TRUE-Bolivia: Trauma Responders Unifying to Empower Communities in Santa Cruz, Bolivia.

BACKGROUND: The aim of this study is to assess the efficacy of the TRUE-Bolivia (Trauma Responders Unifying to Empower Communities Bolivia) trauma first responder course at improving participant confidence in first responder abilities and increasing knowledge of trauma response skills. METHODS: Participants attended the 4-h TRUE-Bolivia course at the municipal department of urban transportation and universities and medical schools in Santa Cruz, Bolivia and completed a demographic survey and pre- and post-course knowledge assessments. All participants who attended the full course and completed both knowledge assessments were included in the study, with 453 people attending at least one portion of the course and 329 completing the full course and assessments. RESULTS: A majority of participants were men, had completed high school or attended university, and worked or trained in the fields of transportation or medicine. Participant ratings of confidence on a 5-point Likert scale improved from a median of 3 (interquartile range [IQR] 2) before the course to 5 (IQR 1) after the course (P < 0.01). The median number of correct answers on the pre-course nine-question knowledge assessment was 3 (IQR 3), improving to 7 (IQR 3) on the post-course assessment (P < 0.01). All demographic groups demonstrated improvements in scores from the pre- to post-test. Female gender, higher education level, a background in medicine, and prior training in first aid were associated with higher pre- and post-test scores. CONCLUSIONS: The TRUE-Bolivia course increased knowledge of first responder skills and improved confidence in these abilities in participants from a variety of backgrounds. Further study is needed to determine the long-term skill utilization by participants and the course's impact on local trauma morbidity and mortality.

Peer mentorship to build research capacity among members of the International Student Surgical Network (InciSioN): a proof of concept study.

BACKGROUND: International Student Surgical Network (InciSioN) is the largest student and trainee global surgery interest group worldwide and its members have contributed significantly to global surgery research. The InciSioN Research Capacity-Building (IReCaB) program aimed to enhance the research skills and confidence of participants via a peer mentorship model. METHODS: After an open call to members of InciSioN to enroll, participants' knowledge of research methods and the process was evaluated through a test to assign mentor and mentee roles, with mentors being those who scored ≥ 20/25. Mentors then delivered a series of four webinars to help disseminate research methodology to mentees. Finally, mentees were tested on their knowledge of research and their satisfaction with the program was also evaluated. RESULTS: Fifty-two participants, mostly from LMICs (n = 23/52, 44.2%) were enrolled, and 36 completed the program. There was a significant improvement in the proportion of questions answered correctly on the post-program test (R = 0.755, p < 0.001). Post-IReCaB test scores were greater than pre-IReCaB scores (p < 0.001). The difference in confidence after the course was also significant (p < 0.001). IReCaB participants successfully designed, implemented, and published an international cross-sectional study. CONCLUSION: This study showed improvements in participants' understanding of theoretical components of scientific research. We offer a model for research capacity building that can be implemented, modeled, and further refined by similar organizations with academic research goals.

Closing the Gender Gap in Global Surgery: Trends at the Academic Surgical Congress.

INTRODUCTION: Female researchers are underrepresented in academic surgery. While they are increasingly producing original research, they lag male researchers in productivity. This disparity is not well understood within the nascent field of global surgery. The following study examines gender parity in global surgery research presented at the Academic Surgical Congress and within subsequent publications. METHODS: Abstracts presented at the Academic Surgical Congress (ASC) between 2015 and 2019 in "Global Surgery" sessions were reviewed to obtain title, the first author (FA) and senior author (SA). The authors were classified by gender. The Scopus database was queried by two reviewers for abstracts with corresponding publications, citations, and journal impact factors. Statistical analysis was conducted using chi-square analysis and t-tests where appropriate. RESULTS: Of a total of 6635 abstracts, 218 global surgery abstracts over a 5-year period were identified. Of these abstracts, 96 (44%) had female FAs, while 56 (26%) had female SAs. When comparing gender, female (44%) FAs and male (56%) FAs were equally represented. While SAs were significantly less likely to be female (26% versus 74%, P < 0.0001), female senior authorship increased significantly within the study period. Output with respect to publications, citations, and journal impact factors were equal by gender. CONCLUSIONS: This study presents 5 y of gender trends in global surgery scholarly work presented at the ASC. Despite an overall predominance of male senior authors, the paradigm is shifting with a recent trend to gender parity. Male and female authors have equal output and are equally impactful. Findings of gender equity in academic global surgery are encouraging, and further study of other disciplines are warranted.

