general surgical trainees performed a mean of 2107 surgical procedures (excluding endoscopy) during their training (10 6-month rotations). Common procedures included abdominal wall hernia repairs (268, 12.7%), cholecystectomies (247, 11.8%), and specialist colorectal procedures (242, 11.5%). MSF surgeons performed a total of 3542 surgical procedures across the 5 projects analyzed. Common procedures included Caesarean sections (443, 12.5%), wound debridement (1115, 31.5%), and other trauma-related procedures (472, 13.3%). CONCLUSIONS Australian general surgical trainees receive exposure to both essential and advanced general surgery but lack exposure to specialty procedures including the obstetric and orthopedic procedures commonly performed by MSF surgeons after SODs. Further training in these areas would likely be beneficial for general surgeons prior to deployment with an EMT.
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Affiliation(s)
- Charles A Coventry
- The Children's Hospital at Westmead Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia.
| | - Lynette Dominguez
- Médecins sans Frontières- Operational Centre Brussels, Brussels, Belgium
| | - David J Read
- National Critical Care and Trauma Response Centre, Darwin, NT, Australia
| | - Miguel Trelles
- Médecins sans Frontières- Operational Centre Brussels, Brussels, Belgium
| | - Rebecca Q Ivers
- School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | | | - Andrew J A Holland
- The Children's Hospital at Westmead Clinical School, The University of Sydney School of Medicine, Sydney, NSW, Australia; Department of Paediatric Surgery, The Children's Hospital at Westmead, Sydney, NSW, Australia
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Cuesta JG, Trelles M, Naseer A, Momin A, Mulamira LN, Caluwaerts S, Guha-Sapir D. Does the presence of conflict affect maternal and neonatal mortality during Caesarean sections? Public Health Action 2019; 9:107-112. [PMID: 31803582 DOI: 10.5588/pha.18.0045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 06/21/2019] [Indexed: 11/10/2022] Open
Abstract
Introduction Conflicts frequently occur in countries with high maternal and neonatal mortality and can aggravate difficulties accessing emergency care. No literature is available on whether the presence of conflict influences the outcomes of mothers and neonates during Caesarean sections (C-sections) in high-mortality settings. Objective To determine whether the presence of conflict was associated with changes in maternal and neonatal mortality during C-sections. Methods We analysed routinely collected data on C-sections from 17 Médecins Sans Frontières (MSF) health facilities in 12 countries. Exposure variables included presence and intensity of conflict, type of health facility and other types of access to emergency care. Results During 2008-2015, 30,921 C-sections were performed in MSF facilities; of which 55.4% were in areas of conflict. No differences were observed in maternal mortality in conflict settings (0.1%) vs. non-conflict settings (0.1%) (P = 0.08), nor in neonatal mortality between conflict (12.2%) and non-conflict settings (11.5%) (P = 0.1). Among the C-sections carried out in conflict settings, neonatal mortality was slightly higher in war zones compared to areas of minor conflict (P = 0.02); there was no difference in maternal mortality (P = 0.38). Conclusions Maternal and neonatal mortality did not appear to be affected by the presence of conflict in a large number of MSF facilities. This finding should encourage humanitarian organisations to support C-sections in conflict settings to ensure access to quality maternity care.
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Affiliation(s)
- J Gil Cuesta
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - M Trelles
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - A Naseer
- Timurgara Hospital, Operational Centre Brussels, Médecins Sans Frontières, Timurgara, Pakistan
| | - A Momin
- Operational Centre Brussels, Médecins Sans Frontières, Ahmad Shah Baba Hospital, Kabul, Afghanistan
| | - L Ngabo Mulamira
- Masisi Hospital, Operational Centre Brussels, Médecins Sans Frontières, Masisi, Democratic Republic of Congo
| | - S Caluwaerts
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - D Guha-Sapir
- Centre for Research on the Epidemiology of Disasters, Université Catholique de Louvain, Brussels, Belgium
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Tounsi LL, Daebes HL, Gerdin Wärnberg M, Nerlander M, Jaweed M, Mamozai BA, Nasim M, Drevin G, Trelles M, von Schreeb J. Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan. World J Surg 2019; 43:2123-2130. [PMID: 31065777 DOI: 10.1007/s00268-019-05015-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males. MATERIALS AND METHODS This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression. RESULTS Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453). CONCLUSION Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
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Affiliation(s)
- Linnea Latifa Tounsi
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Hadjer Latif Daebes
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | | | - Maximilian Nerlander
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Momer Jaweed
- Kunduz Trauma Centre, Médecins Sans Frontières, Kunduz, Afghanistan
| | | | - Masood Nasim
- Kabul Medical Coordination, Médecins Sans Frontières, Kabul, Afghanistan
| | - Gustaf Drevin
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Miguel Trelles
- Medical Department - Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Johan von Schreeb
- Department of Public Health Sciences, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Beltrán Guzmán I, Gil Cuesta J, Trelles M, Jaweed O, Cherestal S, van Loenhout JAF, Guha-Sapir D. Delays in arrival and treatment in emergency departments: Women, children and non-trauma consultations the most at risk in humanitarian settings. PLoS One 2019; 14:e0213362. [PMID: 30835777 PMCID: PMC6400395 DOI: 10.1371/journal.pone.0213362] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/20/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Delays in arrival and treatment at health facilities lead to negative health outcomes. Individual and external factors could be associated with these delays. This study aimed to assess common factors associated with arrival and treatment delays in the emergency departments (ED) of three hospitals in humanitarian settings. METHODOLOGY This was a cross-sectional study based on routine data collected from three MSF-supported hospitals in Afghanistan, Haiti and Sierra Leone. We calculated the proportion of consultations with delay in arrival (>24 hours) and in treatment (based on target time according to triage categories). We used a multinomial logistic regression model (MLR) to analyse the association between age, sex, hospital and diagnosis (trauma and non-trauma) with these delays. RESULTS We included 95,025 consultations. Males represented 65.2%, Delay in arrival was present in 27.8% of cases and delay in treatment in 27.2%. The MLR showed higher risk of delay in arrival for females (OR 1.2, 95% CI 1.2-1.3), children <5 (OR 1.4, 95% CI 1.4-1.5), patients attending to Gondama (OR 30.0, 95% CI 25.6-35.3) and non-trauma cases (OR 4.7, 95% CI 4.4-4.8). A higher risk of delay in treatment was observed for females (OR 1.1, 95% CI 1.0-1.1), children <5 (OR 2.0, 95% CI 1.9-2.1), patients attending to Martissant (OR 14.6, 95% CI 13.9-15.4) and non-trauma cases (OR 1.6, 95% CI 1.5-1.7). CONCLUSIONS Women, children <5 and non-trauma cases suffered most from delays. These delays could relate to educational and cultural barriers, and severity perception of the disease. Treatment delay could be due to insufficient resources with consequent overcrowding, and severity perception from medical staff for non-trauma patients. Extended community outreach, health promotion and support to community health workers could improve emergency care in humanitarian settings.
