Effects of the COVID-19 pandemic on pediatric trauma in Southern California.

PURPOSE: The COVID-19 pandemic resulted in increased penetrating trauma and decreased length of stay (LOS) amongst the adult trauma population, findings important for resource allocation. Studies regarding the pediatric trauma population are sparse and mostly single-center. This multicenter study examined pediatric trauma patients, hypothesizing increased penetrating trauma and decreased LOS after the 3/19/2020 stay-at-home (SAH) orders. METHODS: A multicenter retrospective analysis of trauma patients ≤ 17 years old presenting to 11 centers in California was performed. Demographic data, injury characteristics, and outcomes were collected. Patients were divided into three groups based on injury date: 3/19/2019-6/30/2019 (CONTROL), 1/1/2020-3/18/2020 (PRE), 3/19/2020-6/30/2020 (POST). POST was compared to PRE and CONTROL in separate analyses. RESULTS: 1677 patients were identified across all time periods (CONTROL: 631, PRE: 479, POST: 567). POST penetrating trauma rates were not significantly different compared to both PRE (11.3 vs. 9.0%, p = 0.219) and CONTROL (11.3 vs. 8.2%, p = 0.075), respectively. POST had a shorter mean LOS compared to PRE (2.4 vs. 3.3 days, p = 0.002) and CONTROL (2.4 vs. 3.4 days, p = 0.002). POST was also not significantly different than either group regarding intensive care unit (ICU) LOS, ventilator days, and mortality (all p > 0.05). CONCLUSIONS: This multicenter retrospective study demonstrated no difference in penetrating trauma rates among pediatric patients after SAH orders but did identify a shorter LOS.

Drug and alcohol positivity of traumatically injured patients related to COVID-19 stay-at-home orders.

Background: COVID-19 related stay-at-home (SAH) orders created many economic and social stressors, possibly increasing the risk of drug/alcohol abuse in the community and trauma population.Objectives: Describe changes in alcohol/drug use in traumatically injured patients after SAH orders in California and evaluate demographic or injury pattern changes in alcohol or drug-positive patients.Methods: A retrospective analysis of 11 trauma centers in Southern California (1/1/2020-6/30/2020) was performed. Blood alcohol concentration, urine toxicology results, demographics, and injury characteristics were collected. Patients were grouped based on injury date - before SAH (PRE-SAH), immediately after SAH (POST-SAH), and a historical comparison (3/19/2019-6/30/2019) (CONTROL) - and compared in separate analyses. Groups were compared using chi-square tests for categorical variables and Mann-Whitney U tests for continuous variables.Results: 20,448 trauma patients (13,634 male, 6,814 female) were identified across three time-periods. The POST-SAH group had higher rates of any drug (26.2% vs. 21.6% and 24.7%, OR = 1.26 and 1.08, p < .001 and p = .035), amphetamine (10.4% vs. 7.5% and 9.3%, OR = 1.43 and 1.14, p < .001 and p = .023), tetrahydrocannabinol (THC) (13.8% vs. 11.0% and 11.4%, OR = 1.30 and 1.25, p < .001 and p < .001), and 3,4-methylenedioxy methamphetamine (MDMA) (0.8% vs. 0.4% and 0.2%, OR = 2.02 and 4.97, p = .003 and p < .001) positivity compared to PRE-SAH and CONTROL groups. Alcohol concentration and positivity were similar between groups (p > .05).Conclusion: This Southern California multicenter study demonstrated increased amphetamine, MDMA, and THC positivity in trauma patients after SAH, but no difference in alcohol positivity or blood concentration. Drug prevention strategies should continue to be adapted within and outside of hospitals during a pandemic.

The Heterogeneity of Global Pediatric Surgery: Defining Needs and Opportunities Around the World.

BACKGROUND: The global burden of pediatric surgical conditions continues to remain inadequately addressed, particularly in low- and middle-income countries. Among the many factors contributing to this gap are a lack of access to care secondary to resource shortages and inequitable distribution, underfinancing of healthcare systems, poor quality of care, and contextual challenges such as natural disasters and conflict. The relative contribution of these and other factors varies widely by region and even with countries of a region. METHODS: This review seeks to discuss the heterogeneity of global pediatric surgery and offer recommendations for addressing the barriers to high-quality pediatric surgical care throughout the world. RESULTS: There is significant heterogeneity in pediatric surgical challenges, both between regions and among countries in the same region, although data are limited. This heterogeneity can reflect differences in demographics, epidemiology, geography, income level, health spending, historical health policies, and cultural practices, among others. CONCLUSION: Country-level research and stakeholder engagement are needed to better understand the heterogeneity of local needs and drive policy changes that contribute to sustainable reforms. Key to these efforts will be improved financing, access to and quality of pediatric surgical care.

