The COVID-19 quandemic.

BACKGROUND: The terms syndemic and infodemic have both been applied to the COVID-19 pandemic, and emphasize concurrent socio-cultural dynamics that are distinct from the epidemiological outbreak itself. We argue that the COVID-19 pandemic has exposed yet another important socio-political dynamic that can best be captured by the concept of a quandemic - a portmanteau of "quantification" and "pandemic". MAIN TEXT: The use of quantifiable metrics in policymaking and evaluation has increased throughout the last decades, and is driven by a synergetic relationship between increases in supply and advances in demand for data. In most regards this is a welcome development. However, a quandemic, refers to a situation where a small subset of quantifiable metrics dominate policymaking and the public debate, at the expense of more nuanced and multi-disciplinary discourse. We therefore pose that a quandemic reduces a complex pandemic to a few metrics that present an overly simplified picture. During COVID-19, these metrics were different iterations of case numbers, deaths, hospitalizations, diagnostic tests, bed occupancy rates, the R-number and vaccination coverage. These limited metrics came to constitute the internationally recognized benchmarks for effective pandemic management. Based on experience from the Nordic region, we propose four distinct dynamics that characterize a quandemic: 1) A limited number of metrics tend to dominate both political, expert, and public spheres and exhibit a great deal of rigidity over time. 2) These few metrics crowd-out other forms of evidence relevant to pandemic response. 3) The metrics tend to favour certain outcomes of pandemic management, such as reducing hospitalization rates, while not capturing potential adverse effects such as social isolation and loneliness. 4) Finally, the metrics are easily standardized across countries, and give rise to competitive dynamics based on international comparisons and benchmarking. CONCLUSION: A quandemic is not inevitable. While metrics are an indispensable part of evidence-informed policymaking, being attentive to quandemic dynamics also means identifying relevant evidence that might not be captured by these few but dominant metrics. Pandemic responses need to account for and consider multilayered vulnerabilities and risks, including socioeconomic inequities and comorbidities.

Assessing quality of critical care during an ongoing health emergency-a novel approach to evaluate quality of care at Lebanese public ICUs during COVID-19.

BACKGROUND: Quality of care has been systematically monitored in hospitals in high-income countries to ensure adequate care. However, in low- and middle-income countries, quality indicators are not readily measured. The primary aim of this study was to assess to what extent it was feasible to monitor the quality of intensive care in an ongoing health emergency, and the secondary aim was to assess a quality of care intervention (twinning project) focused on Intensive Care Unit (ICU) quality of care in public hospitals in Lebanon. METHODS: We conducted a retrospective cohort study nested within an intervention implemented by the World Health Organization (WHO) together with partners. To assess the quality of care throughout the project, a monitoring system framed in the Donabedian model and included structure, process, and outcome indicators was developed and implemented. Data collection consisted of a checklist performed by external healthcare workers (HCWs) as well as collection of data from all admitted patients performed by each unit. The association between the number of activities within the interventional project and ICU mortality was evaluated. RESULTS: A total of 1679 patients were admitted to five COVID-19 ICUs during the study period. The project was conducted fully across four out of five hospitals. In these hospitals, a significant reduction in ICU mortality was found (OR: 0.83, P < 0.05, CI: 0.72-0.96). CONCLUSION: We present a feasible way to assess quality of care in ICUs and how it can be used in assessing a quality improvement project during ongoing crises in resource-limited settings. By implementing a quality of care intervention in Lebanon's public hospitals, we have shown that such initiatives might contribute to improvement of ICU care. The observed association between increased numbers of project activities and reduced ICU mortality underscores the potential of quality assurance interventions to improve outcomes for critically ill patients in resource-limited settings. Future research is needed to expand this model to be applicable in similar settings.

Characteristics and treatment outcomes of malnutrition among infants aged less than 6 months in North-East Nigeria (2019-2022).