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Affiliation(s)
- Isabel Beltrán Guzmán
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- Operational Centre Geneva, Médecins Sans Frontières, Geneva, Switzerland
| | - Julita Gil Cuesta
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Miguel Trelles
- Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium
| | - Omar Jaweed
- Mission Afghanistan, Médecins Sans Frontières, Kunduz, Afghanistan
| | - Sophia Cherestal
- Mission Haiti, Operational Centre Brussels, Médecins Sans Frontières, Port-au-Prince, Haiti
| | - Joris Adriaan Frank van Loenhout
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Debarati Guha-Sapir
- Centre for Research on the Epidemiology of Disasters, Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
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Chu KM, Karjiker P, Naidu P, Kruger D, Taylor A, Trelles M, Dominguez L, Rayne S. South African General Surgeon Preparedness for Humanitarian Disasters. World J Surg 2018; 43:973-977. [DOI: 10.1007/s00268-018-04881-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Trelles M, Ahmed AK, Mitchell CH, Josue-Torres I, Rigamonti D, Blitz AM. Natural History of Endoscopic Third Ventriculostomy in Adults: Serial Evaluation with High-Resolution CISS. AJNR Am J Neuroradiol 2018; 39:2231-2236. [PMID: 30442699 DOI: 10.3174/ajnr.a5861] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/17/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Endoscopic third ventriculostomy is a well-accepted treatment choice for hydrocephalus and is used most frequently with a known impediment to CSF flow between the third ventricle and basal cisterns. However, there are scarce data on the imaging evolution of the defect in the floor of the third ventricle and how this affects patency rates and clinical outcomes. The purpose of this study was to assess whether, and how, the endoscopic third ventriculostomy defect changes in size with time. MATERIALS AND METHODS All high-resolution endoscopic third ventriculostomy protocol MRIs performed between 2009 through 2014 were retrospectively identified. Two fellowship-trained neuroradiologists, blinded to clinical information, independently reviewed all retrospective cases. RESULTS A total of 98 imaging studies were included from 34 patients. The average change in the area throughout the studied period was 0.02 mm2/day (7.5 mm2/year), with a higher increase in size noted in the first 3 postsurgical months, with a gradual decrease in the degree of defect-size change. Use of the NICO Myriad device was correlated with the area of the endoscopic third ventriculostomy defect on the last follow-up, demonstrating a larger final defect size in patients in whom the surgical technique included debridement of the endoscopic third ventriculostomy defect walls with the NICO Myriad device (28.21 versus 11.25 mm, P < .05). CONCLUSIONS High-resolution MR imaging with sagittal CISS images is useful in the postoperative evaluation of endoscopic third ventriculostomies. Such findings may prove useful in determining the optimal duration of follow-up with MR imaging of patients who have undergone endoscopic third ventriculostomy.
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Affiliation(s)
- M Trelles
- From the Departments of Radiology and Radiological Sciences (M.T., A.M.B.)
| | - A K Ahmed
- Neurosurgery (A.K.A., I.J.-T., D.R.)
| | - C H Mitchell
- Neurology (C.H.M.), Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - A M Blitz
- From the Departments of Radiology and Radiological Sciences (M.T., A.M.B.)
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16
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Lin Y, Dahm JS, Kushner AL, Lawrence JP, Trelles M, Dominguez LB, Kuwayama DP. Are American Surgical Residents Prepared for Humanitarian Deployment?: A Comparative Analysis of Resident and Humanitarian Case Logs. World J Surg 2017; 42:32-39. [DOI: 10.1007/s00268-017-4137-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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De Plecker E, Zachariah R, Kumar AMV, Trelles M, Caluwaerts S, van den Boogaard W, Manirampa J, Tayler-Smith K, Manzi M, Nanan-N’zeth K, Duchenne B, Ndelema B, Etienne W, Alders P, Veerman R, Van den Bergh R. Emergency obstetric care in a rural district of Burundi: What are the surgical needs? PLoS One 2017; 12:e0170882. [PMID: 28170398 PMCID: PMC5295715 DOI: 10.1371/journal.pone.0170882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 01/13/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes. METHODS A retrospective analysis of EmOC data (2011 and 2012). RESULTS A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died. CONCLUSION Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.
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Affiliation(s)
- E. De Plecker
- Medecins sans Frontieres, Medical department, Brussels Operational Centre, Brussels, Belgium
- * E-mail:
| | - R. Zachariah
- Medecins sans Frontieres, Medical department (Operational Research), Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | - A. M. V. Kumar
- International Union against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi India
| | - M. Trelles
- Medecins sans Frontieres, Medical department, Brussels Operational Centre, Brussels, Belgium
| | - S. Caluwaerts
- Medecins sans Frontieres, Medical department, Brussels Operational Centre, Brussels, Belgium
| | | | | | - K. Tayler-Smith
- Medecins sans Frontieres, Medical department (Operational Research), Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | - M. Manzi
- Medecins sans Frontieres, Medical department (Operational Research), Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | | | - B. Duchenne
- Medecins sans Frontieres, Bujumbura, Burundi
| | - B. Ndelema
- Medecins sans Frontieres, Bujumbura, Burundi
| | - W. Etienne
- Medecins sans Frontieres, Operational department, Brussels Operational Centre, Brussels, Belgium
| | - P. Alders
- Medecins sans Frontieres, Operational department, Brussels Operational Centre, Brussels, Belgium
| | - R. Veerman
- Medecins sans Frontieres, Operational department, Brussels Operational Centre, Brussels, Belgium
| | - R. Van den Bergh
- Medecins sans Frontieres, Medical department (Operational Research), Operational Centre Brussels, MSF-Luxembourg, Luxembourg
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Levine AC, Teicher C, Aluisio AR, Wiskel T, Valles P, Trelles M, Glavis-Bloom J, Grais RF. Regional Anesthesia for Painful Injuries after Disasters (RAPID): study protocol for a randomized controlled trial. Trials 2016; 17:542. [PMID: 27842565 PMCID: PMC5109730 DOI: 10.1186/s13063-016-1671-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 10/25/2016] [Indexed: 01/10/2023] Open
Abstract
Background Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting. Methods/design The Regional Anesthesia for Painful Injuries after Disasters (RAPID) study aims to evaluate whether regional anesthesia (RA), either with or without ultrasound (US) guidance, can reduce pain from earthquake-related lower limb injuries in a disaster setting. The proposed study is a blinded, randomized controlled equivalence trial among earthquake victims with serious lower extremity injuries in a resource-limited setting. After obtaining informed consent, study participants will be randomized in a 1:1:1 allocation to either: standard care (parenteral morphine at 0.1 mg/kg); standard care plus a landmark-guided fascia iliaca compartment block (FICB); or standard care plus an US-guided femoral nerve block. General practice humanitarian response providers who have undergone a focused training in RA will perform nerve blocks with 20 ml 0.5 % levobupivacaine. US sham activities will be used in the standard care and FICB arms and a normal saline injection will be given to the control group to blind both participants and nonresearch team providers. The primary outcome measure will be the summed pain intensity difference calculated using a standard 11-point Numerical Rating Scale reported by patients over 24 h of follow-up. Secondary outcome measures will include overall analgesic requirements, adverse events, and participant satisfaction. Discussion Given the high burden of lower extremity injuries in the aftermath of earthquakes and the currently limited treatment options, research into adjuvant interventions for pain management of these injuries is necessary. While anecdotal reports on the use of RA for patients injured during earthquakes exist, no controlled studies have been undertaken. If demonstrated to be effective in a disaster setting, RA has the potential to significantly assist in reducing both acute suffering and long-term complications for survivors of earthquake trauma. Trial registration ClinicalTrials.gov (NCT02698228), registered on 16 February 2016.
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Affiliation(s)
- Adam C Levine
- Warren Alpert School of Medicine, Brown University, 55 Claverick Street, Room 274, Providence, RI, 02903, USA.
| | | | - Adam R Aluisio
- Warren Alpert School of Medicine, Brown University, 55 Claverick Street, Room 274, Providence, RI, 02903, USA
| | - Tess Wiskel
- Warren Alpert School of Medicine, Brown University, 55 Claverick Street, Room 274, Providence, RI, 02903, USA
| | - Pola Valles
- Médecins Sans Frontières Belgium, Brussels, Belgium
| | | | - Justin Glavis-Bloom
- Warren Alpert School of Medicine, Brown University, 55 Claverick Street, Room 274, Providence, RI, 02903, USA
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Valles P, Van den Bergh R, van den Boogaard W, Tayler-Smith K, Gayraud O, Mammozai BA, Nasim M, Cheréstal S, Majuste A, Charles JP, Trelles M. Emergency department care for trauma patients in settings of active conflict versus urban violence: all of the same calibre? Int Health 2016; 8:390-397. [PMID: 27810881 PMCID: PMC5181548 DOI: 10.1093/inthealth/ihw035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 03/16/2016] [Accepted: 04/05/2016] [Indexed: 11/16/2022] Open
Abstract
Background Trauma is a leading cause of death and represents a major problem in developing countries where access to good quality emergency care is limited. Médecins Sans Frontières delivered a standard package of care in two trauma emergency departments (EDs) in different violence settings: Kunduz, Afghanistan, and Tabarre, Haiti. This study aims to assess whether this standard package resulted in similar performance in these very different contexts. Methods A cross-sectional study using routine programme data, comparing patient characteristics and outcomes in two EDs over the course of 2014. Results 31 158 patients presented to the EDs: 22 076 in Kunduz and 9082 in Tabarre. Patient characteristics, such as delay in presentation (29.6% over 24 h in Kunduz, compared to 8.4% in Tabarre), triage score, and morbidity pattern differed significantly between settings. Nevertheless, both EDs showed an excellent performance, demonstrating low proportions of mortality (0.1% for both settings) and left without being seen (1.3% for both settings), and acceptable triage performance. Physicians’ maximum working capacity was exceeded in both centres, and mainly during rush hours. Conclusions This study supports for the first time the plausibility of using the same ED package in different settings. Mapping of patient attendance is essential for planning of human resources needs.