Beyond a Moral Obligation: A Legal Framework for Emergency and Essential Surgical Care and Anesthesia.

BACKGROUND: Access to quality and timely emergency and essential surgical care and anesthesia (EESCA) is an integral component of the right to health as reinforced by the ratification of the World Health Assembly Resolution 68.15. However, this resolution is merely a guideline and has not been able to bolster the necessary political will to promote EESCA. Our objective was to evaluate international treaties, which carry legal obligations, for EESCA-related text, and develop a human rights-based framework to support EESCA advancement and advocacy. METHODS: We conducted a comprehensive review of all the UN Treaty Collection-Certified True Copies (CTCs) of multilateral treaties database from December 2015 to April 2016. The relevant text was manually searched to abstract and analyze to identify major themes supporting a human rights-based approach to EESCA. RESULTS: Multiple treaties in the UN database addressed EESCA in the areas of human rights, refugees and stateless persons, health, penal matters, and disarmament. A total of 13 treaties containing 23 articles had language that endorsed aspects of EESCA. The three major themes, supported by the phraseology in the treaties, included: (1) equal access to EESCA (eight articles); (2) timely care of injured and those with emergency surgical conditions (eight articles); and (3) protection, rehabilitation, psychosocial support, and social security (seven articles). CONCLUSIONS: A number of United Nations multilateral treaties support available and equitable EESCA. These findings can be used to galvanize support and encourage signatory Member States to promote and implement EESCA development initiatives.

The Effect of 2019 Coronavirus Stay-at-Home Order on Geriatric Trauma Patients in Southern California.

BACKGROUND: California issued stay-at-home (SAH) orders to mitigate COVID-19 spread. Previous studies demonstrated a shift in mechanisms of injuries (MOIs) and decreased length of stay (LOS) for the general trauma population after SAH orders. This study aimed to evaluate the effects of SAH orders on geriatric trauma patients (GTPs), hypothesizing decreased motor vehicle collisions (MVCs) and LOS. METHODS: A post-hoc analysis of GTPs (≥65 years old) from 11 level-I/II trauma centers was performed, stratifying patients into 3 groups: before SAH (1/1/2020-3/18/2020) (PRE), after SAH (3/19/2020-6/30/2020) (POST), and a historical control (3/19/2019-6/30/2019) (CONTROL). Bivariate comparisons were performed. RESULTS: 5486 GTPs were included (PRE-1756; POST-1706; CONTROL-2024). POST had a decreased rate of MVCs (7.6% vs 10.6%, P = .001; vs 11.9%, P < .001) and pedestrian struck (3.4% vs 5.8%, P = .001; vs 5.2%, P = .006) compared with PRE and CONTROL. Other mechanisms of injury, LOS, mortality, and operations performed were similar between cohorts. However, POST had a lower rate of discharge to skilled nursing facility (SNF) (20% vs 24.5%, P = .001; and 20% vs 24.4%, P = .001). CONCLUSION: This retrospective multicenter study demonstrated lower rates of MVCs and pedestrian struck for GTPs, which may be explained by decreased population movement as a result of SAH orders. Contrary to previous studies on the generalized adult population, no differences in other MOIs and LOS were observed after SAH orders. However, there was a lower rate of discharge to SNF, which may be related to a lack of resources due to the COVID-19 pandemic, and thus potentially negatively impacted recovery of GTPs.Keywords.

Plasmalemma permeability and necrotic cell death phenotypes after intracerebral hemorrhage in mice.

