Global Neurotrauma Surveillance: Are National Databases Overrated? Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries".

Injuries are a public health crisis. Neurotrauma, a specific type of injury, is a leading cause of death and disability globally, with the largest burden in low- and middle-income countries (LMICs). However, there is a lack of quality neurotrauma-specific data in LMICs, especially at the national level. Without standard criteria for what constitutes a national registry, and significant challenges frequently preventing this level of data collection, we argue that single-institution or regional databases can provide significant value for context-appropriate solutions. Although granular data for larger populations and a universal minimum dataset to enable comparison remain the gold standard, we must put progress over perfection. It is critical to engage local experts to explore available data and build effective information systems to inform solutions and serve as the foundation for quality and process improvement initiatives. Other items to consider include adequate resource allocation and leveraging of technology as we work to address the persistent but largely preventable injury pandemic.

COVID-19, Racial Injustice, and Medical Student Engagement With Global Health: A Single-Institution Survey.

INTRODUCTION: United States medical schools continue to respond to student interest in global health (GH) and the evolution of the field through strengthening related curricula. The COVID-19 pandemic and superimposed racial justice movements exposed chasms in the US healthcare system. We sought to explore the possible relationship between the pandemic, US racial justice movements, and medical student interest in GH to inform future academic offerings that best meet student needs. METHODS: A novel, mixed-methods 30-question Qualtrics survey was disseminated twice (May-August 2021) through email and social media to all current students. Data underwent descriptive and thematic analysis. RESULTS: Twenty students who self-identified as interested in GH responded to the survey. Most (N = 13, 65%) were in preclinical training, and half were women (N = 10, 50%). Five (25%) selected GH definitions with paternalistic undertones, 11 (55%) defined GH as noncontingent on geography, and 12 (60%) said the pandemic and US racial justice movement altered their definitions to include themes of equity and racial justice. Eighteen (90%) became interested in GH before medical school through primarily volunteering (N = 8, 40%). Twelve (60%) students plan to incorporate GH into their careers. CONCLUSIONS: Our survey showed most respondents entered medical school with GH interest. Nearly all endorsed a changed perspective since enrollment, with a paradigm shift toward equity and racial justice. Shifts were potentially accelerated by the global pandemic, which uncovered disparities at home and abroad. These results highlight the importance of faculty and curricula that address global needs and how this might critically impact medical students.

Outcomes after emergency general surgery and trauma care in incarcerated individuals: An EAST multicenter study.

BACKGROUND: The US incarcerates more individuals than any other country. Prisoners are the only population guaranteed health care by the US constitution, but little is known about their surgical needs. This multicenter study aimed to describe the acute care surgery (ACS) needs of incarcerated individuals. METHODS: Twelve centers prospectively identified incarcerated patients evaluated in their emergency department by the ACS service. Centers collected diagnosis, treatment, and complications from chart review. Patients were classified as either emergency general surgery (EGS) patients or trauma patients and their characteristics and outcomes were investigated. Poisson regression accounting for clustering by center was used to calculate the relative risk (RR) of readmission, representation within 90 days, and failure to follow-up as an outpatient within 90 days for each cohort. RESULTS: More than 12 months, ACS services evaluated 943 patients, 726 (80.3%) from jail, 156 (17.3%) from prison, and 22 (2.4%) from other facilities. Most were men (89.7%) with a median age of 35 years (interquartile range, 27-47). Trauma patients comprised 54.4% (n = 513) of the cohort. Admission rates were similar for trauma (61.5%) and EGS patients (60.2%). Head injuries and facial fractures were the most common injuries, while infections were the most common EGS diagnosis. Self-harm resulted in 102 trauma evaluations (19.9%). Self-inflicted injuries were associated with increased risk of readmission (RR, 4.3; 95% confidence interval, 3.02-6.13) and reevaluation within 90 days (RR, 4.96; 95% confidence interval, 3.07-8.01). CONCLUSION: Incarcerated patients who present with a range of trauma and EGS conditions frequently require admission, and follow-up after hospitalization was low at the treating center. Poor follow-up coupled with high rates of assault, self-harm, mental health, and substance use disorders highlight the vulnerability of this population. Hospital and correctional facility interventions are needed to decrease self-inflicted injuries and assaults while incarcerated. LEVEL OF EVIDENCE: Prognostic and epidemiological, Level III.

The Structural Violence Trap: Disparities in Homicide, Chronic Disease Death, and Social Factors Across San Francisco Neighborhoods.