Evaluation of a First Responders Course in Rural North India.

BACKGROUND: Most mortality in trauma occurs in prehospital settings when the golden hour is spent accessing healthcare facilities rather than resuscitating and stabilizing. Assessments performed in the rural community of Nanakpur, India demonstrated a significant paucity of, and limited access to healthcare facilities. To address deficiencies in prehospital care, the All-India Institute of Medical Sciences (AIIMS) constructed the Basic Emergency Care Course (BECC). This study evaluated the BECCs efficacy in Nanakpur. METHODS: The first responder courses took place in 2017 in Nanakpur. Local community health workers, known as Accredited Social Health Activists (ASHAs) were recruited as participants. Participants completed both a pre- and post-course evaluation to assess baseline knowledge and improvement. Participants then took a one-year post-course assessment to evaluate retention. RESULTS: The course included 204 individuals, and over half (109/204) were ASHAs. Pre- and post-course test results were available for 70 participants and demonstrated a significant improvement in knowledge (P < 0.0001). The one-year knowledge retention assessment was completed by 48.6% (n = 53/109) of the original ASHAs. Comparisons between both the pre- and post-course assessment tests with the 12-mo retention assessment revealed a significant decay in knowledge (P < 0.0001). CONCLUSIONS: This study demonstrates the feasibility of utilizing BECC to train ASHAs in Nanakpur as first responders. Participants demonstrated a significant improvement in knowledge immediately after the course. After one year, there was a significant loss in knowledge, highlighting the need for refresher courses. These data suggest potential for the use of BECC for training ASHAs countrywide to strengthen India's prehospital care system.

Academic Global Surgery Curricula: Current Status and a Call for a More Equitable Approach.

INTRODUCTION: We aimed to search the literature for global surgical curricula, assess if published resources align with existing competency frameworks in global health and surgical education, and determine if there is consensus around a fundamental set of competencies for the developing field of academic global surgery. METHODS: We reviewed SciVerse SCOPUS, PubMed, African Medicus Index, African Journals Online (AJOL), SciELO, Latin American and Caribbean Health Sciences Literature (LILACS) and Bioline for manuscripts on global surgery curricula and evaluated the results using existing competency frameworks in global health and surgical education from Consortium of the Universities for Global Health (CUGH) and Accreditation Council for Graduate Medical Education (ACGME) professional competencies. RESULTS: Our search generated 250 publications, of which 18 were eligible: (1) a total of 10 reported existing competency-based curricula that were concurrent with international experiences, (2) two reported existing pre-departure competency-based curricula, (3) six proposed theoretical competency-based curricula for future global surgery education. All, but one, were based in high-income countries (HICs) and focused on the needs of HIC trainees. None met all 17 competencies, none cited the CUGH competency on "Health Equity and Social Justice" and only one mentioned "Social and Environmental Determinants of Health." Only 22% (n = 4) were available as open-access. CONCLUSION: Currently, there is no universally accepted set of competencies on the fundamentals of academic global surgery. Existing literature are predominantly by and for HIC institutions and trainees. Current frameworks are inadequate for this emerging academic field. The field needs competencies with explicit input from LMIC experts to ensure creation of educational resources that are accessible and relevant to trainees from around the world.

Geriatric Trauma in Santa Cruz, Bolivia.