BACKGROUND AND PURPOSE: Traumatic and ischemic brain injury induce plasmalemma permeability and necrosis; however, no studies have examined these aspects of cellular injury in intracerebral hemorrhage models. METHODS: In vivo propidium iodide (PI) and YOYO-1 were used to assess plasmalemma damage after collagenase-induced intracerebral hemorrhage in mice. Ex vivo aspartylglutamylvalylaspartic acid, terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling, and electron microscopy were used to assess the relationship between plasmalemma permeability and mode of cell death. Cell types vulnerable to plasmalemma damage were determined by immunohistochemistry. RESULTS: Plasmalemma permeability was first detected in the lesion at 1 to 3 hours and peaked at 48 to 72 hours. Neurons and IBA-1-positive cells with morphological features of monocytes were sensitive, whereas resident microglia and astrocytes were resistant to plasmalemma permeability. PI+ cells colocalized with fluorescent-labeled caspase substrates and terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling beginning at 3 to 6 hours. At 48 hours, greater than half of injured cells were PI+/aspartylglutamylvalylaspartic acid- or PI+/terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling- suggesting necrosis, and <5% were PI-/terminal deoxynucleotidyltransferase-mediated dUTP nick end labeling+ or PI-/aspartylglutamylvalylaspartic acid+. Electron microscopy confirmed ultrastructural features of necrosis at 24 hours after intracerebral hemorrhage, high mobility group box protein-1 was released from permeable cells, and mice deficient in receptor interacting protein kinase (RIPK) 3, a known necrosis trigger, had 50% less PI+ cells at 24 hours. Permeable cells remained in the brain for at least 24 hours with <10% spontaneous resealing. CONCLUSIONS: Necrosis contributes to cell demise after intracerebral hemorrhage. Programmed necrosis and plasmalemma damage may represent novel therapeutic targets to prevent cell death or rescue injured cells after intracerebral hemorrhage.

Diaspora engagement: a scoping review of diaspora involvement with strengthening health systems of their origin country.

BACKGROUND: Diaspora communities are a growing source of external aid and resources to address unmet needs of health systems of their homelands. Although numerous articles have been published, these endeavors as a whole have not been systematically assessed. OBJECTIVE: Examine the available literature to assess activities through which diasporas engage with the health system in their origin country and what barriers they face in their interventions. METHODS: This is a scoping review from 1990-2018 using the PRISMA-Scr framework to examine both peer-reviewed and gray literature on (1) specific activities through which diasporas contribute to the health system in their origin country; (2) major health needs diasporas have tried to address; and (3) barriers faced by diaspora healthcare efforts. RESULTS: The initial search identified 119 articles, of which 45 were eligible after excluding non-relevant studies. These were case studies of diaspora contributions to health systems in their origin country (13), interviews (13), literature reviews (9), general articles on the topic (4), and correspondences or presentations (6). The healthcare needs diasporas have sought to address include health workforce emigration ('brain drain') (10), capacity building for research and training (10), inadequate infrastructure (5), and finances (4). Specific activities included short-term missions (11), establishing partnerships (9), emigration back to country of origin (8), specific research and training programs (8), and financial remittances (5). Specific barriers identified were most commonly financial need within the origin country (8), lack of sustainability (6), communication issues (6), lack of intention to return to the origin country (5), infrastructure (4), and political concerns (3). CONCLUSION: Further research on how to expand the scope of and reduce barriers to diaspora engagement is needed to optimize the effectiveness of diaspora contributions to their origin countries. Metrics and standards should be developed for assessing impact of diaspora engagement and interventions.

Adolescent Trauma During the COVID Pandemic: Just Like Adults, Children, or Someone Else?

COVID-19 stay-at-home (SAH) orders were impactful on adolescence, when social interactions affect development. This has the potential to change adolescent trauma. A post-hoc multicenter retrospective analysis of adolescent (13-17 years-old) trauma patients (ATPs) at 11 trauma centers was performed. Patients were divided into 3 groups based on injury date: historical control (CONTROL:3/19/2019-6/30/2019, before SAH (PRE:1/1/2020-3/18/2020), and after SAH (POST:3/19/2020-6/30/2020). The POST group was compared to both PRE and CONTROL groups in separate analyses. 726 ATPs were identified across the 3 time periods. POST had a similar penetrating trauma rate compared to both PRE (15.8% vs 13.8%, P = .56) and CONTROL (15.8% vs 14.5%, P = .69). POST also had a similar rate of suicide attempts compared to both PRE (1.2% vs 1.5%, P = .83) and CONTROL (1.2% vs 2.1%, P = .43). However, POST had a higher rate of drug positivity compared to CONTROL (28.6% vs 20.6%, P = .032), but was similar in all other comparisons of alcohol and drugs to PRE and POST periods (all P > .05). Hence ATPs were affected differently than adults and children, as they had a similar rate of penetrating trauma, suicide attempts, and alcohol positivity after SAH orders. However, they had increased drug positivity compared to the CONTROL, but not PRE group.