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Affiliation(s)
- Pola Valles
- Médecins Sans Frontières - Operational Centre Brussels, Medical Department, Brussels, Belgium
| | - Rafael Van den Bergh
- Médecins Sans Frontières - Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - Wilma van den Boogaard
- Médecins Sans Frontières - Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - Katherine Tayler-Smith
- Médecins Sans Frontières - Operational Centre Brussels, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - Olivia Gayraud
- Médecins Sans Frontières - Operational Centre Brussels, Port-au-Prince, Haiti
| | | | - Masood Nasim
- Médecins Sans Frontières - Operational Centre Brussels, Kunduz, Afghanistan
| | - Sophia Cheréstal
- Médecins Sans Frontières - Operational Centre Brussels, Port-au-Prince, Haiti
| | - Alberta Majuste
- Médecins Sans Frontières - Operational Centre Brussels, Port-au-Prince, Haiti
| | | | - Miguel Trelles
- Médecins Sans Frontières - Operational Centre Brussels, Medical Department, Brussels, Belgium
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20
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Gohy B, Ali E, Van den Bergh R, Schillberg E, Nasim M, Naimi MM, Cheréstal S, Falipou P, Weerts E, Skelton P, Van Overloop C, Trelles M. Early physical and functional rehabilitation of trauma patients in the Médecins Sans Frontières trauma centre in Kunduz, Afghanistan: luxury or necessity? Int Health 2016; 8:381-389. [PMID: 27738078 PMCID: PMC5181549 DOI: 10.1093/inthealth/ihw039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/04/2016] [Accepted: 07/07/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND In Afghanistan, Médecins Sans Frontières provided specialised trauma care in Kunduz Trauma Centre (KTC), including physiotherapy. In this study, we describe the development of an adapted functional score for patient outcome monitoring, and document the rehabilitation care provided and patient outcomes in relation to this functional score. METHODS A descriptive cohort study was done, including all patients admitted in the KTC inpatient department (IPD) between January and June 2015. The adapted functional score was collected at four points in time: admission and discharge from both IPD and outpatient department (OPD). RESULTS Out of the 1528 admitted patients, 92.3% (n = 1410) received at least one physiotherapy session. A total of 1022 patients sustained either lower limb fracture, upper limb fracture, traumatic brain injury or multiple injury. Among them, 966 patients received physiotherapy in IPD, of whom 596 (61.7%) received IPD sessions within 2 days of admission; 696 patients received physiotherapy in OPD. Functional independence increased over time; among patients having a functional score taken at admission and discharge from IPD, 32.2% (172/535) were independent at discharge, and among patients having a functional score at OPD admission and discharge, 79% (75/95) were independent at discharge. CONCLUSIONS The provision of physiotherapy was feasible in this humanitarian setting, and the tailored functional score appeared to be relevant.
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Affiliation(s)
- Bérangère Gohy
- Handicap International, Operational Centre Lyon, Emergency Technical Unit, Lyon, France
| | - Engy Ali
- Médecins sans Frontières, Operational Centre Brussels, Medical Department, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - Rafael Van den Bergh
- Médecins sans Frontières, Operational Centre Brussels, Medical Department, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - Erin Schillberg
- Médecins sans Frontières, Operational Centre Brussels, Medical Department, Operational Research Unit (LuxOR), Luxembourg, Luxembourg
| | - Masood Nasim
- Médecins Sans Frontières-Operational Centre Brussels, Afghanistan mission, Kabul, Afghanistan
| | - Muhammad Mahmood Naimi
- Médecins Sans Frontières-Operational Centre Brussels, Afghanistan mission, Kunduz Trauma Centre, Afghanistan
| | - Sophia Cheréstal
- Médecins Sans Frontières-Operational Centre Brussels, Haiti mission, Port-au-Prince, Haiti
| | - Pauline Falipou
- Handicap International, Operational Centre Lyon, Emergency Technical Unit, Lyon, France
| | - Eric Weerts
- Handicap International, Operational Centre Lyon, Emergency Technical Unit, Lyon, France
| | - Peter Skelton
- Handicap International, Operational Centre Lyon, Emergency Technical Unit, Lyon, France
| | - Catherine Van Overloop
- Médecins Sans Frontières-Operational Centre Brussels, Operational Department, Brussels, Belgium
| | - Miguel Trelles
- Médecins sans Frontières, Operational Centre Brussels, Medical Department, Surgical Unit, Brussels, Belgium
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Shirodkar S, Anande L, Dalal A, Desai C, Corrêa G, Das M, Laxmeshwar C, Mansoor H, Remartinez D, Trelles M, Isaakidis P. Surgical interventions for pulmonary tuberculosis in Mumbai, India: surgical outcomes and programmatic challenges. Public Health Action 2016; 6:193-198. [PMID: 27695683 DOI: 10.5588/pha.16.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/03/2016] [Indexed: 11/10/2022] Open
Abstract
Setting: While surgery for pulmonary tuberculosis (PTB) is considered an important adjunct for specific cases, including drug-resistant tuberculosis, operational evidence on its feasibility and effectiveness is limited. Objective: To describe surgical outcomes and programmatic challenges of providing surgery for PTB in Mumbai, India. Design: A descriptive study of routinely collected data of surgical interventions for PTB from 2010 to 2014 in two Mumbai hospitals, one public, one private. Results: Of 85 patients, 5 (6%) died and 17 (20%) had complications, with wound infection being the most frequent. Repeat operation was required in 12 (14%) patients. Most procedures were performed on an emergency basis, and eligibility was established late in the course of treatment. Median time from admission to surgery was 51 days. Drug susceptibility test (DST) patterns and final treatment outcomes were not systematically collected. Conclusion: In a high-burden setting such as Mumbai, important data on surgery for PTB were surprisingly limited in both the private and public sectors. Eligibility for surgery was established late, culture and DST were not systematically offered, the interval between admission and surgery was long and TB outcomes were not known. Systematic data collection would allow for proper evaluation of surgery as adjunctive therapy for all forms of TB under programmatic conditions.
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Affiliation(s)
- S Shirodkar
- Chest Department, GTB Hospital, Sewri, Mumbai, India
| | - L Anande
- Chest Department, GTB Hospital, Sewri, Mumbai, India
| | - A Dalal
- Chest Department, Jupiter Hospital, Thane, India
| | - C Desai
- Chest Department, GTB Hospital, Sewri, Mumbai, India
| | - G Corrêa
- Médecins Sans Frontières (MSF), Operational Research, Mumbai, India
| | - M Das
- Médecins Sans Frontières (MSF), Operational Research, Mumbai, India
| | - C Laxmeshwar
- Médecins Sans Frontières (MSF), Operational Research, Mumbai, India
| | - H Mansoor
- Médecins Sans Frontières (MSF), Operational Research, Mumbai, India
| | - D Remartinez
- Médecins Sans Frontières (MSF), Operational Research, Mumbai, India
| | - M Trelles
- Medical Department, MSF, Brussels, Belgium
| | - P Isaakidis
- Médecins Sans Frontières (MSF), Operational Research, Mumbai, India
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Trelles M, Stewart BT, Hemat H, Naseem M, Zaheer S, Zakir M, Adel E, Van Overloop C, Kushner AL. Averted health burden over 4 years at Médecins Sans Frontières (MSF) Trauma Centre in Kunduz, Afghanistan, prior to its closure in 2015. Surgery 2016; 160:1414-1421. [PMID: 27407057 DOI: 10.1016/j.surg.2016.05.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 05/03/2016] [Accepted: 05/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND On October 3, 2015, a United States airstrike hit Médecins Sans Frontières (Doctors Without Borders) Trauma Centre in Kunduz, Afghanistan. Our aim was to describe the care provided and estimate the health burden averted by surgical care at the hospital. We also report the benefit rendered by the Trauma Centre to the health of the local population prior to its destruction. METHODS All operations performed in an operating theater at the Trauma Centre from its opening on August 30, 2011, to August 31, 2015, were described. Disability-adjusted life years averted by operative care over the same period were estimated. RESULTS The Trauma Centre performed 13,970 operations, which included 17,928 procedures for 6,685 patients. The median age of patients who required operative intervention was 21 years (interquartile range 12-34 years). More than 85% of patients were men (12,034 patients; 86%). Of the 6,685 patients who required operative care, 4,387 suffered unintentional, non-violence-related injuries (66%), while 2,276 suffered violence-related injuries (34%). The perioperative death rate at the facility decreased from 7.2 deaths per 1,000 operations in 2011 to 1.3 deaths in 2015 (P = .03). More than 154,250 disability-adjusted life years were averted by operative care (95% confidence interval 153,042-155,465). CONCLUSION The health burden averted by the surgical care provided at the Trauma Centre was large; it is critically felt by those still living in the region. Access to essential trauma care for all victims of armed conflict is a human right; as directed by International Humanitarian Law, we must guarantee special protection for the wounded, sick, and medical personnel and facilities during war.
