Trauma systems in Asian countries: challenges and recommendations.

INTRODUCTION: Trauma burden is one of the leading causes of young human life and economic loss in low- and middle-income countries. Improved emergency and trauma care systems may save up to 2 million lives in these countries. METHOD: This is a comprehensive expert opinion participated by 4 experts analyzing 6 Asian countries compiling the most pressing trauma care issues in Asia as well as goal directed solutions for uplifting of trauma care in these countries. RESULT: Lack of legislation, stable funding under a dedicated lead agency is a major deterrent to development and sustainment of trauma systems in most Asian countries. While advocating trauma, critical care as a specialty is a key event in the system establishment, Trauma specialized training is challenging in low resource settings and can be circumvented by regional cooperation in creating trauma specialized academic centers of excellence. Trauma quality improvement process is integral to the system maturity but acquisition and analysis of quality data through trauma specific registries is the least developed in the Asian setting.

Rain, rain, go away, come again another day: do climate variations enhance the spread of COVID-19?

The spread of infectious diseases was further promoted due to busy cities, increased travel, and climate change, which led to outbreaks, epidemics, and even pandemics. The world experienced the severity of the 125 nm virus called the coronavirus disease 2019 (COVID-19), a pandemic declared by the World Health Organization (WHO) in 2019. Many investigations revealed a strong correlation between humidity and temperature relative to the kinetics of the virus's spread into the hosts. This study aimed to solve the riddle of the correlation between environmental factors and COVID-19 by applying RepOrting standards for Systematic Evidence Syntheses (ROSES) with the designed research question. Five temperature and humidity-related themes were deduced via the review processes, namely 1) The link between solar activity and pandemic outbreaks, 2) Regional area, 3) Climate and weather, 4) Relationship between temperature and humidity, and 5) the Governmental disinfection actions and guidelines. A significant relationship between solar activities and pandemic outbreaks was reported throughout the review of past studies. The grand solar minima (1450-1830) and solar minima (1975-2020) coincided with the global pandemic. Meanwhile, the cooler, lower humidity, and low wind movement environment reported higher severity of cases. Moreover, COVID-19 confirmed cases and death cases were higher in countries located within the Northern Hemisphere. The Blackbox of COVID-19 was revealed through the work conducted in this paper that the virus thrives in cooler and low-humidity environments, with emphasis on potential treatments and government measures relative to temperature and humidity. HIGHLIGHTS: • The coronavirus disease 2019 (COIVD-19) is spreading faster in low temperatures and humid area. • Weather and climate serve as environmental drivers in propagating COVID-19. • Solar radiation influences the spreading of COVID-19. • The correlation between weather and population as the factor in spreading of COVID-19.

Military and Civilian Trauma System Integration: A Global Case Series.

INTRODUCTION: Traumatic injury is a leading cause of morbidity globally, particularly in low-income and middle-income countries (LMICs). In high-income countries (HICs), it is well documented that military and civilian integration can positively impact trauma care in both healthcare systems, but it is unknown if this synergy could benefit LMICs. This case series examines the variety of integration between the civilian and military systems of various countries and international partnerships to elucidate if there are commonalities in facilitators and barriers. METHODS: A convenience sampling method was utilized to identify subject matter experts on civilian and military trauma system integration. Data were collected and coded through an iterative process, focusing on the historical impetuses and subsequent outcomes of civilian and military trauma care collaboration. RESULTS: Eight total case studies were completed, five addressing specific countries and three addressing international partnerships. Themes which emerged as drivers for integration included history of conflict, geography, and skill maintenance for military physicians. High-level government support was a central theme for successful integration, and financial issues were often seen as the greatest barrier. CONCLUSIONS: Various approaches in civilian-military integration exist throughout the world, and the studied nations and international partnerships demonstrated similar motivators and barriers to integration. This study highlights the need for further investigation, particularly in LMICs, where less is known about integration strategies.

Learning from terrorist mass casualty incidents: a global survey.

BACKGROUND: Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses. METHODS: We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale. RESULTS: Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement). CONCLUSION: This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Challenges encountered and lessons learnt from venous injuries at Sri Lankan combat theatres.

PURPOSE: The objective of this study was to characterise the spectrum of peripheral venous injury in the Sri Lankan war theatres, including categorisation of anatomic patterns, mechanism and management of casualties, including short-term results of surgical repair of traumatic venous injuries versus ligation. In addition, the effects and outcome of combined arterial and venous injuries versus arterial injury alone are compared. METHODS: All adults with extremity vascular injuries admitted to a military base hospital during an 8-month period were prospectively recorded and those with a venous injury were analysed. RESULT: A total of 123 vascular injuries were recorded in the study period, of which 70 had a venous injury, combined with an arterial injury in 58 (83%) and in isolation in 12 (17%). There were 43 transections, 26 lateral tears and a single through and through penetrating injury. Twenty-five (36%) vein injures were repaired and 45 ligated. Only six popliteal veins were repaired in 21 lower limbs that underwent arterial revascularisation. In the combined arterial/venous injuries group 13 primary amputations were performed and five delayed amputations were necessary. There were no amputations in the isolated venous injury group. There were three deaths (4.3%), 18 infections with four cultures positive for pseudomonas species, five arterial graft thromboses were recorded. There were significantly more blood transfusions and concomitant skeletal injuries, resulting in more amputations, in combined arterial and venous injuries in comparison with arterial injury alone (all p values<0.05). CONCLUSIONS: In an ideal setting, venous injuries should be repaired when possible and tolerated by the patient in order to ameliorate the risk of thrombotic and infectious complications. An aggressive use of shunting, fasciotomies and venous repair in wartime limb injuries at echelon structured care may prevent preventable limb loss in these challenging case scenarios.