Decreased hospital length of stay and intensive care unit admissions for non-COVID blunt trauma patients during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic overwhelmed hospitals, forcing adjustments including discharging patients earlier and limiting intensive care unit (ICU) utilization. This study aimed to evaluate ICU admissions and length of stay (LOS) for blunt trauma patients (BTPs). METHODS: A retrospective review of COVID (3/19/20-6/30/20) versus pre-COVID (3/19/19-6/30/19) BTPs at eleven trauma centers was performed. Multivariable analysis was used to identify risk factors for ICU admission. RESULTS: 12,744 BTPs were included (6942 pre-COVID vs. 5802 COVID). The COVID cohort had decreased mean LOS (3.9 vs. 4.4 days, p = 0.029), ICU LOS (0.9 vs. 1.1 days, p < 0.001), and rate of ICU admission (22.3% vs. 24.9%, p = 0.001) with no increase in complications or mortality compared to the pre-COVID cohort (all p > 0.05). On multivariable analysis, the COVID period was associated with decreased risk of ICU admission (OR = 0.82, CI 0.75-0.90, p < 0.001). CONCLUSIONS: BTPs had decreased LOS and associated risk of ICU admission during COVID, with no corresponding increase in complications or mortality.

Effectiveness of hospital payment reforms in low- and middle-income countries: a systematic review.

Payment mechanisms have attracted substantial research interest because of their consequent effect on care outcomes, including treatment costs, admission and readmission rates and patient satisfaction. Those mechanisms create the incentive environment within which health workers operate and can influence provider behaviour in ways that can facilitate achievement of national health policy goals. This systematic review aims to understand the effects of changes in hospital payment mechanisms introduced in low- and middle-income countries (LMICs) on hospital- and patient-level outcomes. A standardised search of seven databases and a manual search of the grey literature and reference lists of existing reviews were performed to identify relevant articles published between January 2000 and July 2019. We included original studies focused on hospital payment reforms and their effect on hospital and patient outcomes in LMICs. Narrative descriptions or studies focusing only on provider payments or primary care settings were excluded. The authors used the Risk of Bias in Non-Randomized Studies of Interventions tool to assess the risk of bias and quality. Results were synthesized in a narrative description due to methodological heterogeneity. A total of 24 articles from seven middle-income countries were included, the majority of which are from Asia. In most cases, hospital payment reforms included shifts from passive (fee-for-service) to active payment models-the most common being diagnosis-related group payments, capitation and global budget. In general, hospital payment reforms were associated with decreases in hospital expenditures, out-of-pocket payments, length of hospital stay and readmission rates. The majority of the articles scored low on quality due to weak study design. A shift from passive to active hospital payment methods in LMICs has been associated with lower hospital and patient costs as well as increased efficiency without any apparent compromise on quality. However, there is an important need for high-quality studies in this area.

Changes in traumatic mechanisms of injury in Southern California related to COVID-19: Penetrating trauma as a second pandemic.

BACKGROUND: The COVID-19 pandemic resulted in a statewide stay-at-home (SAH) order in California beginning March 19, 2020, forcing large-scale behavioral changes and taking an emotional and economic toll. The effects of SAH orders on the trauma population remain unknown. We hypothesized an increase in rates of penetrating trauma, gunshot wounds, suicide attempts, and domestic violence in the Southern California trauma population after the SAH order. METHODS: A multicenter retrospective analysis of all trauma patients presenting to 11 American College of Surgeons levels I and II trauma centers spanning seven counties in California was performed. Demographic data, injury characteristics, clinical data, and outcomes were collected. Patients were divided into three groups based on injury date: before SAH from January 1, 2020, to March 18, 2020 (PRE), after SAH from March 19, 2020, to June 30, 2020 (POST), and a historical control from March 19, 2019, to June 30, 2019 (CONTROL). POST was compared with both PRE and CONTROL in two separate analyses. RESULTS: Across all periods, 20,448 trauma patients were identified (CONTROL, 7,707; PRE, 6,022; POST, 6,719). POST had a significantly increased rate of penetrating trauma (13.0% vs. 10.3%, p < 0.001 and 13.0% vs. 9.9%, p < 0.001) and gunshot wounds (4.5% vs. 2.4%, p = 0.002 and 4.5% vs. 3.7%, p = 0.025) compared with PRE and CONTROL, respectively. POST had a suicide attempt rate of 1.9% and a domestic violence rate of 0.7%, which were similar to PRE (p = 0.478, p = 0.514) and CONTROL (p = 0.160, p = 0.618). CONCLUSION: This multicenter Southern California study demonstrated an increased rate of penetrating trauma and gunshot wounds after the COVID-19 SAH orders but no difference in attempted suicide or domestic violence rates. These findings may provide useful information regarding resource utilization and a target for societal intervention during the current or future pandemic(s). LEVEL OF EVIDENCE: Epidemiological, level IV.