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Affiliation(s)
- Miguel Trelles
- Anaesthesia, Gynaecology, and Emergency Medicine Unit, Operational Centre Brussels, Médecins Sans Frontières, Brussels, Belgium.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA; School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Hamayoun Hemat
- Médecins Sans Frontières, Afghanistan Mission, Kabul, Afghanistan
| | - Masood Naseem
- Médecins Sans Frontières, Afghanistan Mission, Kabul, Afghanistan
| | - Sattar Zaheer
- Médecins Sans Frontières Trauma Centre, Kunduz, Afghanistan
| | - Mutallib Zakir
- Médecins Sans Frontières Trauma Centre, Kunduz, Afghanistan
| | - Edris Adel
- Médecins Sans Frontières Trauma Centre, Kunduz, Afghanistan
| | | | - Adam L Kushner
- Surgeons Over Seas (SOS), New York, NY; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Department of Surgery, Columbia University, New York, NY
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Flynn-O’Brien KT, Trelles M, Dominguez L, Hassani GH, Akemani C, Naseer A, Ntawukiruwabo IB, Kushner AL, Rothstein DH, Stewart BT. Surgery for children in low-income countries affected by humanitarian emergencies from 2008 to 2014: The Médecins Sans Frontières Operations Centre Brussels experience. J Pediatr Surg 2016; 51:659-69. [PMID: 26454469 PMCID: PMC5860656 DOI: 10.1016/j.jpedsurg.2015.08.063] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/16/2015] [Accepted: 08/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Pediatric surgical care is deficient in developing countries disrupted by crisis. We aimed to describe pediatric surgical care at Médecins Sans Frontières-Brussels (MSF-OCB) projects to inform resource allocation and define the pediatric-specific skillset necessary for humanitarian surgical teams. METHODS Procedures performed by MSF-OCB from July 2008 to December 2014 were reviewed. Project characteristics, patient demographics and clinical data were described. Multivariable logistic regression was performed to determine predictors of perioperative death. RESULTS Of 109,828 procedures, 26,284 were performed for 24,576 children (22% of all procedures). The most common pediatric operative indication was trauma (13,984; 57%). Nine percent of all surgical indications were due to violence (e.g., land mines, firearms, gender-based violence, etc.). The majority of procedures (19,582; 75%) were general surgical, followed by orthopedic (4350; 17%), and obstetric/gynecologic/urologic (2135; 8%). Perioperative death was low (42; 0.17%); independent predictors of death included age <1year, use of general anesthesia with a definitive airway, and operation during conflict. CONCLUSION Surgical care for children comprised nearly a quarter of all procedures performed by MSF-OCB between 2008 and 2014. Attention to trauma surgery and infant perioperative care is particularly needed. These findings are important when resourcing projects and training surgical staff for humanitarian missions.
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Affiliation(s)
- Katherine T. Flynn-O’Brien
- Department of Surgery, University of Washington, Seattle, WA, USA,Harborview Injury Prevention and Research Center, Seattle, WA, USA,Corresponding author at: University of Washington, Department of Surgery, 1959 NE Pacific St., Suite BB-487, P.O. Box 356410, Seattle, WA 98195-6410. Tel.: +1 206 543 3680. (K.T. Flynn-O’Brien)
| | - Miguel Trelles
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Lynette Dominguez
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Ghulam Hiadar Hassani
- Médecins sans Frontières-Operational Centre Brussels, Surgical Unit, Brussels, Belgium,Boost General Hospital, Médecins sans Frontières, Lashkar-Gah, Afghanistan
| | - Clemence Akemani
- Médecins sans Frontières-Operational Centre Brussels, Surgical Unit, Brussels, Belgium,General Referral Hospital, Médecins sans Frontières, Lubutu, Democratic Republic of the Congo
| | - Aamer Naseer
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium,Dargai DHQ Hospital, Dargai, Pakistan
| | - Innocent Bagura Ntawukiruwabo
- Médecins sans Frontières-Operational Centre Brussels, Surgical Unit, Brussels, Belgium,General Referral Hospital, Médecins sans Frontières, Masisi, Democratic Republic of the Congo
| | - Adam L. Kushner
- Surgeons OverSeas (SOS), New York, NY, USA,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA,Department of Surgery, Columbia University, New York, NY, USA
| | - David H. Rothstein
- Department of Surgery, Women & Children's Hospital of Buffalo, NY, USA,Department of Surgery, University at Buffalo, SUNY, Buffalo, NY, USA
| | - Barclay T. Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA,School of Medical Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana,Department of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana
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Trelles M, Stewart BT, Kushner AL. Attacks on civilians and hospitals must stop. Lancet Glob Health 2016; 4:e298-9. [PMID: 27012677 DOI: 10.1016/s2214-109x(16)00070-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 03/06/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Miguel Trelles
- Anaesthesia, Gynaecology, and Emergency Medicine Unit, Operational Centre Brussels, Médecins Sans Frontières, 1050 Brussels, Belgium.
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA; School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Adam L Kushner
- Surgeons Over Seas (SOS), New York, NY, USA; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Department of Surgery, Columbia University, New York, NY, USA
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Izquierdo G, Trelles M, Khan N. Reduciendo la mortalidad materna en zonas de conflicto: experiencia quirúrgica-anestésica en el Hospital Boost, Afganistán. Revista Colombiana de Anestesiología 2016. [DOI: 10.1016/j.rca.2015.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Trelles M, Dominguez L, Tayler-Smith K, Kisswani K, Zerboni A, Vandenborre T, Dallatomasina S, Rahmoun A, Ferir MC. Providing surgery in a war-torn context: the Médecins Sans Frontières experience in Syria. Confl Health 2015; 9:36. [PMID: 26674297 PMCID: PMC4678579 DOI: 10.1186/s13031-015-0064-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 11/08/2015] [Indexed: 01/28/2023] Open
Abstract
Background Since 2011, civil war has crippled Syria leaving much of the population without access to healthcare. Various field hospitals have been clandestinely set up to provide basic healthcare but few have been able to provide quality surgical care. In 2012, Medecins Sans Frontieres (MSF) began providing surgical care in the Jabal al-Akrad region of north-western Syria. Based on the MSF experience, we describe, for the period 5th September 2012 to 1st January 2014: a) the volume and profile of surgical cases, b) the volume and type of anaesthetic and surgical procedures performed, and c) the intraoperative mortality rate. Methods A descriptive study using routinely collected MSF programme data. Quality surgical care was assured through strict adherence to the following minimum standards: adequate infrastructure, adequate water and sanitation provisions, availability of all essential disposables, drugs and equipment, strict adherence to hygiene requirements and universal precautions, mandatory use of sterile equipment for surgical and anaesthesia procedures, capability for blood transfusion and adequate human resources. Results During the study period, MSF operated on 578 new patients, of whom 57 % were male and median age was 25 years (Interquartile range: 21–32 years). Violent trauma was the most common surgical indication (n-254, 44 %), followed by obstetric emergencies (n-191, 33 %) and accidental trauma (n-59, 10 %). In total, 712 anaesthetic procedures were performed. General anaesthesia without intubation was the most common type of anaesthesia (47 % of all anaesthetics) followed by spinal anaesthesia (25 %). A total of 831 surgical procedures were performed, just over half being minor/wound care procedures and nearly one fifth, caesarean sections. There were four intra-operative deaths, giving an intra-operative mortality rate of 0.7 %. Conclusions Surgical needs in a conflict-afflicted setting like Syria are high and include both combat and non-combat indications, particularly obstetric emergencies. Provision of quality surgical care in a complex and volatile setting like this is possible providing appropriate measures, supported by highly experienced staff, can be implemented that allow a specific set of minimum standards of care to be adhered to. This is particularly important when patient outcomes - as a reflection of quality of care - are difficult to assess.
