What Proportion of East African Refugees Report Musculoskeletal Problems? A Cross-sectional Survey.

BACKGROUND: Musculoskeletal conditions are the leading cause of disability worldwide and disproportionally affect individuals in low-income and middle-income countries. There is a dearth of evidence on musculoskeletal problems among refugees, 74% of whom reside in low-income and middle-income countries. QUESTIONS/PURPOSES: (1) What proportion of refugees in Nyarugusu Camp, Kigoma, western Tanzania, are affected by musculoskeletal problems and what are the characteristics of those individuals? (2) What are the characteristics of these musculoskeletal problems, including their causes, location, and duration? (3) What forms of healthcare do those with musculoskeletal problems seek, including those for both musculoskeletal and nonmusculoskeletal problems? METHODS: We conducted a cross-sectional study among refugees in Nyarugusu Camp, using the Surgeons OverSeas Assessment of Surgical Need tool. The Surgeons OverSeas Assessment of Surgical Need tool is a validated population-based survey tool developed for use in limited-resource settings that is intended to determine the prevalence of surgical disease in a community. It uses a cluster random sampling methodology with house-to-house data collection in the form of a verbal head-to-toe examination that is performed by a trained community healthcare worker. A total of 99% responded, and 3574 records were analyzed. The mean age of respondents was 23 ± 18 years, with under 18 as the most-represented age group (44% [1563]). A total of 57% (2026) of respondents were women, 79% (2802 of 3536) were generally healthy, and 92% (3297 of 3570) had visited a camp medical facility. Only records endorsing musculoskeletal problems (extremity or back) were included in this analysis. Using all refugees surveyed as our denominator and refugees who endorsed a musculoskeletal problem (extremity or back) as the numerator, we calculated the proportion of refugees who endorsed a musculoskeletal problem. We then analyzed the characteristics of those endorsing musculoskeletal problems, including their healthcare-seeking behavior, and the characteristics of the musculoskeletal problems themselves. RESULTS: Among 3574 refugees interviewed, 22% (769) reported musculoskeletal problems, with 17% (609) reporting extremity problems and 7% (266) reporting back problems. Among all people surveyed, 8% (290) reported current extremity problems while 5% (188) reported current back problems. Among those reporting musculoskeletal problems, respondents younger than 18 years were the most-represented age group (28% [169 of 609]) whereas respondents between 30 and 44 years of age were the most-represented age group for back problems (29% [76 of 266]). Wounds from an injury or trauma (24% [133 of 557]) and acquired disability (24% [133 of 557]) were the most-common causes of extremity problems, whereas acquired disability (53% [97 of 184]) followed by a wound not from injury or trauma (25% [45 of 184]) were the most common causes of back problems. Fifty percent (303) of those with extremity problems characterized it as disabling, whereas 76% (203) of those with back problems did. CONCLUSION: Over one of five refugees endorsed musculoskeletal problems, which are most often caused by acquired disease and injury. These musculoskeletal problems are often characterized as disabling, yet only slightly more than half have sought treatment for problems. This warrants further research on care-seeking behavior in this setting, and emphasizes that investing in the spectrum of musculoskeletal health systems, including medical management and rehabilitation services, is critical to decreasing disability caused by musculoskeletal problems. LEVEL OF EVIDENCE: Level IV, prognostic study.

Untreated Surgical Problems Among East African Refugees: A Cluster Randomized, Cross-Sectional Study.

OBJECTIVE: The goal of this study was to estimate the prevalence of surgical conditions among refugees in East Africa. BACKGROUND: Surgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions in low- and middle-income countries. Despite numbering over 80 million people globally, forced migrant populations have often been neglected from this body of research. METHODS: We administered a validated survey using random cluster sampling to determine surgical need among refugees in western Tanzania. Primary outcome was history or presence of a surgical problem. Analysis included descriptive and multivariable logistic regression including an average marginal effects model. RESULTS: We analyzed data from 3,574 refugee participants in East Africa. A total of 1,654 participants (46.3%) reported a history or presence of at least one problem that may be surgical in nature. Of those 1,654 participants who did report a problem 1,022 participants (61.8%) reported the problem was still ongoing. Multivariable analysis revealed several factors associated with having a surgical problem (increasing age, occupation, illness within past year). CONCLUSION: To our knowledge, this is the first and largest population-based survey in estimating the prevalence of surgical disease among refugees in sub-Saharan Africa. Our results imply that more than one-in-four refugees has an ongoing surgical problem, suggesting over double the burden of surgical need in refugee populations compared to non-refugee settings.

Prevalence of pediatric surgical problems among east African refugees: estimates from a cross-sectional survey using random cluster sampling.