COVID-19 in trauma: a propensity-matched analysis of COVID and non-COVID trauma patients.

PURPOSE: There is mounting evidence that surgical patients with COVID-19 have higher morbidity and mortality than patients without COVID-19. Infection is prevalent amongst the trauma population, but any effect of COVID-19 on trauma patients is unknown. We aimed to evaluate the effect of COVID-19 on a trauma population, hypothesizing increased mortality and pulmonary complications for COVID-19-positive (COVID) trauma patients compared to propensity-matched COVID-19-negative (non-COVID) patients. METHODS: A retrospective analysis of trauma patients presenting to 11 Level-I and II trauma centers in California between 1/1/2019-6/30/2019 and 1/1/2020-6/30/2020 was performed. A 1:2 propensity score model was used to match COVID to non-COVID trauma patients using age, blunt/penetrating mechanism, injury severity score, Glasgow Coma Scale score, systolic blood pressure, respiratory rate, and heart rate. Outcomes were compared between the two groups. RESULTS: A total of 20,448 trauma patients were identified during the study period. 53 COVID trauma patients were matched with 106 non-COVID trauma patients. COVID patients had higher rates of mortality (9.4% vs 1.9%, p = 0.029) and pneumonia (7.5% vs. 0.0%, p = 0.011), as well as a longer mean length of stay (LOS) (7.47 vs 3.28 days, p < 0.001) and intensive care unit LOS (1.40 vs 0.80 days, p = 0.008), compared to non-COVID patients. CONCLUSION: This multicenter retrospective study found increased rates of mortality and pneumonia, as well as a longer LOS, for COVID trauma patients compared to a propensity-matched cohort of non-COVID patients. Further studies are warranted to validate these findings and to elucidate the underlying pathways responsible for higher mortality in COVID trauma patients.

The coronavirus disease 2019 (COVID-19) stay-at-home order's unequal effects on trauma volume by insurance status in Southern California.

BACKGROUND: The rapid spread of coronavirus disease 2019 in the United States led to a variety of mandates intended to decrease population movement and "flatten the curve." However, there is evidence some are not able to stay-at-home due to certain disadvantages, thus remaining exposed to both coronavirus disease 2019 and trauma. We therefore sought to identify any unequal effects of the California stay-at-home orders between races and insurance statuses in a multicenter study utilizing trauma volume data. METHODS: A posthoc multicenter retrospective analysis of trauma patients presenting to 11 centers in Southern California between the dates of January 1, 2020, and June 30, 2020, and January 1, 2019, and June 30, 2019, was performed. The number of trauma patients of each race/insurance status was tabulated per day. We then calculated the changes in trauma volume related to stay-at-home orders for each race/insurance status and compared the magnitude of these changes using statistical resampling. RESULTS: Compared to baseline, there was a 40.1% drop in total trauma volume, which occurred 20 days after stay-at-home orders. During stay-at-home orders, the average daily trauma volume of patients with Medicaid increased by 13.7 ± 5.3%, whereas the volume of those with Medicare, private insurance, and no insurance decreased. The average daily trauma volume decreased for White, Black, Asian, and Latino patients with the volume of Black and Latino patients dropping to a similar degree compared to White patients. CONCLUSION: This retrospective multicenter study demonstrated that patients with Medicaid had a paradoxical increase in trauma volume during stay-at-home orders, suggesting that the most impoverished groups remain disproportionately exposed to trauma during a pandemic, further exacerbating existing health disparities.

Applying trauma systems concepts to humanitarian battlefield care: a qualitative analysis of the Mosul trauma pathway.