BACKGROUND: The population of Latin America is aging. Research from high-income countries demonstrates geriatric trauma is associated with higher morbidity and mortality. Very little research exists on geriatric patient (GP) injury prevalence in low-resource settings, like Bolivia. METHODS: Data were collected prospectively for 34 mo in the emergency departments of six trauma registry hospitals in Santa Cruz, Bolivia. Data were analyzed with Stata v14. Comparisons were made between GPs, defined as age greater than 65 y, and younger patients (YPs), with ages 18-64 y. RESULTS: Of n = 8796 trauma registry patients, 10.1% (n = 797) were aged 65 y or above, and n = 4989 (63.1%) were aged 18-64 y. The majority of GPs suffered falls (n = 543, 69.6%) versus 30.9% (n = 1541) of YPs (P < 0.001). Frequently, GPs had isolated injuries of the pelvis/hip (15.9% versus 1.4% YP, P < 0.0001) or upper extremity (15.8% versus 18.5% YP, P = 0.07), while YPs had a higher incidence of multiple injuries (YP 14.8% versus GP 8.4%, P < 0.001). While the majority of patients were discharged home (GP 43.0% versus YP 48.1%, P = 0.008), GPs were more likely to be admitted to the hospital (32.3% versus 22.3%, P < 0.001). CONCLUSIONS: As life expectancy improves, the incidence of geriatric trauma will continue to increase. Understanding the characteristics associated with trauma in GP can allow for effective prevention methods, resource distribution, and discharge planning.

Empowering Bystanders to Intervene: Trauma Responders Unify to Empower (TRUE) Communities.

BACKGROUND: Timely and effective bystander first aid can improve outcomes for trauma victims. Bystanders are present at most traumas and are more likely to assist with prior training. MATERIALS AND METHODS: An evidence-based course was created for the general public in high-risk Chicago neighborhoods focused on basic traumatic first aid, including scene management, hemorrhage control, and mitigating the psychological impact of trauma to overcome the bystander effect. Prospectively, participants completed knowledge-based and self-efficacy assessments precourse, postcourse, and 6 mo follow-up. The change in self-efficacy and knowledge scores was analyzed. RESULTS: Over 32 courses, 503 participants were taught; 474 and 460 participants completed precourse and postcourse surveys, respectively, whereas 60 of 327 who consented for follow-up completed the 6-mo survey. Postcourse, participants were more likely to assist trauma victims and felt more confident in the quality of care they could provide; the effect remained significant at 6 mo (all P < 0.001). All seven self-efficacy empowerment-based questions individually demonstrated improvement from precourse to postcourse (P < 0.001), with an overall mean (SD) increase of 2.8 (2.1, P < 0.001); six maintained significance at follow-up with an overall mean increase of 2.8 (1.9, P < 0.001). Knowledge scores improved from 6.2 of 10 to 7.2 postcourse and 7.7 at follow-up (P < 0.001). Most improved were the ability to render first aid and apply tourniquets. CONCLUSIONS: The TFRC increased self-efficacy, successfully teaching initial trauma care, particularly hemorrhage control and scene safety, suggesting that a grassroots approach to trauma care may improve outcomes in communities that experience high violence rates.

Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.

Correction to: Strengthening Surgery Strengthens Health Systems: A New Paradigm and Potential Pathway for Horizontal Development in Low- and Middle-Income Countries.

In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.

Utilizing Technology for Global Surgery: A Survey of the West African College of Surgeons.

BACKGROUND: Information and communication technology (ICT) has been heralded as a possible mechanism for expanding global surgery collaborations. However, little is known regarding feasibility of ICT use in low- and middle-income countries (LMIC). We sought to determine the appropriate ICT platforms for surgical education initiatives and international collaborations. MATERIALS AND METHODS: We conducted a survey of members of the West African College of Surgeons. Topics included computer and internet access/utilization, familiarity with ICT, such as social media (SM), virtual document sharing platforms (VDS), virtual meeting applications (VM), and learning management systems (LM), and interest in ICT adoption. Statistical analyses were done using chi-squared tests, with Bonferroni corrections. RESULTS: Survey respondents included 83 individuals from 10 countries, 50% of whom had been in practice >10 y. All had computer access, with most (95%) using SM compared to all other modalities (P < 0.001); 77% used SM for professional reasons and 57% for education. Sixty percent of participants used VDS, 73% of whom used it for education. The utilization of other ICTs was lower (VM 43%, LM 32%). Unreliable Wi-Fi hindered every ICT, less often SM (41%) and VDS (23%), and more commonly VM (64%) and LM (52%). Despite this, VM was most often used in international collaboration (79%, P < 0.01). Most respondents (98%) supported ICT use for international collaboration. CONCLUSIONS: ICT platforms can support education initiatives and international collaborations in resource-limited areas. Deployment of similar surveys and ICT workshops across other LMIC regions could maximize ICT utilization, further expanding global surgical collaborations.