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Affiliation(s)
- Miguel Trelles
- Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB), Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium
| | - Lynette Dominguez
- Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB), Surgery, Anaesthesia, Gynaecology, and Emergency Medicine Unit, Brussels, Belgium
| | - Katie Tayler-Smith
- MSF-OCB, Operational Research Unit, MSF-Luxembourg, Luxembourg, Luxembourg
| | | | | | | | | | - Alaa Rahmoun
- MSF-OCB, MSF Syria project, Latakia Governorate, Syria
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Dalwai MK, Tayler-Smith K, Trelles M, Jemmy JP, Maikéré J, Twomey M, Wakeel M, Iqbal M, Zachariah R. Implementation of a triage score system in an emergency room in Timergara, Pakistan. Public Health Action 2015; 3:43-5. [PMID: 26392995 DOI: 10.5588/pha.12.0083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 12/10/2012] [Indexed: 11/10/2022] Open
Abstract
Following implementation of the South African Triage Scale (SATS) system in the emergency department (ED) at the District Headquarter Hospital in Timergara, Pakistan, we 1) describe the implementation process, and 2) report on how accurately emergency staff used the system. Of the 370 triage forms evaluated, 320 (86%) were completed without errors, resulting in the correct triage priority being assigned. Fifty completed forms displayed errors, but only 16 (4%) resulted in an incorrect triage priority being assigned. This experience shows that the SATS can be implemented successfully and used accurately by nurses in an ED in Pakistan.
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Affiliation(s)
- M K Dalwai
- Médecins Sans Frontières (MSF), Islamabad, Pakistan ; Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - K Tayler-Smith
- Medical Department, Operational Research, Operational Centre Brussels, MSF-Luxembourg, Luxembourg
| | - M Trelles
- MSF, Brussels Operational Centre, Brussels, Belgium
| | - J-P Jemmy
- MSF, Brussels Operational Centre, Brussels, Belgium
| | - J Maikéré
- Médecins Sans Frontières (MSF), Islamabad, Pakistan
| | - M Twomey
- Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - M Wakeel
- Ministry of Health, Timergara, Lower Dir, Pakistan
| | - M Iqbal
- Médecins Sans Frontières (MSF), Islamabad, Pakistan
| | - R Zachariah
- Medical Department, Operational Research, Operational Centre Brussels, MSF-Luxembourg, Luxembourg
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Huapaya JA, Chávez-Trujillo K, Trelles M, Carbajal RD, Espadin RF. Anatomic variations of the branches of the aortic arch in a Peruvian population. Medwave 2015; 15:e6194. [DOI: 10.5867/medwave.2015.06.6194] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 07/21/2015] [Indexed: 11/27/2022] Open
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Sharma D, Hayman K, Stewart BT, Dominguez L, Trelles M, Saqeb S, Kasonga C, Hangi TK, Mupenda J, Naseer A, Wong E, Kushner AL. Surgery for Conditions of Infectious Etiology in Resource-Limited Countries Affected by Crisis: The Médecins Sans Frontières Operations Centre Brussels Experience. Surg Infect (Larchmt) 2015; 16:721-7. [PMID: 26230672 DOI: 10.1089/sur.2015.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Surgery for infection represents a substantial, although undefined, disease burden in low- and middle-income countries (LMICs). Médecins Sans Frontières-Operations Centre Brussels (MSF-OCB) provides surgical care in LMICs and collects data useful for describing operative epidemiology of surgical need otherwise unmet by national health services. This study aimed to describe the experience of MSF-OCB operations for infections in LMICs. By doing so, the results might aid effective resource allocation and preparation of future humanitarian staff. METHODS Procedures performed in operating rooms at facilities run by MSF-OCB from July 2008 through June 2014 were reviewed. Projects providing specialty care only were excluded. Procedures for infection were described and related to demographics and reason for humanitarian response. RESULTS A total of 96,239 operations were performed at 27 MSF-OCB sites in 15 countries between 2008 and 2014. Of the 61,177 general operations, 7,762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions (p<0.001), intra-abdominal infections during hospital support missions (p<0.001) and orthopedic infections during conflict missions (p<0.001). CONCLUSION Surgical infections are common causes for operation in LMICs, particularly during crisis. This study found that infections require greater than expected surgical input given frequent need for serial operations to overcome contextual challenges and those associated with limited resources in other areas (e.g., ward care). Furthermore, these results demonstrate that the pattern of operations for infections is related to nature of the crisis. Incorporating training into humanitarian preparation (e.g., surgical sepsis care, ultrasound-guided drainage procedures) and ensuring adequate resources for the care of surgical infections are necessary components for providing essential surgical care during crisis.
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Affiliation(s)
- Davina Sharma
- 1 Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Kate Hayman
- 1 Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland
| | - Barclay T Stewart
- 2 Department of Surgery, University of Washington , Seattle, Washington
| | - Lynette Dominguez
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium
| | - Miguel Trelles
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium
| | - Sanaulhaq Saqeb
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium .,4 Hospital Ahmad Sha Baba , Médecins sans Frontières, Kabul, Afghanistan
| | - Cheride Kasonga
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium .,5 General Referral Hospital , Médecins sans Frontières, Niangara, Democratic Republic of the Congo
| | - Theophile Kubuya Hangi
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium .,6 General Referral Hospital , Médecins sans Frontières, Masisi, Democratic Republic of the Congo
| | - Jerome Mupenda
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium .,7 General Referral Hospital , Médecins sans Frontières, Lubutu, Democratic Republic of the Congo
| | - Aamer Naseer
- 3 Médecins sans Frontières-Operational Centre Brussels , Surgical Unit, Brussels, Belgium .,8 District Headquarters Hospital , Médecins sans Frontières, Timurgara, Lower Dir, Pakistan
| | - Evan Wong
- 9 Centre for Global Surgery, McGill University Health Centre , Montreal, Quebec, Canada
| | - Adam L Kushner
- 1 Department of International Health, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland.,10 Surgeons over Seas (SOS) , New York, New York
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Trelles M, Dominguez L, Stewart BT. Surgery in low-income countries during crisis: experience at Médecins Sans Frontières facilities in 20 countries between 2008 and 2014. Trop Med Int Health 2015; 20:968-71. [PMID: 25877854 DOI: 10.1111/tmi.12523] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Miguel Trelles
- Surgery, Anesthesia, Gynecology and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Lynette Dominguez
- Surgery, Anesthesia, Gynecology and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Barclay T Stewart
- Department of Surgery, University of Washington, Seattle, WA, USA.,Department of Surgery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
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Sharma D, Hayman K, Stewart BT, Dominguez L, Trelles M, Saqeb S, Kasonga C, Hangi TK, Mupenda J, Naseer A, Wong E, Kushner AL. Care of surgical infections by Médecins Sans Frontières Operations Centre Brussels in 2008-14. Lancet 2015; 385 Suppl 2:S31. [PMID: 26313079 DOI: 10.1016/s0140-6736(15)60826-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Surgical infections represent a substantial yet undefined burden of disease in low-income and middle-income countries (LMICs). Médecins Sans Frontières (MSF) provides surgical care in LMICs and collects data useful to describe the operative epidemiology of surgical need that would otherwise be unmet by national health services. We aimed to describe the experience of MSF Operations Centre Brussels surgery for infections during crisis; aid effective resource allocation; prepare humanitarian surgical staff; and further characterise unmet surgical needs in LMICs. METHODS We reviewed all procedures undertaken in operating theatres at facilities run by the MSF Operations Centre Brussels between July, 2008, and June, 2014. Projects providing only specialty care were excluded. Procedures for infections were quantified, related to demographics and reason for humanitarian response was described. FINDINGS 96 239 operations were undertaken at 27 MSF Operations Centre Brussels sites in 15 countries. Of 61 177 general operations, 7762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopaedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions, intra-abdominal infections during hospital support missions, and orthopaedic infections during conflict missions. Most procedures for skin and soft tissue infections were minor (76%), whereas most operations for intra-abdominal infections were major (98%). INTERPRETATION Surgical infections are among the most common causes for operation in LMICs. Although many procedures were minor, they represent substantial use of perioperative resources. Growing evidence shows the need for improved perioperative capacity to aptly care for the volume and variety of conditions comprising the global burden of surgical disease. FUNDING Médecins Sans Frontières.
