Evaluating Global Surgery Partnerships From Low and Middle Income Country Perspectives.

INTRODUCTION: Little is known about perceptions of low-income and middle-income country (LMIC) partners regarding global surgery collaborations with high-income countries (HICs). METHODS: A survey was distributed to surgeons from LMICs to assess the nature and perception of collaborations, funding, benefits, communication, and the effects of COVID-19 on partnerships. RESULTS: We received 19 responses from LMIC representatives in 12 countries on three continents. The majority (83%) had participated in collaborations within the past 5 y with 39% of collaborations were facilitated virtually. Clinical and educational partnerships (39% each) were ranked most important by respondents. Sustainability of the partnership was most successfully achieved in domains of education/training (78%) and research (61%). The majority (77%) of respondents reported expressing their needs before HIC team arrival. However, 54% of respondents were the ones to initiate the conversation and only 47% said HIC partners understood the overall environment well at arrival to LMIC. Almost all participants (95%) felt a formal process of collaboration and a structured partnership would benefit all parties in assessing needs. During the COVID-19 pandemic, 87% of participants reported continued collaborations; however, 44% of partners felt that relationships were weaker, 31% felt relationships were stronger, and 25% felt they were unchanged. CONCLUSIONS: Our study provides a snapshot of LMIC surgeons' perspectives on collaboration in global surgery. Independent of location, LMIC partners cite inadequate structure for long-term collaborations. We propose a formal pathway and initiation process to assess resources and needs at the outset of a partnership.

Picture Cards Versus Physical Examination: A Proof-of-Concept Study to Improve the SOSAS Survey Tool.

INTRODUCTION: The Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool is used to determine the unmet surgical needs in the community and has been validated in several countries. A major weakness is the absence of an objective assessment to verify patient-reported surgically treatable conditions. The goal of this study was to determine whether a picture portfolio, a tool previously shown to improve parental recognition of their child's congenital deformity, could improve the accuracy of the SOSAS tool by how it compares with physical examination. This study focused on children as many surgical conditions in them require prompt treatment but are often not promptly diagnosed. METHODS: We conducted a descriptive cross-sectional community-based study to determine the prevalence of congenital and acquired surgical conditions among children and adults in a mixed rural-urban area of Lagos, Southwest Nigeria. The picture portfolio was administered only to children and the surgical conditions to be assessed were predetermined using an e-Delphi process among pediatric surgeons. The modified The Surgeons OverSeas Assessment of Surgical Needs-Nigeria Survey Tool (SOSAS-NST) was administered to household members to collect other relevant data. Data were analyzed using the REDCap analytic tool. RESULTS: Eight hundred and fifty-six households were surveyed. There were 1984 adults (49.5%) and 2027 children (50.5%). Thirty-six children met the predetermined criteria for the picture portfolio-hydrocephalus (n = 1); lymphatic malformation (n = 1); umbilical hernia (n = 14); Hydrocele (n = 5); inguinal hernia (n = 10) and undescended testes (n = 5). The picture portfolio predicted all correctly except a case of undescended testis that was mistaken for a hernia. The sensitivity of the picture portfolio was therefore 35/36 or 97.2%. CONCLUSIONS: The SOSAS-NST has improved on the original SOSAS tool and within the limits of the small numbers, the picture portfolio has a high accuracy in predicting diagnosis in children in lieu of physical examination.

The Impact of Global Collaboration on the Academic Focus of the West African College of Surgeons: Are Worldwide Efforts Aligning with Local Priorities?

BACKGROUND: Global collaboration has the potential to induce a shift in research focus away from the priorities of those in low- and low-middle-income countries (LICs and LMICs). This study quantified international collaboration among surgery publications by Fellows of the West African College of Surgeons (WACS) and investigated if collaboration with upper-middle-income and high-income countries (UMICs and HICs) decreases the homophily of research focus. METHODS: Publications by WACS surgery Fellows from 1960 to 2019 were characterized as local WACS publications, collaborative publications without UMIC/HIC participation, or collaborative publications with UMIC/HIC participation. Research topics were determined for each publication, and topic percentages were compared between collaboration groups. RESULTS: We analyzed 5065 publications. Most (3690 publications, 73%) were local WACS publications, while 742 (15%) were collaborative publications with UMIC/HIC participation and 633 (12%) were collaborative publications without UMIC/HIC participation. UMIC/HIC collaborations contributed to 49% of the increase (378 out of 766 publications) from 2000 to 2019. Topic homophily was significantly lower between local WACS publications and collaborations with UMIC/HIC participation (differed in nine research topics) than it was between local WACS publications and collaborations without UMIC/HIC participation (differed in two research topics). CONCLUSIONS: Publications without international collaboration comprise most WACS research, but the rate of UMIC/HIC collaborations is rapidly increasing. We found that UMIC/HIC collaborations decreased the homophily of topic focus in WACS publications, indicating that global collaborations need to have greater emphasis on the priorities of those in LICs and LMICs.