BACKGROUND: On average, a person living in San Francisco can expect to live 83 years. This number conceals significant variation by sex, race, and place of residence. We examined deaths and area-based social factors by San Francisco neighborhood, hypothesizing that socially disadvantaged neighborhoods shoulder a disproportionate mortality burden across generations, especially deaths attributable to violence and chronic disease. These data will inform targeted interventions and guide further research into effective solutions for San Francisco's marginalized communities. STUDY DESIGN: The San Francisco Department of Public Health provided data for the 2010-2014 top 20 causes of premature death by San Francisco neighborhood. Population-level demographic data were obtained from the US American Community Survey 2015 5-year estimate (2011-2015). The primary outcome was the association between years of life loss (YLL) and adjusted years of life lost (AYLL) for the top 20 causes of death in San Francisco and select social factors by neighborhood via linear regression analysis and heatmaps. RESULTS: The top 20 causes accounted for N = 15,687 San Francisco resident deaths from 2010-2014. Eight neighborhoods (21.0%) accounted for 47.9% of city-wide YLLs, with 6 falling below the city-wide median household income and many having a higher percent population Black, and lower education and higher unemployment levels. For chronic diseases and homicides, AYLLs increased as a neighborhood's percent Black, below poverty level, unemployment, and below high school education increased. CONCLUSIONS: Our study highlights the mortality inequity burdening socially disadvantaged San Francisco neighborhoods, which align with areas subjected to historical discriminatory policies like redlining. These data emphasize the need to address past injustices and move toward equal access to wealth and health for all San Franciscans.

Turning value into action: Healthcare workers using digital media advocacy to drive change.

BACKGROUND: The standard method of sharing information in academia is the scientific journal. Yet health advocacy requires alternative methods to reach key stakeholders to drive change. The purpose of this study was to analyze the impact of social media and public narrative for advocacy in matters of firearm-related injury and death. STUDY DESIGN: The movement This Is Our Lane was evaluated through the #ThisIsOurLane and #ThisIsMyLane hashtags. Sources were assessed from November 2018 through March 2019. Analyses specifically examined message volume, time course, global engagement, and content across Twitter, scientific literature, and mass media. Twitter data were analyzed via Symplur Signals. Scientific literature reviews were performed using PubMed, EMBASE, Web of Science, and Google Scholar. Mass media was compiled using Access World News/Newsbank, Newspaper Source, and Google. RESULTS: A total of 507,813 tweets were shared using #ThisIsOurLane, #ThisIsMyLane, or both (co-occurrence 21-39%). Fifteen scientific items and n = 358 mass media publications were published during the study period; the latter included articles, blogs, television interviews, petitions, press releases, and audio interviews/podcasts. Peak messaging appeared first on Twitter on November 10th, followed by mass media on November 12th and 20th, and scientific publications during December. CONCLUSIONS: Social media enables clinicians to quickly disseminate information about a complex public health issue like firearms to the mainstream media, scientific community, and general public alike. Humanized data resonates with people and has the ability to transcend the barriers of language, culture, and geography. Showing society the reality of caring for firearm-related injuries through healthcare worker stories via digital media appears to be effective in shaping the public agenda and influencing real-world events.

Surgical and Trauma Capacity Assessment in Rural Haryana, India.

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified. Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools. Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively. Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures. Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.

The Bolivian trauma patient's experience: A qualitative needs assessment.

BACKGROUND: Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement. METHODS: Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care. RESULTS: Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care. CONCLUSIONS: This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.

What is trauma? Qualitatively assessing stakeholder perceptions in Santa Cruz de la Sierra, Bolivia.

Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.

Ensuring safe surgical care across resource settings via surgical outcomes data & quality improvement initiatives.

Staggering statistics regarding the global burden of disease due to lack of surgical care worldwide has been gaining attention in the global health literature over the last 10 years. The Lancet Commission on Global Surgery reported that 16.9 million lives were lost due to an absence of surgical care in 2010, equivalent to 33% of all deaths worldwide. Although data from low- and middle-income countries (LMICs) are limited, recent investigations, such as the African Surgical Outcomes Study, highlight that despite operating on low risk patients, there is increased postoperative mortality in LMICs versus higher-resource settings, a majority of which occur secondary to seemingly preventable complications like surgical site infections. We propose that implementing creative, low-cost surgical outcomes monitoring and select quality improvement systems proven effective in high-income countries, such as surgical infection prevention programs and safety checklists, can enhance the delivery of safe surgical care in existing LMIC surgical systems. While efforts to initiate and expand surgical access and capacity continues to deserve attention in the global health community, here we advocate for creative modifications to current service structures, such as promoting a culture of safety, employing technology and mobile health (mHealth) for patient data collection and follow-up, and harnessing partnerships for information sharing, to create a framework for improving morbidity and mortality in responsible, scalable, and sustainable ways.