Recommendations for the management of malnutrition among infants aged less than 6 months (<6 m) are based on limited evidence. This study aimed to describe the characteristics, treatment outcomes and outcome-associated factors among malnourished infants <6 m admitted at Médecins Sans Frontières (MSF) inpatient and ambulatory therapeutic feeding centres (ITFC and ATFC) in North-East Nigeria, 2019-2022. We conducted a descriptive analysis of the cohorts and logistic regression to measure the association between two selected outcomes-inpatient mortality and defaulting from the ambulatory programme-and possible factors associated. In total, 940 infants <6 m were admitted at ITFC. Most of them presented severe acute malnutrition and comorbidities, with diarrhoea being the most frequent. On discharge, 13.3% (n = 125) of infants were cured, 72.9% (n = 684) stabilized (referred to ATFC), 6.5% (n = 61) left against medical advice and 4.2% (n = 39) died. The median length of hospital stay was 10 days [IQR 7-14]. A hospital stay shorter than 10 days was significantly associated with inpatient mortality (aOR = 12.51, 95% confidence interval [CI] = 3.72-42.11, p ≤ 0.01). Among 561 infants followed up at the ATFC, only 2.8% reported comorbidities. On discharge, 80.9% (n = 429) were cured, 16.2% (n = 86) defaulted and 1.1% (n = 6) died. Male sex (aOR = 1.94, 95% CI = 1.15-3.27, p = 0.01), internally displaced status (aOR = 1.70, 95% CI = 1.05-2.79, p = 0.03) and <-3 WLZ (aOR = 1.95, 95% CI = 1.05-3.63, p = 0.03) were significantly associated with programme defaulting. Stabilization and recovery rates among malnourished infants <6 m in the studied project align with acceptable standards in this humanitarian setting. Notable defaulting rates from outpatient care should be further explored.

"Being prevented from providing good care: a conceptual analysis of moral stress among health care workers during the COVID-19 pandemic".

BACKGROUND: Health care workers (HCWs) are susceptible to moral stress and distress when they are faced with morally challenging situations where it is difficult to act in line with their moral standards. In times of crisis, such as disasters and pandemics, morally challenging situations are more frequent, due to the increased imbalance between patient needs and resources. However, the concepts of moral stress and distress vary and there is unclarity regarding the definitions used in the literature. This study aims to map and analyze the descriptions used by HCWs regarding morally challenging situations (moral stress) and refine a definition through conceptual analysis. METHODS: Qualitative data were collected in a survey of 16,044 Swedish HCWs who attended a COVID-19 online course in autumn 2020. In total, 643 free-text answers with descriptions of moral stress were analyzed through content analysis. RESULTS: Three themes emerged from the content analysis (1) "Seeing, but being prevented to act; feeling insufficient/inadequate and constrained in the profession," (2) "Someone or something hindered me; organizational structures as an obstacle," and (3) "The pandemic hindered us; pandemic-related obstacles." The three themes correspond to the main theme, "Being prevented from providing good care." DISCUSSION: The main theme describes moral stress as various obstacles to providing good care to patients in need and acting upon empathic ability within the professional role. The themes are discussed in relation to established definitions of moral stress and are assessed through conceptual analysis. A definition of moral stress was refined, based on one of the established definitions. CONCLUSIONS: On the basis of the study results and conceptual analysis, it is argued that the presented definition fulfils certain conditions of adequacy. It is essential to frame the concept of moral stress, which has been defined in different ways in different disciplines, in order to know what we are talking about and move forward in developing prevention measures for the negative outcomes of this phenomenon.

Exploratory laparotomy during the battle of Mosul, 2016-2017: results from a tertiary civilian hospital in Erbil, Iraqi Kurdistan.

BACKGROUND: The Battle of Mosul (2016-2017) was an urban conflict resulting in over 9000 civilian deaths. Emergency Management Centre (EMC), located 90 km from Mosul, was designated as a civilian-run trauma centre as part of the novel Mosul Trauma Pathway. Patients necessitating exploratory laparotomy (ex-lap) provide a unique window into the system of care delivery in conflicts, given the importance of timely, resource-intensive care. However, there is insufficient knowledge regarding the presentation and outcomes for conflict-related ex-lap in civilian institutions. METHODS: This is a descriptive study retrospectively analyzing routinely collected data for all patients who underwent ex-lap at EMC for injuries sustained during the battle of Mosul. Differences in demographics, pre-hospital/hospital course, and New Injury Severity Scores (NISS) were analysed using student t-test, Hotelling T-squared, and linear regression. RESULTS: During the battle, 1832 patients with conflict-related injuries were admitted to EMC. Some 73/1832 (4.0%) underwent ex-lap, of whom 22/73 (30.1%) were children and 40/73 (54.8%) were non-combatant adults. Men constituted 51/73 (69%) patients. Gunshot wounds caused 19/73 (26.0%) injuries, while ordnances caused 52/73 (71.2%). Information regarding hospital course was available for 47/73 (64.4%) patients. Children had prolonged time from injury to first laparotomy compared to adults (600 vs 208 min, p < 0.05). Median LOS was 6 days (IQR 4-9.5); however, 11/47 (23%) patients left against medical advice. Post-operative complications occurred in 11/47 (23.4%) patients; 6/11 (54.5%) were surgical site infections. There were 12 (25.5%) patients who underwent relaparotomies after index surgery elsewhere; 10/12 (83.3%) were for failed repairs or missed injuries. Median NISS was 18 (IQR 12-27). NISS were significantly higher for women (vs men; 28.5 vs 19.8), children (vs adults; 28.8 vs 20), and relaparotomy patients (vs primary laparotomy patients; 32.0 vs 19.0). Some 3 patients died, 2 of whom were relaparotomies. CONCLUSION: At this civilian tertiary trauma centre, conflict-related exploratory laparotomies were associated with low morbidity and mortality. Long transport times, high rates of repeat laparotomies, and high numbers of patients leaving against medical advice raise questions regarding continuity of care along the Mosul Trauma Pathway. TRIAL REGISTRATION: The study protocol was registered at Clinicaltrails.gov, ID NCT03490305, prior to collection of data.