Perceptions regarding helmet use: a cross-sectional survey of female pillions in Karachi, Pakistan.

BACKGROUND: In 2011, road traffic injury-associated fatalities among motorized two-wheeler (MTW) pillion riders (backseat two-wheeler passengers) rose 30% in Karachi. Despite mandatory helmet laws, helmet use fell 20% the same year. This study aims to identify opinions of female pillions on helmet usage and whether various forms of media influence their self-perception. METHODS: Trained surveyors, using a survey tool used in similar studies in South Asia, conducted random, man-on-the-street interviews of 400 women in four areas of Karachi. Data pertaining to demographics, opinions on helmet laws, media influences, and helmet usage were collected. Data were analyzed in SAS 9.3 using chi-squared or Fisher's exact tests. RESULTS: Of the 400 women, 98.8% (n = 394) reported never wearing a helmet while riding on a MTW as a pillion rider. Women with a postsecondary or higher (US ninth grade) education level were more likely to be aware of helmet laws (38.6%) than women with lower education levels (24.6%, P = 0.005). Most women (82.4%, n = 329) supported mandatory laws and 97% (n = 289) recognized that disability was the more likely to result than death in event of a traumatic brain injury. Nearly all (98.5%, n = 394) stated that they would use a helmet if they were men, regardless of age, education level, or employment status. Television news was the most influential media form (83.7%, n = 334), with most women finding it effective because of its informative nature (91.3%, n = 303). CONCLUSIONS: Most Pakistani women do not personally use helmets when riding MTWs, yet most believe helmet use should be legally required for MTW riders and drivers. These data show that media outlets such as television can be used as a platform to educate the public about helmet usage, which may lead to improved helmet compliance among female MTW pillions in Pakistan. Furthermore, investigations into improved helmet comfort and appearance by collaborating with helmet manufacturers may have a positive impact on helmet use in Pakistan.

Surgical and trauma care in low- and middle-income countries: a review of capacity assessments.

BACKGROUND: Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool. MATERIALS AND METHODS: Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included. RESULTS: Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration. CONCLUSIONS: Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.

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

BACKGROUND: Road traffic injury has emerged as a leading cause of mortality, contributing to 2·1% of deaths globally and is predicted to be the third highest contributor to the global burden of mortality by 2020. This major public health problem disproportionately affects low-income and middle-income countries, where such incidents are too often underreported. Our study aims to explore the epidemiology of road traffic injurys in Nepal at a population level via a countrywide study. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a cluster randomised, cross-sectional nationwide survey, was conducted in Nepal between May 25, and June 12, 2014. Two-stage cluster sampling was performed: 15 of 75 districts were chosen randomly proportional to population; within each district, after stratification for urban and rural, and three clusters were randomly chosen. Questions were structured anatomically and designed around a representative spectrum of surgical conditions. Road traffic injury-related results were reported. FINDINGS: 1350 households and 2695 individuals were surveyed with a response rate of 97%. 75 road traffic injuries were reported in 72 individuals (2·67% [95% CI 2·10-3·35] of the study population), with a mean age of 33·2 years (SD 1·85). The most commonly affected age group was 30-44 years, with females showing significantly lower odds of sustaining a road traffic injury than men (crude odds ratio 0·29 [95% CI 0·16-0·52]). Road traffic injuries composed 19·8% of the injuries reported. Motorcycle crashes were the most common road traffic injuries (48·0%), followed by car, truck, or bus crashes (26·7%), and pedestrian or bicycle crashes (25·3%). The extremity was the most common anatomic site injured (74·7%). Of the 80 deaths reported in the previous year, 7·5% (n=6) were due to road traffic injuries. INTERPRETATION: This study provides the epidemiology of road traffic injuries at a population-based level in the first countrywide surgical needs assessment in Nepal. WHO reported that mortality due to road traffic injuries in Nepal in 2011 was 1·7%, whereas our study reported 7·5%, consistent with the concept of underreporting of deaths in police and hospital level data noted in previous literature. Road traffic injuries continue to be a significant problem in Nepal, probably greater than previously reported; future efforts should focus on addressing this growing epidemic through preventive and mitigating strategies. FUNDING: The Association for Academic Surgery and Surgeons OverSeas.