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Affiliation(s)
- Davina Sharma
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kate Hayman
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Lynette Dominguez
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium
| | - Miguel Trelles
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium
| | - Sanaulhaq Saqeb
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium; Hospital Ahmad Sha Baba, Médecins Sans Frontières, Kabul, Afghanistan
| | - Cheride Kasonga
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium; General Referral Hospital, Médecins Sans Frontières, Niangara, DR Congo
| | - Theophile Kubuya Hangi
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium; General Referral Hospital, Médecins Sans Frontières, Masis, DR Congo
| | - Jerome Mupenda
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium; General Referral Hospital, Médecins Sans Frontières, Lubutu, DR Congo
| | - Aamer Naseer
- Médecins sans Frontières - Operational Centre Brussels, Surgical Unit, Brussels, Belgium; District Headquarters Hospital, Médecins Sans Frontières, Timurgara, Lower Dir, Occupied Palestinian Territory, Montreal, QC, Canada
| | - Evan Wong
- Centre for Global Surgery, Mc Gill University Health Centre, Montreal, QC, Canada
| | - Adam L Kushner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Surgeons Over Seas (SOS), New York, NY, USA
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Groen RS, Trelles M, Caluwaerts S, Papillon-Smith J, Noor S, Qudsia B, Ndelema B, Kondo KM, Wong EG, Patel HD, Kushner AL. A cross-sectional study of indications for cesarean deliveries in Médecins Sans Frontières facilities across 17 countries. Int J Gynaecol Obstet 2015; 129:231-5. [DOI: 10.1016/j.ijgo.2014.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 12/14/2014] [Accepted: 02/19/2015] [Indexed: 10/23/2022]
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Trelles M, Jusue-Torres I, Mitchell C, David S, Sankey EW, Daniele R, Blitz A. Natural history of Endoscopic Third Ventriculostomy followed with high resolution MRI. Fluids Barriers CNS 2015. [PMCID: PMC4582231 DOI: 10.1186/2045-8118-12-s1-o15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Grimm JM, Schindler A, Schwarz F, Cyran CC, Bayer-Karpinska A, Freilinger T, Yuan C, Linn J, Trelles M, Reiser MF, Nikolaou K, Saam T. Computed tomography angiography vs 3 T black-blood cardiovascular magnetic resonance for identification of symptomatic carotid plaques. J Cardiovasc Magn Reson 2014; 16:84. [PMID: 25315518 PMCID: PMC4189681 DOI: 10.1186/s12968-014-0084-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 09/23/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The purpose of this prospective study was to perform a head-to-head comparison of the two methods most frequently used for evaluation of carotid plaque characteristics: Multi-detector Computed Tomography Angiography (MDCTA) and black-blood 3 T-cardiovascular magnetic resonance (bb-CMR) with respect to their ability to identify symptomatic carotid plaques. METHODS 22 stroke unit patients with unilateral symptomatic carotid disease and >50% stenosis by duplex ultrasound underwent MDCTA and bb-CMR (TOF, pre- and post-contrast fsT1w-, and fsT2w- sequences) within 15 days of symptom onset. Both symptomatic and contralateral asymptomatic sides were evaluated. By bb-CMR, plaque morphology, composition and prevalence of complicated AHA type VI lesions (AHA-LT6) were evaluated. By MDCTA, plaque type (non-calcified, mixed, calcified), plaque density in HU and presence of ulceration and/or thrombus were evaluated. Sensitivity (SE), specificity (SP), positive and negative predictive value (PPV, NPV) were calculated using a 2-by-2-table. RESULTS To distinguish between symptomatic and asymptomatic plaques AHA-LT6 was the best CMR variable and presence / absence of plaque ulceration was the best CT variable, resulting in a SE, SP, PPV and NPV of 80%, 80%, 80% and 80% for AHA-LT6 as assessed by bb-CMR and 40%, 95%, 89% and 61% for plaque ulceration as assessed by MDCTA. The combined SE, SP, PPV and NPV of bb-CMR and MDCTA was 85%, 75%, 77% and 83%, respectively. CONCLUSIONS Bb-CMR is superior to MDCTA at identifying symptomatic carotid plaques, while MDCTA offers high specificity at the cost of low sensitivity. Results were only slightly improved over bb-CMR alone when combining both techniques.
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Affiliation(s)
- Jochen M Grimm
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
- Department of Medical Radiology, University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Andreas Schindler
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Florian Schwarz
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Clemens C Cyran
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Anna Bayer-Karpinska
- Institute for Stroke and Dementia Research, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Tobias Freilinger
- Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tuebingen, Tuebingen, Germany.
| | - Chun Yuan
- Department of Radiology, University of Washington School of Medicine, Seattle, USA.
| | - Jennifer Linn
- Department of Neuroradiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Miguel Trelles
- Department of Radiology, University of Texas Medical Branch, Galveston, USA.
| | - Maximilian F Reiser
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Konstantin Nikolaou
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
| | - Tobias Saam
- Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany.
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Saam T, Eberhardt K, Buchholz M, Schindler A, Bayer-Karpinska A, Dichgans M, Reiser M, Nikolaou K, Trelles M. Evaluation der Karotis-CTA als Screening Methode für die Detektion komplizierter American Heart Association Typ VI Plaques. ROFO-FORTSCHR RONTG 2014. [DOI: 10.1055/s-0034-1372918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Wong EG, Trelles M, Dominguez L, Gupta S, Burnham G, Kushner AL. Surgical skills needed for humanitarian missions in resource-limited settings: common operative procedures performed at Médecins Sans Frontières facilities. Surgery 2014; 156:642-9. [PMID: 24661767 DOI: 10.1016/j.surg.2014.02.002] [Citation(s) in RCA: 85] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 02/04/2014] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Evan G Wong
- Centre for Global Surgery, McGill University Health Centre, Montreal, QC, Canada; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Surgeons OverSeas (SOS), New York, NY.
| | - Miguel Trelles
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Lynette Dominguez
- Surgery, Anesthesia, Gynecology, and Emergency Medicine Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Shailvi Gupta
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Surgeons OverSeas (SOS), New York, NY; Department of Surgery, University of California San Francisco-East Bay, Oakland, CA
| | - Gilbert Burnham
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Adam L Kushner
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; Surgeons OverSeas (SOS), New York, NY; Department of Surgery, Columbia University, New York, NY
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Tayler-Smith K, Zachariah R, Manzi M, van den Boogaard W, Vandeborne A, Bishinga A, De Plecker E, Lambert V, Christiaens B, Sinabajije G, Trelles M, Goetghebuer S, Reid T, Harries A. Obstetric fistula in Burundi: a comprehensive approach to managing women with this neglected disease. BMC Pregnancy Childbirth 2013; 13:164. [PMID: 23965150 PMCID: PMC3765123 DOI: 10.1186/1471-2393-13-164] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Accepted: 08/10/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Burundi, the annual incidence of obstetric fistula is estimated to be 0.2-0.5% of all deliveries, with 1000-2000 new cases per year. Despite this relatively high incidence, national capacity for identifying and managing obstetric fistula is very limited. Thus, in July 2010, Medecins Sans Frontieres (MSF) set up a specialised Obstetric Fistula Centre in Gitega (Gitega Fistula Centre, GFC), the only permanent referral centre for obstetric fistula in Burundi. A comprehensive model of care is offered including psychosocial support, conservative and surgical management, post-operative care and follow-up. We describe this model of care, patient outcomes and the operational challenges. METHODS Descriptive study using routine programme data. RESULTS Between July 2010 and December 2011, 470 women with obstetric fistula presented for the first time at GFC, of whom 458 (98%) received treatment. Early urinary catheterization (conservative management) was successful in four out of 35 (11%) women. Of 454 (99%) women requiring surgical management, 394 (87%) were discharged with a closed fistula, of whom 301 (76%) were continent of urine and/or faeces, while 93 (24%) remained incontinent of urine and/or faeces. In 59 (13%) cases, the fistula was complex and could not be closed. Outcome status was unknown for one woman. Median duration of stay at GFC was 39 days (Interquartile range IQR, 31-51 days). CONCLUSION In a rural African setting, it is feasible to implement a comprehensive package of fistula care using a dedicated fistula facility, and satisfactory surgical repair outcomes can be achieved. Several operational challenges are discussed.