Interventions to support the re-establishment of breastfeeding and their application in humanitarian settings: A systematic review.

In 1998, the World Health Organisation (WHO) published general guidelines proposing essential measures to achieve relactation. Yet, increased knowledge about the practical set-up of relactation support interventions in different contexts is needed, especially in humanitarian settings, where nonbreastfed infants are particularly at risk. This study aimed to compile and assess the characteristics, outcomes and factors influencing the implementation of relactation support interventions reported since the latest WHO recommendations. We conducted a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, undertaking a search from Medline, Embase, PubMed Central, Web of Science, Global Health and CINAHL electronic databases. Studies published in English and Spanish, reporting characteristics and outcomes of relactation support provided to non-(breastfeeding) BF mothers with infants aged less than 6 months were included. Data were analysed by narrative synthesis and the Johanna Briggs Institute Critical Appraisal Tools were used for quality assessment. Overall, 16 studies met the inclusion criteria. Most were observational and conducted in middle-income countries, only one focused on humanitarian settings. Studies reported inpatient and community-based interventions, which generally followed WHO recommendations for relactation. In 13 out of 16 studies, over 80% of mothers restarted BF after receiving relactation support. Enabling factors included younger infant age, shorter lactation gap, mother's strong motivation, family support, and continuous skilled support. Although current literature suggests that intensive relactation support can contribute to re-establish BF, its application and effectiveness in humanitarian settings remain uncertain. Further research is needed to explore the effectiveness, feasibility and acceptability of different approaches to relactation support, especially in humanitarian settings.

Development of a quality assurance tool for intensive care units in Lebanon during the COVID-19 pandemic.

BACKGROUND: During the coronavirus disease (COVID-19) pandemic, low- and middle-income countries have rapidly scaled up intensive care unit (ICU) capacities. Doing this without monitoring the quality of care poses risks to patient safety and may negatively affect patient outcomes. While monitoring the quality of care is routine in high-income countries, it is not systematically implemented in most low- and middle-income countries. In this resource-scarce context, there is a paucity of feasibly implementable tools to monitor the quality of ICU care. Lebanon is an upper middle-income country that, during the autumn and winter of 2020-1, has had increasing demands for ICU beds for COVID-19. The World Health Organization has supported the Ministry of Public Health to increase ICU beds at public hospitals by 300%, but no readily available tool to monitor the quality of ICU care was available. OBJECTIVE: The objective with this study was to describe the process of rapidly developing and implementing a tool to monitor the quality of ICU care at public hospitals in Lebanon. METHODS: In the midst of the escalating pandemic, we applied a systematic approach to develop a realistically implementable quality assurance tool. We conducted a literature review, held expert meetings and did a pilot study to select among identified quality indicators for ICU care that were feasible to collect during a 1-hour ICU visit. In addition, a limited set of the identified indicators that were quantifiable were specifically selected for a scoring protocol to allow comparison over time as well as between ICUs. RESULTS: A total of 44 quality indicators, which, using different methods, could be collected by an external person, were selected for the quality of care tool. Out of these, 33 were included for scoring. When tested, the scores showed a large difference between hospitals with low versus high resources, indicating considerable variation in the quality of care. CONCLUSIONS: The proposed tool is a promising way to systematically assess and monitor the quality of care in ICUs in the absence of more advanced and resource-demanding systems. It is currently in use in Lebanon. The proposed tool may help identifying quality gaps to be targeted and can monitor progress. More studies to validate the tool are needed.

Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan, 2015.