IMPORTANCE: Surgery is a foundational aspect to high functioning health care systems. In the wake of the Lancet Commission on Global Surgery, previous research has focused on defining the burden of surgical conditions among a pediatric population, however these studies often fail to include forced migrant or refugees. The goal of this study was to estimate the prevalence of pediatric surgical conditions among refugees in east Africa. METHODS: We used the previously validated Surgeons OverSeas Assessment of Surgical Need (SOSAS) that utilizes cross-sectional design with random cluster sampling to assess prevalence of surgical disease among participants aged 0 to 18 years in Nyarugusu refugee camp, Tanzania. We used descriptive and multivariable analyses including an average marginal effects model. RESULTS: A total of 1,658 participants were included in the study. The mean age of our sample was 8.3 ± 5.8 years. A total of 841 participants (50.7%) were male and 817 participants (49.3%) were female. A total of 513 (n = 30.9%) reported a history or presence of a problem that may be surgical in nature, and 280 (54.6%) of them reported the problem was ongoing or untreated. Overall, 16.9% had an ongoing problem that may be amenable to surgery. We found that increasing age and recent illness were associated with having a surgical problem on both our multivariable analyses. CONCLUSION: To our knowledge, this is the first and largest study of prevalence of surgical conditions among refugee children in sub-Saharan Africa. We found that over 16% (one-in-six) of refugee children have a problem that may be amenable to surgery. Our results provide a benchmark upon which other studies in conflict or post-conflict zones with refugee or forced migrant populations may be compared.

Epidemiology of surgery in a protracted humanitarian setting: a 20-year retrospective study of Nyarugusu Refugee Camp, Kigoma, Western Tanzania.

BACKGROUND: There are 80 million forcibly displaced persons worldwide, 26.3 million of whom are refugees. Many refugees live in camps and have complex health needs, including a high burden of non-communicable disease. It is estimated that 3 million procedures are needed for refugees worldwide, yet very few studies exist on surgery in refugee camps, particularly protracted refugee settings. This study utilizes a 20-year dataset, the longest dataset of surgery in a refugee setting to be published to date, to assess surgical output in a setting of protracted displacement. METHODS: A retrospective review of surgeries performed in Nyarugusu Camp was conducted using paper logbooks containing entries between November 2000 and September 2020 inclusive. Abstracted data were digitized into standard electronic form and included date, patient nationality, sex, age, indication, procedure performed, and anesthesia used. A second reviewer checked 10% of entries for accuracy. Entries illegible to both reviewers were excluded. Demographics, indication for surgery, procedures performed, and type of anesthesia were standardized for descriptive analysis, which was performed in STATA. RESULTS: There were 10,799 operations performed over the 20-year period. Tanzanians underwent a quarter of the operations while refugees underwent the remaining 75%. Ninety percent of patients were female and 88% were 18 years of age or older. Caesarean sections were the most common performed procedure followed by herniorrhaphies, tubal ligations, exploratory laparotomies, hysterectomies, appendectomies, and repairs. The most common indications for laparotomy procedures were ectopic pregnancy, uterine rupture, and acute abdomen. Spinal anesthesia was the most common anesthesia type used. Although there was a consistent increase in procedural volume over the study period, this is largely explained by an increase in overall camp population and an increase in caesarean sections rather than increases in other, specific surgical procedures. CONCLUSION: There is significant surgical volume in Nyarugusu Camp, performed by staff physicians and visiting surgeons. Both refugees and the host population utilize these surgical services. This work provides context to the surgical training these settings require, but further study is needed to assess the burden of surgical disease and the extent to which it is met in this setting and others.

Acute Care Surgery for Transplant Recipients: A National Survey of Surgeon Perspectives and Practices.

BACKGROUND: Transplant recipients are living longer than ever before, and occasionally require acute care surgery for nontransplant-related issues. We hypothesized that while both acute care surgeons (ACS) and transplant surgeons would feel comfortable operating on this unique patient population, both would believe transplant centers provide superior care. METHODS: To characterize surgeon perspectives, we conducted a national survey of ACS and transplant surgeons. Surgeon- and center-specific demographics were collected; surgeon preferences were compared using χ2, Fisher's exact, and Kruskal-Wallis tests. RESULTS: We obtained 230 responses from ACS and 204 from transplant surgeons. ACS and transplant surgeons believed care is better at transplant centers (78% and 100%), and transplant recipients requiring acute care surgery should be transferred to a transplant center (80.2% and 87.2%). ACS felt comfortable operating (97.5%) and performing laparoscopy (94.0%) on transplant recipients. ACS cited transplant medication use as the most important underlying cause of increased surgical complications for transplant recipients. Transplant surgeons felt it was their responsibility to perform acute care surgery on transplant recipients (67.3%), but less so if patient underwent transplant at a different institution (26.5%). Transplant surgeons cited poor transplanted organ resiliency as the most important underlying cause of increased surgical complications for transplant recipients. CONCLUSIONS: ACS and transplant surgeons feel comfortable performing laparoscopic and open acute care surgery on transplant recipients, and recommend treating transplant recipients at transplant centers, despite the lack of supportive evidence. Elucidating common goals allows surgeons to provide optimal care for this unique patient population.