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Trelles M, Eberhardt KM, Buchholz M, Schindler A, Bayer-Karpinska A, Dichgans M, Reiser MF, Nikolaou K, Saam T. CTA for screening of complicated atherosclerotic carotid plaque--American Heart Association type VI lesions as defined by MRI. AJNR Am J Neuroradiol 2013; 34:2331-7. [PMID: 23868157 DOI: 10.3174/ajnr.a3607] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE High-resolution carotid MR imaging can accurately identify complicated American Heart Association lesion type VI plaques, which are characterized by thrombus, hemorrhage, or a ruptured fibrous cap. The purpose of this study is to evaluate whether CTA can be used as screening tool to predict the presence or absence of American Heart Association lesion type VI plaques as defined by high-resolution MR imaging. METHODS Fifty-one patients with suspected ischemic stroke or TIA with carotid CTA and carotid MR imaging performed within 14 days of the event/admission from April 2008 to December 2010 were reviewed. Vessels with stents or occlusion were excluded (n = 2). Each carotid artery was assigned an American Heart Association lesion type classification by MR imaging. The maximum wall thickness, maximum soft plaque component thickness, maximum calcified component thickness, and its attenuation (if the soft plaque component thickness was >2 mm) were obtained from the CTA. RESULTS The maximum soft plaque component thickness proved the best discriminating factor to predict a complicated plaque by MR imaging, with a receiver operating characteristic area under the curve of 0.89. The optimal sensitivity and specificity for detection of complicated plaque by MR imaging was achieved with a soft plaque component thickness threshold of 4.4 mm (sensitivity, 0.65; specificity, 0.94; positive predictive value, 0.75; and negative predictive value, 0.9). No complicated plaque had a soft tissue plaque thickness <2.2 mm (negative predictive value, 1) and no simple (noncomplicated) plaque had a thickness >5.6 mm (positive predictive value, 1). CONCLUSIONS Maximum soft plaque component thickness as measured by carotid CTA is a reliable indicator of a complicated plaque, with a threshold of 2.2 mm representing little to no probability of a complicated American Heart Association lesion type VI plaque.
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Affiliation(s)
- M Trelles
- Department of Radiology, University of Texas Medical Branch, Galveston, Texas
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Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres. PLoS One 2012; 7:e44484. [PMID: 22962616 PMCID: PMC3433452 DOI: 10.1371/journal.pone.0044484] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/08/2012] [Indexed: 11/19/2022] Open
Abstract
Objectives The World Health Organization considers Cesarean section rates of 5–15% to be the optimal range for targeted provision of this life saving intervention. However, access to safe Cesarean section in resource-limited settings is much lower, estimated at 1–2% reported in sub-Saharan Africa. This study reports Cesarean sections rates and indications in Democratic Republic of Congo, Burundi, and Sierra Leone, and describe the main parameters associated with maternal and early neonatal mortality. Methods Women undergoing Cesarean section from August 1 2010 to January 31 2011 were included in this prospective study. Logistic regression was used to model determinants of maternal and early neonatal mortality. Results 1276 women underwent a Cesarean section, giving a frequency of 6.2% (range 4.1–16.8%). The most common indications were obstructed labor (399, 31%), poor presentation (233, 18%), previous Cesarean section (184, 14%), and fetal distress (128, 10%), uterine rupture (117, 9%) and antepartum hemorrhage (101, 8%). Parity >6 (adjusted odds ratio [aOR] = 8.6, P = 0.015), uterine rupture (aOR = 20.5; P = .010), antepartum hemorrhage (aOR = 13.1; P = .045), and pre-eclampsia/eclampsia (aOR = 42.9; P = .017) were associated with maternal death. Uterine rupture (aOR = 6.6, P<0.001), anterpartum hemorrhage (aOR = 3.6, P<0.001), and cord prolapse (aOR = 2.7, P = 0.017) were associated with early neonatal death. Conclusions This study demonstrates that target Cesarean section rates can be achieved in sub-Saharan Africa. Identifying the common indications for Cesarean section and associations with mortality can target improvements in antenatal services and emergency obstetric care.
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Affiliation(s)
- Kathryn Chu
- Médecins sans Frontières, Johannesburg, South Africa.
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Wuesten O, Morelli JN, Miller MW, Tuzun E, Lenox MW, Fossum TW, Trelles M, Cotes C, Krombach GA, Runge VM. MR angiography of carotid artery aneurysms in a porcine model at 3 Tesla: comparison of two different macrocyclic gadolinium chelates and of dynamic and conventional techniques. J Magn Reson Imaging 2012; 36:1203-12. [PMID: 22826184 DOI: 10.1002/jmri.23757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 06/15/2012] [Indexed: 11/10/2022] Open
Abstract
PURPOSE To evaluate the differences in image quality of two macrocyclic gadolinium-based contrast agents, gadobutrol and gadoterate meglumine, using time-resolved, contrast-enhanced MR angiography (CE-MRA) in a porcine carotid artery aneurysm model and to compare image quality between dynamic and conventional, single acquisition CE-MRA. MATERIALS AND METHODS Bilateral carotid aneurysms were created surgically in this Institutional Animal Care and Use Committee approved study. Dynamic CE-MRA studies optimized for high temporal resolution were performed at 3 Tesla. Scans using equivalently dosed (on a per mmol basis) gadobutrol and gadoterate meglumine were compared qualitatively and quantitatively in terms of contrast-to-noise ratio (CNR). Higher spatial resolution dynamic and conventional CE-MRA were also compared. RESULTS N = 16 aneurysms were assessed. Qualitative evaluation of dynamic CE-MRA scans demonstrated a preference for gadobutrol over gadoterate meglumine. Significantly higher aneurysm CNR was found with gadobutrol (133 ± 44) versus gadoterate meglumine, the latter at both equivalent and double injection rates (94 ± 35 and 102 ± 38). In a blinded assessment, conventional CE-MRA was preferred qualitatively when compared with dynamic CE-MRA. However, dynamic CE-MRA was generally capable of providing diagnostic image quality. CONCLUSION Gadobutrol is preferred to gadoterate meglumine for high temporal resolution dynamic CE-MRA, a fact with important clinical implications for low dose CE-MRA protocols in patients at risk for nephrogenic systemic fibrosis. Conventional high resolution CE-MRA provides superior image quality when compared with dynamic CE-MRA.
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Affiliation(s)
- Oliver Wuesten
- Department of Radiology, University of Texas Medical Branch (UTMB), 301 University Boulevard, Galveston, Texas, USA.
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Trelles M, Trelles K. Vascular lesions of the oral cavity: Treatment approach with different lasers. Med Oral Patol Oral Cir Bucal 2012. [DOI: 10.4317/medoral.17643622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Abstract
Humanitarian surgical programs are set up de novo, within days or hours in emergency or disaster settings. In such circumstances, insuring quality of care is extremely challenging. Basic structural inputs such as a safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, appropriate medications should be established. Currently, no specific credentials are needed for surgeons to operate in a humanitarian setting; the training of more humanitarian surgeons is desperately needed. Standard perioperative protocols for the humanitarian setting after common procedures such as Cesarean section, burn care, open fractures, and amputations and antibiotic prophylaxis, and post-operative pain management must be developed. Outcome data, especially long-term outcomes, are difficult to collect as patients often do not return for follow-up and may be difficult to trace; standard databases for post-operative infections and mortality rates should be established. Checklists have recently received significant attention as an instrument to support the improvement of surgical quality; knowing which items are most applicable to humanitarian settings remains unknown. In conclusion, the quality of surgical services in humanitarian settings must be regulated. Many other core medical activities of humanitarian organizations such as therapeutic feeding, mass vaccination, and the treatment of infectious diseases, such as tuberculosis and human immunodeficiency virus, are subject to rigorous reporting of quality indicators. There is no reason why surgery should be exempted from quality oversight. The surgical humanitarian community should pull together before the next disaster strikes.