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.

Mitigating Moral Distress in Leaders of Healthcare Organizations: A Scoping Review.

GOAL: Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key areas for both theoretical and practical elaboration. We conducted a scoping review to frame our understanding of this largely unexplored dynamic of moral distress and better situate our existing knowledge of moral distress and leadership. METHODS: Using moral distress theory as our conceptual framework, we evaluated recent literature on moral distress and leadership to understand how prior studies have conceptualized the effects of moral distress. Our search yielded 1,640 total abstracts. Further screening with the PRISMA process resulted in 72 included articles. PRINCIPAL FINDINGS: Our scoping review found that leaders-not just their employees- personally experience moral distress. In addition, we identified an important role for leaders and organizations in addressing the theoretical conceptualization and practical effects of moral distress. PRACTICAL APPLICATIONS: Although moral distress is unlikely to ever be eliminated, the literature in this review points to a singular need for organizational responses that are intended to intervene at the level of the organization itself, not just at the individual level. Best practices require creating stronger organizational cultures that are designed to mitigate moral distress. This can be achieved through transparency and alignment of personal, professional, and organizational values.

Epidemiology of Patients Treated at the Emergency Department of a Médecins Sans Frontières Field Hospital During the Mosul Offensive: Iraq, 2017.

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.

Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study.

BACKGROUND: In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings. METHODS: A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC's hospitals in Peshawar, 2009-2012 and Goma, 2012-2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC). RESULTS: A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74-0.78) than for KTS (0.53, 95% CI 0.50-0.56) and RTS (0.51, 95% CI 0.48-0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79-0.88) than for KTS (0.71, 95% CI 0.65-0.76) and RTS (0.70, 95% CI 0.63-0.76) for all patients, but not for patients with complete data. CONCLUSION: RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings.

A Last Resort When There is No Blood: Experiences and Perceptions of Intraoperative Autotransfusion Among Medical Doctors Deployed to Resource-Limited Settings.

BACKGROUND: Four and a half million people die globally every year due to traumatic injuries. One major cause of preventable death is bleeding. Blood for transfusion is often unavailable in resource-limited settings, where a majority of trauma deaths occur. Intraoperative autotransfusion (IAT) has been proposed as a safe and feasible lifesaving alternative to allogeneic blood transfusion. However, there is limited knowledge regarding its use among doctors working for international non-governmental organisations (INGOs) in resource-limited settings. The aim of this study was to explore the experiences and perceptions of IAT among INGO-affiliated medical doctors with clinical experience in resource-limited settings. METHODS: We conducted semi-structured interviews via telephone or Skype with 12 purposefully sampled surgeons and anaesthesiologists. The interviews were recorded, transcribed verbatim, and analysed using content analysis. RESULTS: We identified three main themes relating to IAT and bottlenecks preventing the scale-up of its use: variation in techniques and systems, contextual factors, and individual medical doctor factors. The participants gave detailed reports of missed opportunities for usage of IAT in resource-limited settings. Bottlenecks included the lack of simple and cost-effective products, limited availability of protocols in the field, and insufficient knowledge and experience of IAT. CONCLUSIONS: The participants found that simple IAT is under-utilised in resource-limited settings. Missed opportunities to use IAT were mainly associated with armed conflict settings and obstetrical emergencies. In order to meet the need for IAT in resource-limited settings, we suggest further consideration of the identified bottlenecks.

Trends in Demographics and Surgical Treatment of Weapon-Related Limb Injuries Over Two Decades in a Resource-Scarce Setting.

BACKGROUND: In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. METHODS: Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. RESULTS: Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p < 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p < 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p < 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. CONCLUSION: In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.

Correction to: The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap.

In the original article, Johan von Schreeb's last name was spelled incorrectly. It is correct as reflected here.

Epidemiology of Trauma Patients from the Mosul Offensive, 2016-2017: Results from a Dedicated Trauma Center in Erbil, Iraqi Kurdistan.