SOSAS Study in Rural India: Using Accredited Social Health Activists as Enumerators.

BACKGROUND: Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world's population receives approximately 73.6% of the world's total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators. MATERIAL AND METHODS: Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care. RESULTS: One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%). CONCLUSIONS: This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India.

The academic tweet: Twitter as a tool to advance academic surgery.

Social media, Twitter in particular, has emerged as an essential tool for surgeons. In the realm of academic surgery, it enables surgeons to advance the core values of academic surgery, as outlined by the Association for Academic Surgery: inclusion, leadership, innovation, scholarship, and mentorship. This article details the ways in which surgeons are using Twitter to embody these values and how the Twitter account for the Association of Academic Surgeons accomplishes its goal of inspiring and developing young academic surgeons.

American College of Surgeons Member Involvement in Global Surgery: Results from the 2015 Operation Giving Back Survey.

BACKGROUND: Five billion people worldwide lack access to safe surgery. American College of Surgeons (ACS) members have a strong history of humanitarian and volunteer work. Since its founding in 2004, Operation Giving Back (OGB) has served as a volunteer resource portal. This study sought to understand current activities, needs, and barriers to ACS member volunteerism, and to re-assess the role of OGB. METHODS: A 25-question electronic survey was sent to ACS members in August 2015. Utilizing branching logic, those who were involved or interested in volunteerism completed the full survey. Data were assessed using univariable analysis methods. RESULTS: Three percent (n = 1764) of those e-mailed answered the survey. Respondents were mostly men (82%), ≥50 years of age (61%), and general surgeons (70%). Fifty-three percent (n = 937) reported current or past volunteer activities, and 76.5% (n = 1349) were interested in activities within three years. Approximately 84% were interested in international volunteerism and 55% in domestic volunteerism. Few (5.7%) had both training and experience in emergency and disaster response, and only 17% had institutional salary support. Eighty-two percent wished to work with OGB, and 418 indicated organizations with whom they are involved could benefit from OGB collaboration. CONCLUSIONS: Interest in surgical volunteerism among ACS member survey respondents is high. OGB has the opportunity to meet member needs by developing programmatic activities, identifying volunteer prospects, facilitating multi-institutional consortia, and leading pre-deployment training. By maximizing volunteer efforts, OGB has the potential to foster sustainable and scalable ethical practices to improve basic access to surgical care globally.

The development and implementation of a layperson trauma first responder course in La Paz, Bolivia: A pilot study.

BACKGROUND: Ninety percent of nearly five million annual global injury deaths occur in low- and middle-income countries (LMICs), where prehospital care systems are frequently rudimentary or nonexistent. The World Health Organization considers layperson first-responders as essential for emergency medical services in low-resource settings lacking more formalized systems. This study sought to develop and implement a layperson trauma first responder course (TFRC) in Bolivia. MATERIALS AND METHODS: In March and April 2013 nine sessions of the eight-hour TFRC were held in La Paz, Bolivia. The course charged a nominal fee, and was led by an American surgeon and medical student. The TFRC built upon existing models with local stakeholder input, and included both didactic and practical components. Participants completed a baseline survey, and pre and posttests. The primary outcome was test performance, with secondary outcomes including demographic sub-group test score analyses and exam question validation. Data were assessed using nonparametric and psychometric methods RESULTS: One hundred fifty-nine individuals met study inclusion criteria. Participant median age was 28 (IQR 24, 36), 49.1% were male, 59.1% worked in a medical field, most had secondary (35.2%) or university (56.0%) level educations, and 67.3% had prior first aid training. Median test scores improved after course completion (48% vs. 76%, p <0.001), along with skill confidence (4 vs. 4.5, p <0.001). Most questions had appropriate item difficulty indices, point bi-serial correlation coefficients, and positive Pretest Posttest Difference Indices. Cronbach alpha coefficients for pre and posttest scores were 0.72 and 0.78, respectively. CONCLUSIONS: This study presents data from the first offering of an original TFRC for laypeople in Bolivia. Increased participant knowledge and skill confidence after course completion, and acceptable overall psychometric test properties, indicate this model is valid and effective. Future aims include TFRC revision, and enrollment of more layperson first responders to increase population-level impacts.

Assessment of Surgical and Trauma Capacity in Potosí, Bolivia.