Surgeon variation in operating times and charges for emergency general surgery.

BACKGROUND: Patients and hospitals face significant financial burdens from emergency general surgeries (EGSs), which have been termed a public health crisis in the United States. We evaluated hospitalization charges, operating charges, and variations in operating time by surgeon volume for three common EGS procedures. METHODS: Using Maryland's Health Services Cost Review Commission database, we performed a retrospective study of laparoscopic appendectomies, laparoscopic cholecystectomies, and open bowel resections performed by general surgeons among adult patients from July 2012 to September 2014. We compared operating charges to total hospitalization charges and quantified variations in operating time for each procedure. We then divided patients into quartiles based on their surgeon's procedure-specific case volume and used hierarchical linear regressions to calculate differences in both operating time and charges between quartiles. RESULTS: We identified 3194 appendectomies, 4143 cholecystectomies, and 1478 bowel resections. Operating charges accounted for one-quarter (26.9%) of total hospitalization charges and widespread variation existed in operating time (appendectomies: median 79 min [interquartile range 66-100 min], cholecystectomies: 96 min [76-125 min], bowel resections: 155 min [117-209 min]). After adjustment, low-volume surgeons relative to high-volume surgeons did not operate statistically longer for appendectomies (+1%, 95% confidence interval [CI]: -2% to 5%) but operated +16% (95% CI: 12%-20%) longer for cholecystectomies (+14 min) and +40% (95% CI: 30%-50%) longer for bowel resections (+59 min). Adjusted median operating charges from low-volume surgeons relative to high-volume surgeons were $554 (26.7%), $621 (22.0%), and $1801 (47.0%) greater for appendectomies, cholecystectomies, and bowel resections, respectively. CONCLUSIONS: Operating charges contributed substantially to total EGS hospitalization charges, where low-volume surgeons operated longer and had higher operative charges relative to high-volume surgeons. Reducing variations in operating times and charges represents an opportunity to alleviate the financial burden from EGS procedures.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures.

BACKGROUND: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. METHODS: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. RESULTS: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. CONCLUSIONS: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country. METHODS: We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a structured questionnaire. All patients ≥18 years of age, presenting with OHCA of cardiac origin, were included. Patients with do-not-resuscitate status or referred from other hospitals were excluded. Our primary outcome was survival of OHCA patients at the end of ED stay. RESULTS: During the three month period, data was obtained from 310 OHCA patients. The overall survival to ED discharge was 1.6 % which decreased to 0 % at 2-months after discharge. More than half (58.3 %) of these OHCA patients were brought to the hospital in a non-EMS (emergency medical service) vehicle i.e. public or private transportation. Patients utilizing non-EMS transportation reached the hospital earlier with a median time of 23 min compared to patients utilizing any type of ambulances which had a delay of 7 min hospital reaching time (median time 30 min). However, patients utilizing ambulances with life-support facilities, as compared to all other types of pre-hospital transportation, had the shortest time to first life-support intervention (15 min). Most of the patients (92.9 %) had a witnessed cardiac arrest out of which only a small percentage (2.3 %) received bystander CPR (cardio pulmonary resuscitation). Median time from arrest to receiving first CPR was 20 min. Only 1 % of patients were found to have a shockable rhythm on first assessment. CONCLUSION: This study showed that the overall survival of OHCA is null in this population. Lack of bystander CPR and weaker emergency medical services (EMS) leading to a delay in receiving life-support interventions were some of the important observations. Poor survival emphasizes the need to standardize EMS systems, initiate public awareness programs and strengthen links in the chain of survival.

A cross-sectional survey of emergency and essential surgical care capacity among hospitals with high trauma burden in a Central African country.