Surgeons, Infectious Diseases, and Twitter Hit a Home Run for Antibiotic Stewardship.

Many infectious diseases (ID) clinicians join Twitter to follow other ID colleagues or "like" people. While there is great value in engaging with people who have similar interests, there is equal value in engaging with "unlike" or non-ID people. Here, we describe how Twitter connected an ID pharmacist with a pediatric surgeon, a vice chair of surgery, a surgeon chief medical officer from Spain, and a surgical intensive care unit pharmacist. This Twitter collaboration resulted in several scholarly activities related to antibiotic resistance and antibiotic stewardship and served as a conduit for global collaboration.

Virtual curriculum delivery in the COVID-19 era: the pediatric surgery boot camp v2.0.

PURPOSE: We evaluated the impact of a virtual Pediatric Surgery Bootcamp curriculum on resource utilization, learner engagement, knowledge retention, and stakeholder satisfaction. METHODS: A virtual curriculum was developed around Pediatric Surgery Milestones. GlobalCastMD delivered pre-recorded and live content over a single 10-h day with a concluding social hour. Metrics of learner engagement, faculty interaction, knowledge retention, and satisfaction were collected and analyzed during and after the course. RESULTS: Of 56 PS residencies, 31 registered (55.4%; 8/8 Canadian and 23/48 US; p = 0.006), including 42 learners overall. The virtual BC budget was $15,500 (USD), 54% of the anticipated in-person course. Pre- and post-tests were administered, revealing significant knowledge improvement (48.6% [286/589] vs 66.9% [89/133] p < 0.0002). Learner surveys (n = 14) suggested the virtual BC facilitated fellowship transition (85%) and strengthened peer-group camaraderie (69%), but in-person events were still favored (77%). Program Directors (PD) were surveyed, and respondents (n = 22) also favored in-person events (61%). PDs not registering their learners (n = 7) perceived insufficient value-added and concern for excessive participants. CONCLUSIONS: The virtual bootcamp format reduced overall expenses, interfered less with schedules, achieved more inclusive reach, and facilitated content archiving. Despite these advantages, learners and program directors still favored in-person education. LEVEL OF EVIDENCE: III.

Complications of traditional bonesetting in contemporary fracture care in low- and middle-income countries: A systematic review.

OBJECTIVE: To provide an overview of the evidence on the prevalence and pattern of complications among patients treated by traditional bonesetting presenting for modern orthopaedic services in low- and middle-income countries (LMIC). METHODS: Systematic review following PRISMA guidelines. Articles were identified by searching PubMed, Embase, ScienceDirect, SCOPUS, and Web of Science using the keywords "fracture care", "traditional bonesetters" and "complications". Papers included for review were original articles set in an LMIC that directly reported the prevalence and pattern of musculoskeletal complications of traditional bonesetters' fracture treatment in LMIC settings. RESULTS: A total of 176 papers were screened for eligibility and 15 studies were finally included. Nine were prospective studies, six were retrospective studies. All were hospital-based, observational studies that investigated the outcomes of treatment of fractures by traditional bonesetters published between 1986 and 2018. In total, this review covers 1389 participants with 1470 complications of fracture treatment. CONCLUSION: Traditional bonesetting complications are associated with significant morbidity. However, traditional bonesetters have the potential to contribute positively to primary fracture care when they are trained.

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.

Global Surgery Pro-Con Debate: A Pathway to Bilateral Academic Success or the Bold New Face of Colonialism?

Global surgery, especially academic global surgery, is of tremendous interest to many surgeons. Classically, it entails personnel from high-income countries going to low- and middle-income countries and engaging in educational activities as well as procedures. Academic medical personnel have included students, residents, and attendings. The pervasive notion is that this is a win-win situation for the volunteers and the hosts, that is, a pathway to bilateral academic success. However, a critical examination demonstrates that it can easily become the bold new face of colonialism of a low- and middle-income country by a high-income country.

Ethics in Global Pediatric Surgery: Existing Dilemmas and Emerging Challenges.

The rapid growth of global pediatric surgery beyond direct care delivery into research, education, and advocacy necessitates re-evaluation of the traditional ethical paradigms which have governed our partnerships in low- and middle-income countries (LMIC). Within this paper, we consider current and emerging ethical challenges and discuss principles to consider in order to promote autonomous systems for pediatric surgical care in LMIC.

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.

Attrition in general surgery residency: can global and rural surgery shift the paradigm?