Humanitarian skill set acquisition trends among graduating US surgical residents, 2004-2014.

BACKGROUND: Although interest in practicing surgery in resource-constrained settings is on the rise among graduating US surgical residents, there is ongoing debate about an optimal humanitarian skill set for surgeons who chose to work in such settings. In addition, increased emphasis on general surgery case exposure at the cost of specialty surgery case exposure has been documented and may have a negative impact on the breadth of resident training. Review of general surgery resident case logs to gauge experience in specialty surgery may provide insight into residents' readiness for work in resource-limited settings. METHODS: We compared Accreditation Council for Graduate Medical Education general surgery resident case logs from 2004 to 2014 for operations thought to be essential for working in resource-constrained settings. These operations were chosen from published literature on this topic and authors' personal experience. Case numbers for specialty operations were compared by unpaired t-test analysis between the two periods. RESULTS: Case averages in pediatric, genitourinary, and gynecologic surgery decreased significantly from 2004 to 2014 (range, 27%-46%). Orthopedic surgery case averages were unchanged, and plastic and general abdominal surgery case averages increased (range, 47%-50%). CONCLUSIONS: Case mix among graduating US surgical residents has narrowed over the past 10 y. Resident experience in a variety of specialty fields, thought to be essential in resource-constrained settings, decreased markedly over the study period. Residents who intend to work in resource-constrained settings may need to craft individualized residency experiences or pursue postgraduate training in specialty surgery courses to best prepare for such work.

Patterns of injury among motorized two-wheeler pillion riders in New Delhi, India.

BACKGROUND: Motorized two-wheelers (MTWs) such as scooters and motorcycles place drivers and passengers at significant risk of injury and death in the event of a road traffic accident. In India, where road traffic is poorly regulated and consists of vehicles ranging from semitrucks to animal carts, the MTW pillion rider (backseat passenger) is particularly vulnerable. Annually, approximately 140,000 Indians are injured or killed in MTW road traffic accidents. In 2011, the city of New Delhi renewed a mandatory helmet use exemption for its 8 million women. We sought to identify the patterns of injury among MTW pillion riders in the city of New Delhi, including differences between helmeted and unhelmeted male and female pillion riders. METHODS: All records of incoming trauma patients to the Jai Prakash Narayan Apex Trauma Center, New Delhi, were reviewed for the 23-mo period from April 1, 2009 until March 1, 2011. More than 3000 charts were reviewed selecting for patients who were MTW pillion riders involved in road traffic accidents. Data including Glasgow Coma Scale score, number of surgical procedures performed, length of stay, and demographic information were collected from charts that met the criteria. Fisher's exact test was used for categorical variables and Kruskal-Wallis test for continuous variables. RESULTS: A total of 466 charts of MTW pillions in road traffic accidents were identified with 108 helmeted males, 161 unhelmeted males, three helmeted females, and 194 unhelmeted females. Females, both unhelmeted and helmeted, were more likely to have head and neck injury than unhelmeted males or helmeted males (66.0% and 66.7% versus 53.4% and 27.8%, P < 0.001). Unhelmeted females were most likely to suffer inhospital mortality (17.6%, P = 0.008) and require intensive care unit admission (40.0%, P = 0.004). Unhelmeted pillions, both male and female, had significantly lower Glasgow Coma Scale scores than helmeted pillions (12.6 and 12.8 versus 13.8 and 15, P = 0.04). CONCLUSIONS: Female pillions are more likely to have head and neck injury than male pillions, and unhelmeted pillions are more likely to have injuries resulting in their death. This firmly establishes the protective benefit of helmet use for pillions. Encouraging helmet use among all pillions may prevent a significant number of injuries and deaths, and mandatory helmet laws may decrease morbidity and mortality of MTW road traffic accidents for the women of New Delhi and all of India.