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Affiliation(s)
- Kathryn M Chu
- Medical Department, Médecins Sans Frontières-South Africa, 49 Jorrisen St, Braamfontein 2017, Johannesburg, South Africa.
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Abstract
Background Somalia is one of the most political unstable countries in the world. Ongoing insecurity has forced an inconsistent medical response by the international community, with little data collection. This paper describes the "remote" model of surgical care by Medecins Sans Frontieres, in Guri-El, Somalia. The challenges of providing the necessary prerequisites for safe surgery are discussed as well as the successes and limitations of task shifting in this resource-limited context. Methods In January 2006, MSF opened a project in Guri-El located between Mogadishu and Galcayo. The objectives were to reduce mortality due to complications of pregnancy and childbirth and from violent and non-violent trauma. At the start of the program, expatriate surgeons and anesthesiologists established safe surgical practices and performed surgical procedures. After January 2008, expatriates were evacuated due to insecurity and surgical care has been provided by local Somalian doctors and nurses with periodic supervisory visits from expatriate staff. Results Between October 2006 and December 2009, 2086 operations were performed on 1602 patients. The majority (1049, 65%) were male and the median age was 22 (interquartile range, 17-30). 1460 (70%) of interventions were emergent. Trauma accounted for 76% (1585) of all surgical pathology; gunshot wounds accounted for 89% (584) of violent injuries. Operative mortality (0.5% of all surgical interventions) was not higher when Somalian staff provided care compared to when expatriate surgeons and anesthesiologists. Conclusions The delivery of surgical care in any conflict-settings is difficult, but in situations where international support is limited, the challenges are more extreme. In this model, task shifting, or the provision of services by less trained cadres, was utilized and peri-operative mortality remained low demonstrating that safe surgical practices can be accomplished even without the presence of fully trained surgeon and anesthesiologists. If security improves in Somalia, on-site training by expatriate surgeons and anesthesiologists will be re-established. Until then, the best way MSF has found to support surgical care in Somalia is continue to support in a "remote" manner.
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Affiliation(s)
- Kathryn M Chu
- Médecins sans Frontières, 49 Jorrisen St, Braamfontein 2017, Johannesburg, South Africa.
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Abstract
Kathryn Chu and colleagues describe the experiences of Médecins sans Frontières after the 2010 Haiti earthquake, and discuss how to improve delivery of surgery in humanitarian disasters.
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Affiliation(s)
- Kathryn Chu
- Médecins sans Frontières, Cape Town, South Africa.
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Chu KM, Ford N, Trelles M. Operative mortality in resource-limited settings: the experience of Medecins Sans Frontieres in 13 countries. Arch Surg 2010; 145:721-5. [PMID: 20713922 DOI: 10.1001/archsurg.2010.137] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To determine operative mortality in surgical programs from resource-limited settings. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures. MAIN OUTCOME MEASURE Operative mortality. Determinants of mortality were modeled using logistic regression. RESULTS Between 2001 and 2008, 19,643 procedures were performed on 18,653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001). CONCLUSIONS Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.
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Affiliation(s)
- Kathryn M Chu
- Department of Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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Chu K, Havet P, Ford N, Trelles M. Surgical care for the direct and indirect victims of violence in the eastern Democratic Republic of Congo. Confl Health 2010; 4:6. [PMID: 20398250 PMCID: PMC2873460 DOI: 10.1186/1752-1505-4-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2010] [Accepted: 04/14/2010] [Indexed: 12/05/2022] Open
Abstract
Background The provision of surgical assistance in conflict is often associated with care for victims of violence. However, there is an increasing appreciation that surgical care is needed for non-traumatic morbidities. In this paper we report on surgical interventions carried out by Médecins sans Frontières in Masisi, North Kivu, Democratic Republic of Congo to contribute to the scarce evidence base on surgical needs in conflict. Methods We analysed data on all surgical interventions done at Masisi district hospital between September 2007 and December 2009. Types of interventions are described, and logistic regression used to model associations with violence-related injury. Results 2869 operations were performed on 2441 patients. Obstetric emergencies accounted for over half (675, 57%) of all surgical pathology and infections for another quarter (160, 14%). Trauma-related injuries accounted for only one quarter (681, 24%) of all interventions; among these, 363 (13%) were violence-related. Male gender (adjusted odds ratio (AOR) = 20.0, p < 0.001), military status (AOR = 4.1, p < 0.001), and age less than 20 years (AOR = 2.1, p < 0.001) were associated with violence-related injury. Immediate peri-operative mortality was 0.2%. Conclusions In this study, most surgical interventions were unrelated to violent trauma and rather reflected the general surgical needs of a low-income tropical country. Programs in conflict zones in low-income countries need to be prepared to treat both the war-wounded and non-trauma related life-threatening surgical needs of the general population. Given the limited surgical workforce in these areas, training of local staff and task shifting is recommended to support broad availability of essential surgical care. Further studies into the surgical needs of the population are warranted, including population-based surveys, to improve program planning and resource allocation and the effectiveness of the humanitarian response.
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Affiliation(s)
- Kathryn Chu
- Médecins sans Frontières, 49 Jorrisen St, Braamfontein 2017, Johannesburg, South Africa.
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Affiliation(s)
- Kathryn Chu
- Médecins Sans Frontières, Braamfontein 2017, Johannesburg, Gauteng, South Africa
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Rosseel P, Trelles M, Guilavogui S, Ford N, Chu K. Ten Years of Experience Training Non-Physician Anesthesia Providers in Haiti. World J Surg 2009; 34:453-8. [DOI: 10.1007/s00268-009-0192-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Huicho L, Trelles M, Gonzales F, Mendoza W, Miranda J. Mortality profiles in a country facing epidemiological transition: an analysis of registered data. BMC Public Health 2009; 9:47. [PMID: 19187553 PMCID: PMC2640471 DOI: 10.1186/1471-2458-9-47] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Accepted: 02/02/2009] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sub-national analyses of causes of death and time-trends help to define public health policy priorities. They are particularly important in countries undergoing epidemiological transition like Peru. There are no studies exploring Peruvian national and regional characteristics of such epidemiological transition. We aimed to describe Peru's national and regional mortality profiles between 1996 and 2000. METHODS Registered mortality data for the study period were corrected for under-registration following standardized methods. Main causes of death by age group and by geographical region were determined. Departmental mortality profiles were constructed to evaluate mortality transition, using 1996 data as baseline. Annual cumulative slopes for the period 1996-2000 were estimated for each department and region. RESULTS For the study period non-communicable diseases explained more than half of all causes of death, communicable diseases more than one third, and injuries 10.8% of all deaths. Lima accounted for 32% of total population and 20% of total deaths. The Andean region, with 38% of Peru's population, accounted for half of all country deaths. Departmental mortality predominance shifted from communicable diseases in 1996 towards non-communicable diseases and injuries in 2000. Maternal and perinatal conditions, and nutritional deficiencies and nutritional anaemia declined markedly in all departments and regions. Infectious diseases decreased in all regions except Lima. In all regions acute respiratory infections are a leading cause of death, but their proportion ranged from 9.3% in Lima and Callao to 15.3% in the Andean region. Tuberculosis and injuries ranked high in Lima and the Andean region. CONCLUSION Peruvian mortality shows a double burden of communicable and non-communicable, with increasing importance of non-communicable diseases and injuries. This challenges national and sub-national health system performance and policy making.
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Affiliation(s)
- Luis Huicho
- Department of Paediatrics, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Department of Paediatrics, Instituto Nacional de Salud del Niño, Lima, Peru
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Miguel Trelles
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | | | - Jaime Miranda
- School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
- School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
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