General surgery is one of the more popular career choices among medical students worldwide. An alarming one in five general surgery residents, however, abandon residency training-a rate that is much higher than most other medical and surgical specialities. We believe that additional measures are needed to decrease attrition and increase "grit" among house staff. Specifically, the diversification of the surgery training experience to include global and rural surgery may help mitigate burnout among surgical house staff.

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.

Guidelines and checklists for short-term missions in global pediatric surgery: Recommendations from the American Academy of Pediatrics Delivery of Surgical Care Global Health Subcommittee, American Pediatric Surgical Association Global Pediatric Surgery Committee, Society for Pediatric Anesthesia Committee on International Education and Service, and American Pediatric Surgical Nurses Association, Inc. Global Health Special Interest Group.

Pediatric surgeons, anesthesia providers, and nurses from North America and other high-income countries are increasingly engaged in resource-limited areas, with short-term missions as the most common form of involvement. However, consensus recommendations currently do not exist for short-term missions in pediatric general surgery and associated perioperative care. The American Academy of Pediatrics (AAP) Delivery of Surgical Care Subcommittee and American Pediatric Surgical Association (APSA) Global Pediatric Surgery Committee, with the American Pediatric Surgical Nurses Association, Inc. (APSNA) Global Health Special Interest Group, and the Society for Pediatric Anesthesia (SPA) Committee on International Education and Service generated consensus recommendations for short-term missions based on extensive experience with short-term missions. Three distinct, but related areas were identified: (i) Broad goals of surgical partnerships between high-income countries and low- and middle-income countries. A previous set of guidelines published by the Global Paediatric Surgery Network Collaborative (GPSN) was endorsed by all groups; (ii) Guidelines for the conduct of short-term missions were developed, including planning, in-country perioperative patient care, post-trip follow-up, and sustainability; and (iii) travel and safety considerations critical to short-term mission success were enumerated. A diverse group of stakeholders developed these guidelines for short-term missions in low- and middle-income countries. These guidelines may be a useful tool to ensure safe, responsible, and ethical short-term missions given increasing engagement of high-income country providers in this work.

Surgical site infection after stoma closure in children: outcomes and predictors.

BACKGROUND: Surgical site infection (SSI) is a burdensome complication following intestinal stoma closure, with reported rates ranging from 0% to 40%. We aimed to identify risk factors for SSI in children undergoing stoma closure. MATERIALS AND METHODS: Using 2012-2014 NSQIP Pediatric data, we identified patients aged 0-18 years undergoing stoma closure. Demographic, clinical, and 30-day outcome characteristics between children with and without SSI were compared. A multivariable logistic model was used to identify predictors of SSI. RESULTS: Among 2110 children who underwent stoma closure, 7.6% developed SSI. Patients who developed SSI had significantly longer time in the operating room, longer anesthesia times, longer total operation times, and longer lengths of stay (all P ≤ 0.01). Patients who developed SSI postoperatively had significantly higher rates of postoperative complications, including need for postoperative ventilation, sepsis, need for nutritional support on discharge, unplanned reoperation, unplanned readmission, postoperative lengths of stay >30 days, and transfusion within 72 hours after the start of surgery (all P ≤ 0.018). There was a significant relationship between operation time and SSI probability. Specifically, operation time greater than 105 minutes was associated with a higher SSI risk. On adjusted multivariable analyses, age, cardiac risk factors, Hirschsprung disease, and operation time greater than 105 minutes were independently predictive of SSI. CONCLUSIONS: Longer operation time, age, Hirschsprung disease, and cardiac risk factors are associated with an increased risk for SSI after stoma closure. Studies of perioperative adjuncts to reduce SSI in high-risk children based on expected procedure length and other preoperative characteristics are warranted.

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.

Neonatal surgery in Africa: a systematic review and meta-analysis of challenges of management and outcome.