Trauma system development in low- and middle-income countries: a review.

BACKGROUND: Trauma systems in resource-rich countries have decreased mortality for trauma patients through centralizing resources and standardizing treatment. Rapid industrialization and urbanization have increased the demand for formalized emergency medical services and trauma services (EMS and TS) in low- and middle-income countries (LMICs). This systematic review examines initiatives to develop EMS and TS systems in LMICs to inform the development of comprehensive prehospital care systems in resource-poor settings. MATERIALS AND METHODS: EMS and TS system development publications were identified using MEDLINE, PubMed, and Scopus databases. Articles addressing subspecialty skill sets, public policy, or physicians were excluded. Two independent reviewers assessed titles, abstracts, and full texts in a hierarchical manner. RESULTS: A total of 12 publications met inclusion criteria, and 10 unique LMIC EMS and TS programs were identified. Common initiatives included the integration of existing EMS and TS services and provision of standardized training and formalized certification processes for prehospital care providers, as well as the construction of a conceptual framework for system development through the public health model. CONCLUSIONS: There is no single model of EMS and TS systems, and successful programs are heterogeneous across regions. Successful EMS and TS systems share common characteristics. A predevelopment needs assessment is critical in identifying existing EMS and TS resources as a foundation for further development. Implementation requires coordination of preexisting resources with cost-effective initiatives that involve local stakeholders. High-impact priority areas are identified to focus improvements. Financial stresses and mismatching of resources in LMICs are common and are more commonly encountered when implementing a high-income model EMS and TS in an LMIC. Preimplementation and postimplementation evaluations can determine the efficacy of initiatives to strengthen EMS and TS systems.

The problem of the pillion rider: India's helmet law and New Delhi's exemption.

BACKGROUND: In India, motorized two-wheeler (MTW) road traffic accidents injure or kill 72,000 women annually. Before the Motor Vehicle Act of 1988, which required mandatory helmet use for MTW riders, a study found 0.6% of all MTW pillions (backseat passengers) were helmeted. Citing religious protests to the legislation, Delhi's high court exempted the city's 12 million women from the law. We hypothesize that currently male pillions use helmets more frequently than females, and that overall pillion helmet usage has increased over the last 20 y. METHODS: Continuous video was recorded in half-hour blocks at four locations in Delhi on separate days, totaling 8 hours of high- and low-volume traffic. Videos were reviewed with at least two reviewers extracting the number of MTW pillions, as well as their gender, approximate age, and helmet usage. RESULTS: Of 4010 pillions identified, 63.8% were male, 32.4% female, and 3.3% children. Among males, there were significantly more helmeted pillions (88.4%, P < 0.001); among females, there were significantly more unhelmeted pillions (99.4%, P < 0.001). Among unhelmeted pillions, significantly more were female (81.4%) than male (P < 0.001). Current overall pillion helmet use is significantly higher than historical rate (P < 0.001). CONCLUSIONS: The significantly higher male pillion helmet usage compared with females indicates Delhi's helmet law is associated with increased compliance among those who fall under its jurisdiction. This augments the growing body of evidence that mandatory helmet laws are efficacious, thus repealing the exemption of women is an important step in increasing female pillion helmet usage.

Layperson trauma training in low- and middle-income countries: a review.

BACKGROUND: Prehospital trauma systems are rudimentary in many low- and middle-income countries (LMICs) and require laypersons to stabilize and transport injured patients. The World Health Organization recommends educating layperson first responders as an essential step in the development of Emergency Medical Services systems in LMICs. This systematic review examines trauma educational initiatives for layperson first responders in resource-poor settings. MATERIALS AND METHODS: Layperson first-responder training and education program publications were identified using PubMed MEDLINE and Scopus databases. Articles addressing physicians, professional Emergency Medical Services training, or epidemiologic descriptions were excluded. Publications were assessed by independent reviewers, and those included underwent thematic analysis. RESULTS: Thirteen publications met inclusion criteria. Four themes emerged regarding the development of layperson first-responder training programs: (1) An initial needs assessment of a region's existing trauma system of care and laypersons' baseline emergency care knowledge focuses subsequent educational interventions; (2) effective programs adapt to and leverage existing resources; (3) training methods should anticipate participants with low levels of education and literacy; and (4) postimplementation evaluation allows for curriculum improvement. Technology, such as online and remote learning platforms, can be used to operationalize each theme. CONCLUSIONS: Successful training programs for layperson first responders in LMICs identify and maximize existing resources are adaptable to learners with little formal education and are responsive to postimplementation evaluation. Educational platforms that leverage technology to deliver content may facilitate first-responder trauma education in underresourced areas. Themes identified can inform the development of trauma systems of care to decrease mortality and physiological severity scores in trauma patients in LMICs.