BACKGROUND: Scaling up surgical and trauma care in low- and middle-income countries could prevent nearly 2 million annual deaths. Various survey instruments exist to measure surgical and trauma capacity, including Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT). OBJECTIVE: We sought to evaluate surgical and trauma capacity in the Bolivian department of Potosí using a combined PIPES and INTACT tool, with additional questions to further inform intervention targets. METHODS: In June and July 2014 a combined PIPES and INTACT survey was administered to 20 government facilities in Potosí with a minimum of 1 operating room: 2 third-level, 10 second-level, and 8 first-level facilities. A surgeon, head physician, director, or obstetrician-gynecologist completed the survey. Additional personnel responded to 4 short-answer questions. Survey items were divided into subsections, and PIPES and INTACT indices calculated. Medians were compared via Wilcoxon rank sum and Kruskal-Wallis tests. FINDINGS: Six of 20 facilities were located in the capital city and designated urban. Urban establishments had higher median PIPES (8.5 vs 6.7, P = .11) and INTACT (8.5 vs 6.9, P = .16) indices compared with rural. More than half of surgeons and anesthesiologists worked in urban hospitals. Urban facilities had higher median infrastructure and procedure scores compared with rural. Fifty-three individuals completed short-answer questions. Training was most desired in laparoscopic surgery and trauma management; less than half of establishments reported staff with trauma training. CONCLUSIONS: Surgical and trauma capacity in Potosí was most limited in personnel, infrastructure, and procedures at rural facilities, with greater personnel deficiencies than previously reported. Interventions should focus on increasing the number of surgical and anesthesia personnel in rural areas, with a particular focus on the reported desire for trauma management training. Results have been made available to key stakeholders in Potosí to inform targeted quality improvement interventions.

Assessing access to surgical care in Nepal via a cross-sectional, countrywide survey.

BACKGROUND: Adequate surgical care is lacking in many low- and middle-income countries because of diverse barriers preventing patients from reaching providers. We sought to assess perceived difficulties to accessing surgical care in Nepal using the Surgeons OverSeas Assessment of Surgical Need tool. METHODS: Fifteen of 75 Nepali districts were selected proportionate to the population, with 1,350 households surveyed. Household heads answered questions regarding access to health facilities, and 2 household members were interviewed for medical history. Continuous and categorical variables were analyzed via Wilcoxon rank sum test and Pearson χ(2) test. Multivariable logistic regressions for independent predictors of care access were performed controlling for age, sex, location, and literacy. RESULTS: Of respondents with a surgical condition (n = 1,342), 650 (48.4%) accessed care and 237 (17.7%) did not. Unadjusted analyses showed greater median travel times to all facilities (P < .001) and median transport costs to secondary and tertiary centers (P < .001) for those who did not access care versus those who did. Literate respondents were more likely to access care across all facilities and access variables in adjusted models (odds ratio 1.66-1.80, P < .01). Those without transport money were less likely to access care at any facility in all analyses (P < .01). CONCLUSION: The data project that at least 2.4 million individuals lack access to needed surgical care in Nepal during their lifetimes, with those not accessing health facilities having lower literacy rates and fewer transport resources. Promoting education, outreach programs, and transportation access could lessen barriers but will require further exploration.

Resident awareness of documentation requirements and reimbursement: a multi-institutional survey.

BACKGROUND: The current economic environment necessitates efforts to prevent avoidable losses in clinical revenue in academic cardiothoracic surgery programs. Inadequate documentation frequently results in delayed, denied, or reduced reimbursement. With the recent increase in integrated residency programs, documentation and compliance are becoming increasingly dependent on junior residents; however, their understanding of reimbursement and documentation guidelines is currently unknown. METHODS: An electronically distributed, multi-institutional survey of 6 general and subspecialty surgery programs was conducted consisting of open-ended numeric estimation of Medicare reimbursement for various levels of patient encounters. Closed-ended questions were used to assess resident knowledge of documentation requirements, accompanied by self-estimated compliance with those requirements. RESULTS: Thirty-seven percent (n = 106) of residents completed the survey. Most residents (77%) believe they play the primary role in documentation; however, knowledge of and compliance with higher level documentation practices range from 19% to 78% and 41% to 76%, respectively. On average, residents overestimate Medicare reimbursement of lower level encounters by as much as 77% and underestimate higher level encounters by as much as 38%. In many cases, the standard deviation of residents' estimates approaches the actual reimbursement value. CONCLUSIONS: Residents have a limited knowledge of documentation requirements. Self-reported compliance, even when guidelines are known, is low. Estimation of financial reimbursement is extremely variable. Residents overestimate reimbursement of lower level encounters and underappreciate reimbursement at higher levels. Ensuring appropriate reimbursement for services rendered will require formal cardiothoracic resident education and ongoing quality control.