BACKGROUND: Advances in diagnostic techniques and perioperative care have greatly improved the outcome of neonatal surgery. Despite this, disparity still exists in the outcome of neonatal surgery between high-income countries and low-income and middle-income countries. This study reviews publications on neonatal surgery in Africa over 20 years with a focus on challenges of management, trends in outcome, and potential interventions to improve outcome. METHODS: We did a literature review by searching PubMed and African Index Medicus for original articles published in any language between January, 1995, and September, 2014, with the search terms "neonatal surgery" and "Africa", further supplemented by "(surgery OR anaesthesia) AND (neonatal OR newborn) AND (developing countries OR Africa)". A data extraction sheet was used to collect information, including type of study, demographics, number of cases, outcome, challenges, and suggestions to improve outcome. For the meta-analysis, data were analysed by χ(2) test or Student's t-test as appropriate. In all, the significance level was set to p<0·05. FINDINGS: We identified 859 published papers, of which 51 studies from 11 countries met the inclusion criteria. The 16 studies in the first 10 years (before 2005; group A) were compared with the 35 in the last 10 years (2005-14; group B). Nigeria (n=32; 62·7%), South Africa (n=7; 13·7%), Tanzania (n=2; 3·9%), and Tunisia (n=2; 3·9%) were the predominant source of the publications, of which were retrospective in 38 (74·5%) studies and prospective in 13 (25·5%) studies. The mean sample size of the studies was 97·8 (range 5-640). Overall, 4989 neonates were studied, with median age of 6 days (range 1-30). Common neonatal conditions reported were intestinal atresia in 28 (54·9%) studies, abdominal wall defects in 27 (52·9%), anorectal malformations in 24 (47·1%), and Hirschsprung's disease, necrotising enterocolitis, and volvulus neonatorum in 23 (45·1%) each. Mortality was lowest (<3%) in spina bifida and facial cleft procedures, and highest (>50%) in emergency neonatal surgeries involving bowel perforation, bowel resection, congenital diaphragmatic hernia, oesophageal atresia, and ruptured omphalocele or gastroschisis. Overall average mortality rate was higher in group A than in group B (36·9% vs 29·1%; p<0·001), but mortality did not vary between the groups for similar neonatal conditions. The major documented challenges were delayed presentation and inadequate facilities in 39 (76·5%) studies, dearth of trained support personnel in 32 (62·7%), and absence of neonatal intensive care in 29 (56·9%). The challenges varied from country to country but did not differ in the two groups. INTERPRETATION: Improvement has been achieved in outcomes of neonatal surgery in Africa in the past two decades, although several of the studies reviewed are retrospective and poorly designed. Cost-effective adaptations for neonatal intensive care, improved health-care funding, coordinated neonatal surgical care via regional centres, and collaboration with international partners are potential interventions that could help to address the challenges and further improve outcome. FUNDING: None.

Surgical need in an ageing population: a cluster-based household survey in Nepal.

BACKGROUND: With an ageing global population comes major non-communicable disease burden, especially in low-income and middle-income countries. An unknown proportion of this burden is treatable or palliated with surgery. This study aimed to estimate the surgical needs of individuals aged 50 years or older in Nepal. METHODS: A two-stage, 30 randomised cluster by 30 households, community-based survey was performed in Nepal with the validated Surgeons OverSeas Assessment of Surgical Need (SOSAS). Respondents aged older than 50 years were included. After verbal informed consent was obtained, SOSAS collected household demographics, completed a verbal autopsy, and randomly selected household members for verbal head-to-toe examinations for surgical conditions. The Nepal Health Research Council in Kathmandu and the Nationwide Children's Hospital in Columbus, OH, USA, granted ethical approval. FINDINGS: The survey sampled 1350 households, totalling 2695 individuals (97% response rate); 49% were aged 50-59 years, 33% were 60-69 years, and 17% were 70 years and older. Of these, 273 surgical conditions were reported by 507 individuals. A growth or mass (including hernias and goiters) was the most commonly reported potentially surgical condition (25%), injuries and fractures were also common and had the greatest disability. Acquired deformities (13%), incontinence (11%), non-injury wounds (9%), and pelvic organ prolapse were also prevalent. Together, head and neck (24%) and back and extremity conditions (32%) were responsible for more than half of the conditions potentially treatable with surgery. These were followed by genitourinary (28%), abdominal (14%) and chest and breast conditions (2%). Extrapolated nationwide, roughly 1·25 million elderly individuals have a surgically treatable condition (32 150 per 100 000 people). There were 108 deaths in the year before to the survey. 20 (19%) were potentially preventable with surgery. Half of the deaths were due to a growth or mass, 20% to injury, 20% to abdominal pain or distension, and 10% to a non-injury wound. The age-standardised death rate of those with a potentially surgical condition was 24 per 1000 persons for individuals in their 6th decadte, 60 per 1000 for those in their 7th, and 44 per 1000 for those in their 8th. One in five deaths were potentially treatable or palliated by surgery. Literacy and distance to secondary and tertiary health facilities were associated with not receiving care for surgical conditions (p<0·05). INTERPRETATION: Surgical need is largely unmet among elderly individuals in Nepal. Literacy and distance from a capable health facility are the greatest barriers to care. Although verbal examination findings were used as proxies for surgical conditions, the survey tool has been previously validated. Also, there is potential for recall bias with overestimation of tragic deaths and underestimation of unknown or forgotten surgical causes of death and disease. However, this is the most comprehensive evaluation of surgical need in a developing country among the elderly. As the global population ages, there is an increasing need to improve access to surgical services and strengthen health systems to care for this group. FUNDING: The Association for Academic Surgery, Surgeons OverSeas, and the Fogarty International Center.

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.