Cultural competency and ethical behavior for collaboration in limited-resource settings: Guidelines from the Society of University Surgeons Academic Global Surgery Committee and the Association for Academic Global Surgery.

BACKGROUND: There are an increasing number of global surgery activities worldwide. With such tremendous growth, there is a potential risk for untoward interactions between high-income country members and low-middle income country members, leading to programmatic failure, poor results, and/or low impact. METHODS: Key concepts for cultural competency and ethical behavior were generated by the Academic Global Surgery Committee of the Society for University Surgeons in collaboration with the Association for Academic Global Surgery. Both societies ensured active participation from high-income countries and low-middle income countries. RESULTS: The guidelines provide a framework for cultural competency and ethical behavior for high-income country members when collaborating with low-middle income country partners by offering recommendations for: (1) preparation for work with low-middle income countries; (2) process standardization; (3) working with the local community; (4) limits of practice; (5) patient autonomy and consent; (6) trainees; (7) potential pitfalls; and (8) gray areas. CONCLUSION: The article provides an actionable framework to address potential cultural competency and ethical behavior issues in high-income country - low-middle income country global surgery collaborations.

Bronchoalveolar lavage amylase is associated with risk factors for aspiration and predicts bacterial pneumonia.

OBJECTIVES: Aspiration of oropharyngeal or gastric contents into the respiratory tract leads to a spectrum of disorders with high morbidity. Aspiration is a diagnostic dilemma, because clinical characteristics and diagnostic tests are not effective predicting or confirming aspiration. We sought to determine whether α-amylase, a protein secreted by salivary glands and the pancreas, is elevated in bronchoalveolar lavage specimens in patients with clinical risk factors for aspiration and whether bronchoalveolar lavage amylase predicts bacterial pneumonia. DESIGN: Retrospective analysis. SETTING: Five adult ICUs at a tertiary care urban medical center. PATIENTS: Mechanically ventilated patients who underwent either bronchoscopic or nonbronchoscopic bronchoalveolar lavage within 72 hrs of endotracheal intubation between August 1, 2008 and June 30, 2010. MEASUREMENTS AND MAIN RESULTS: A total of 296 bronchoalveolar lavage amylase results from 280 patients were included in the analysis, and 155 bronchoalveolar lavage amylase specimens were obtained from patients with at least one predefined preintubation risk factor (altered consciousness, swallowing dysfunction, difficult intubation, peri-intubation vomiting, or cardiac arrest). Bronchoalveolar lavage amylase concentration increased as the number of preintubation risk factors increased (p < 0.001). In addition, bronchoalveolar lavage amylase was elevated in patients with bacterial pneumonia (cfu/mL ≥ 10) (p < 0.001). The area under the receiver operator curve for the ability of bronchoalveolar lavage amylase to differentiate between positive and negative bronchoalveolar lavage culture was 0.67 (95% confidence interval, 0.60-0.75). The lower 95% confidence interval for bronchoalveolar lavage amylase in patients with at least one preintubation risk factor for aspiration was 125.9 units/L. In multivariate analysis, bronchoalveolar lavage amylase < 125 units/L was associated with significantly lower odds of bacterial pneumonia (odds ratio 0.39, 95% confidence interval 0.21-0.71, p = 0.002). CONCLUSIONS: Elevated bronchoalveolar lavage amylase is associated with risk factors for aspiration and may predict bacterial pneumonia. Bronchoalveolar lavage amylase may be useful as an early screening tool to guide management of patients suspected of aspiration.