INTRODUCTION: Most epidemiological studies from conflicts are restricted to either combatants or civilians. It is largely unknown how the epidemiology differs between the two groups. In 2016, an Iraqi-led coalition began retaking Mosul from the terrorist group Islamic State of Iraq and Syria. One key institution that received trauma patients from Mosul was Emergency Management Center (EMC) in Erbil, 90 km away. The aim of this study was to describe the epidemiology, morbidity, and mortality of civilians and combatants admitted during the ongoing conflict. METHOD: This retrospective cohort study utilized routinely collected data on patients with conflict-related injuries who were admitted to EMC between October 16, 2016, and July 10, 2017. Data processing and analysis was carried out using JMP 13. Categorical variables were compared using Fisher's exact test. RESULTS: The analysis included 1725 patients, out of which 46% were civilian. Ordnance accounted for most injuries (68%), followed by firearms (18%) and improvised explosive devices (IEDs) (14%). The proportion of IED-related injuries among combatants were almost three times that of civilians. The proportions of abdominal injuries, need for surgery, laparotomies, and amputations were significantly higher among civilians than among combatants. The mortality rate was 0.5%. DISCUSSION: The fact that civilians had greater surgical needs than combatants may be explained by several factors including a lack of ballistic protection. The extremely low mortality rate indicates significant gaps in prehospital care and transport. Our results may provide useful information to guide medical preparedness and response during future conflicts. CLINICALTRIALS. GOV ID: NCT03358758.

Association Between Gender, Surgery and Mortality for Patients Treated at Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan.

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.

Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan.

BACKGROUND: Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. METHODS: We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014-2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. RESULTS: Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42-4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). CONCLUSIONS: Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT02744144 ). Registered April 13, 2016. Retrospectively registered.

Hospital Workload for Weapon-Wounded Females Treated by the International Committee of the Red Cross: More Work Needed than for Males.

BACKGROUND: Civilians constitute 33-51% of victims in armed conflicts. Several reports on civilian injuries exist, but few have focused on injuries afflicting females. We analyzed routinely collected data on weapon-related injuries from the International Committee of the Red Cross (ICRC) hospital in northwestern Pakistan in order to define injury patterns and types of surgical treatment for females. METHODS: A total of 3028 patient files (376 females) from consecutively admitted patients to the ICRC-hospital in Peshawar from February 2009 to May 2012 were included. Information regarding injury-mechanism, time since injury, vital parameters at admission, type of injury, treatment and basic outcome was extracted from the files and analyzed. Comparisons between gender and age-groups were done by cross-table analyses or nonparametric tests. RESULTS: Females were younger than males (20 vs. 25 years), arrived sooner after injury (24 vs. 48 h) (p < 0.001 for both) and were victims of bombs and missiles more frequently (64.4 vs. 54.6%) (p < 0.001). Vital parameters such as systolic blood pressure (110 vs. 113 mmHg) and pulse rate (100 vs. 86) were more affected at admission (p < 0.001 for both). Females were subjected to surgery (83.0 vs. 77.4%) (p < 0.05) and were given blood transfusions more often (18.8 vs. 13.6%) (p < 0.01). No differences in amputations or in-hospital mortality were found. CONCLUSIONS: Females treated at the ICRC-hospital in northwestern Pakistan are markedly affected by indiscriminate weapons such as bombs and missiles. Their average consumption of surgery is greater than for males, and this might be relevant in planning for staffing and facility needs in similar contexts.

The Met Needs for Pediatric Surgical Conditions in Sierra Leone: Estimating the Gap.

BACKGROUND: In low- and middle-income countries, there is a gap between the need for surgery and its equitable provision, and a lack of proxy indicators to estimate this gap. Sierra Leone is a West African country with close to three million children. It is unknown to what extent the surgical needs of these children are met. AIM: To describe a nationwide provision of pediatric surgical procedures and to assess pediatric hernia repair as a proxy indicator for the shortage of surgical care in the pediatric population in Sierra Leone. METHODS: We analyzed results from a nationwide facility survey in Sierra Leone that collected data on surgical procedures from operation and anesthesia logbooks in all facilities performing surgery. We included data on all patients under the age of 16 years undergoing surgery. Primary outcomes were rate and volume of surgical procedures. We calculated the expected number of inguinal hernia in children and estimated the unmet need for hernia repair. RESULTS: In 2012, a total of 2381 pediatric surgical procedures were performed in Sierra Leone. The rate of pediatric surgical procedures was 84 per 100,000 children 0-15 years of age. The most common pediatric surgical procedure was hernia repair (18%), corresponding to a rate of 16 per 100,000 children 0-15 years of age. The estimated unmet need for inguinal hernia repair was 88%. CONCLUSIONS: The rate of pediatric surgery in Sierra Leone was very low, and inguinal hernia was the single most common procedure noted among children in Sierra Leone.

Prepared for Mission? A Survey of Medical Personnel Training Needs Within the International Committee of the Red Cross.

BACKGROUND: Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel. METHODS: All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents' personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment. RESULTS: The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p < 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150). CONCLUSION: ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.