BACKGROUND: Trauma systems have been shown to save lives in military and civilian settings, but their use by humanitarians in conflict settings has been more limited. During the Battle of Mosul (October 2016-July 2017), trauma care for injured civilians was provided through a novel approach in which humanitarian actors were organized into a trauma pathway involving echelons of care, a key component of military trauma systems. A better understanding of this approach may help inform trauma care delivery in future humanitarian responses in conflicts. METHODOLOGY: A qualitative study design was used to examine the Mosul civilian trauma response. From August-December 2017, in-depth semi-structured interviews were conducted with stakeholders (n = 54) representing nearly two dozen organizations that directly participated in or had first-hand knowledge of the response. Source document reviews were also conducted. Responses were analyzed in accordance with a published framework on civilian battlefield trauma systems, focusing on whether the response functioned as an integrated trauma system. Opportunities for improvement were identified. RESULTS: The Mosul civilian trauma pathway was implemented as a chain of care for civilian casualties with three successive echelons (trauma stabilization points, field hospitals, and referral hospitals). Coordinated by the World Health Organization, it comprised a variety of actors, including non-governmental organizations, civilian institutions, and at least one private medical company. Stakeholders generally felt that this approach improved access to trauma care for civilians injured near the frontlines compared to what would have been available. Several trauma systems elements such as transportation, data collection, field coordination, and post-operative rehabilitative care might have been further developed to support a more integrated system. CONCLUSIONS: The Mosul trauma pathway evolved to address critical gaps in trauma care during the Battle of Mosul. It adapted the concept of echelons of care from western military practice to push humanitarian actors closer to the frontlines and improve access to care for injured civilians. Although efforts were made to incorporate some of the integrative components (e.g. evidence-based pre-hospital care, transportation, and data collection) that have enabled recent achievements by military trauma systems, many of these proved difficult to implement in the Mosul context. Further discussion and research are needed to determine how trauma systems insights can be adapted in future humanitarian responses given resource, logistical, and security constraints, as well as to clarify the responsibilities of various actors.

Estimating access to health care in Yemen, a complex humanitarian emergency setting: a descriptive applied geospatial analysis.

BACKGROUND: In conflict settings, data to guide humanitarian and development responses are often scarce. Although geospatial analyses have been used to estimate health-care access in many countries, such techniques have not been widely applied to inform real-time operations in protracted health emergencies. Doing so could provide a more robust approach for identifying and prioritising populations in need, targeting assistance, and assessing impact. We aimed to use geospatial analyses to overcome such data gaps in Yemen, the site of one of the world's worst ongoing humanitarian crises. METHODS: We derived geospatial coordinates, functionality, and service availability data for Yemen health facilities from the Health Resources and Services Availability Monitoring System assessment done by WHO and the Yemen Ministry of Public Health and Population. We modelled population spatial distribution using high-resolution satellite imagery, UN population estimates, and census data. A road network grid was built from OpenStreetMap and satellite data and modified using UN Yemen Logistics Cluster data and other datasets to account for lines of conflict and road accessibility. Using this information, we created a geospatial network model to deduce the travel time of Yemeni people to their nearest health-care facilities. FINDINGS: In 2018, we estimated that nearly 8·8 million (30·6%) of the total estimated Yemeni population of 28·7 million people lived more than 30-min travel time from the nearest fully or partially functional public primary health-care facility, and more than 12·1 million (42·4%) Yemeni people lived more than 1 h from the nearest fully or partially functional public hospital, assuming access to motorised transport. We found that access varied widely by district and type of health service, with almost 40% of the population living more than 2 h from comprehensive emergency obstetric and surgical care. We identified and ranked districts according to the number of people living beyond acceptable travel times to facilities and services. We found substantial variability in access and that many front-line districts were among those with the poorest access. INTERPRETATION: These findings provide the most comprehensive estimates of geographical access to health care in Yemen since the outbreak of the current conflict, and they provide proof of concept for how geospatial techniques can be used to address data gaps and rigorously inform health programming. Such information is of crucial importance for humanitarian and development organisations seeking to improve effectiveness and accountability. FUNDING: Global Financing Facility for Women, Children, and Adolescents Trust Fund; Development and Data Science grant; and the Yemen Emergency Health and Nutrition Project, a partnership between the World Bank, UNICEF, and WHO.

A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare.

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.

Xenophobia as a determinant of health: an integrative review.

Though xenophobia has become increasingly relevant in today's political climate, little is known about the impact of xenophobia on health. While some studies have shown that xenophobia, in local contexts, may contribute to worse mental health outcomes, none have attempted to review the published literature to integrate these findings. This integrative scoping review examines the strength of these publications, then synthesizes their findings to provide a global perspective on xenophobia. The results show that it is not merely a political threat, but also has real, negative impact on the health of individuals and their communities. Given the multiple negative effects on individual and community health, xenophobia warrants more attention from both a public health and political perspective. Policies that promote cultural integration and understanding are essential to improving community health.