BACKGROUND: As the overwhelming surgical burden of injury and disease steadily increases, disproportionately affecting low- and middle-income countries, adequate surgical and trauma care systems are essential. Yet, little is known about the emergency and essential surgical care (EESC) capacity of facilities in many African countries. The objective of this study was to assess the EESC capacity in different types of hospitals across Cameroon. METHODS: This cross-sectional survey used the WHO Tool for Situational Analysis to Assess EESC, investigating four key areas: infrastructure, human resources, interventions, and equipment and supplies. Twelve hospitals were surveyed between August and September 2009. Facilities were conveniently sampled based on proximity to road traffic and sociodemographic composition of population served in four regions of Cameroon. To complete the survey, investigators interviewed heads of facilities, medical advisors, and nursing officers and consulted hospital records and statistics at each facility. RESULTS: Seven district hospitals, two regional hospitals, two general hospitals, and one missionary hospital completed the survey. Infrastructure for EESC was generally inadequate with the largest gaps in availability of oxygen concentrator supply, an on-site blood bank, and pain relief management guidelines. Human resources were scarce with a combined total of six qualified surgeons, seven qualified obstetrician/gynecologists, and no anesthesiologists at district, regional, and missionary hospitals. Of 35 surgical interventions, 16 were provided by all hospitals. District hospitals reported referring patients for 22 interventions. Only nine of the 67 pieces of equipment were available at all hospitals for all patients all of the time. CONCLUSIONS: Severe shortages highlighted by this survey demonstrate the significant gaps in capacity of hospitals to deliver EESC and effectively address the increasing surgical burden of disease and injury in Cameroon. This data provides a foundation for evidence-based decision-making surrounding appropriate allocation and provision of resources for adequate EESC in the country.

Emergency care of traumatic brain injuries in Pakistan: a multicenter study.

BACKGROUND: This study assessed factors associated with emergency care outcomes and out-of-pocket treatment costs in traumatic brain injury (TBI) patients in Pakistan. METHODS: Data on TBI patients were extracted from a four-month surveillance study conducted in the emergency departments (ED) of seven large teaching hospitals. Emergency care access to physicians and imaging facilities were compared with respect to ED outcomes (discharged, admitted or dead). Out-of-pocket treatment costs (in United States dollars [USD]) were compared among different patient strata. RESULTS: ED outcomes were available for 1,787 TBI patients. Of them, most were males (79%), aged <25 years (46%) and arrived by ambulances (32%). Nurses or paramedical staff saw almost all patients (95%). Physicians with practice privileges (medical officers, residents or consultants) saw about half (55%) of them. Computerized tomography (CT) scans were performed in two of five patients (40%). Of all, 26% (n = 460) were admitted and 3% died (n = 52). Emergency care factors significantly associated with being admitted or died were arriving by ambulance (adjusted odds ratio [aOR] = 2.37, 95% confidence interval (CI) [95%CI] = 1.78-3.16); seen by medical officer/residents (aOR = 2.11; 95%CI = 1.49-2.99); and had CT scan (aOR = 2.93; 95%CI = 2.25-3.83). Out-of-pocket treatment costs at the ED were reported in 803 patients. Average costs were USD 8, (standard deviation [SD] = 23). Costs were twice as high in those arriving in ambulances (USD 20, SD = 49) or who underwent CT scans (USD 16, SD = 37). CONCLUSION: TBI patients' access to ambulance transport, experienced physicians, and imaging facilities during emergency care needs to be improved in Pakistan.

Trauma systems in Kenya: a qualitative analysis at the district level.

Injury is a leading cause of death and disability in low- and middle-income countries. Kenya has a particularly high burden of injuries, accounting for 88.4 deaths per 100,000 population. Despite recent attempts to prioritize injury prevention in Kenya, trauma care systems have not been assessed. We assessed perceptions of formal and informal district-level trauma systems through 25 qualitative semi-structured interviews and 16 focus group discussions with Ministry of Health officials, district hospital administrators, health care providers, police, and community members. We used the principles of theoretical analysis to identify common themes of prehospital and hospital trauma care. We found prehospital care relied primarily on "good Samaritans" and police. We described hospital care in terms of human resources, infrastructure, and definitive care. The interviewers repeatedly emphasized the lack of hospital infrastructure. We showed the need to develop prehospital care systems and strengthen hospital trauma care services.

Is the Kampala trauma score an effective predictor of mortality in low-resource settings? A comparison of multiple trauma severity scores.

BACKGROUND: In the developed world, multiple injury severity scores have been used for trauma patient evaluation and study. However, few studies have supported the effectiveness of different trauma scoring methods in the developing world. The Kampala Trauma Score (KTS) was developed for use in resource-limited settings and has been shown to be a robust predictor of death. This study evaluates the ability of KTS to predict the mortality of trauma patients compared to other trauma scoring systems. METHODS: Data were collected on injured patients presenting to Central Hospital of Yaoundé, Cameroon from April 15 to October 15, 2009. The KTS, Injury Severity Score, Revised Trauma Score, Glasgow Coma Scale, and Trauma Injury Severity Score were calculated for each patient. Scores were evaluated as predictors of mortality using logistic regression models. Areas under receiver operating characteristic (ROC) curves were compared. RESULTS: Altogether, 2855 patients were evaluated with a mortality rate of 6 per 1000. Each score analyzed was a statistically significant predictor of mortality. The area under the ROC for KTS as a predictor of mortality was 0.7748 (95% CI 0.6285-0.9212). There were no statistically significant pairwise differences between ROC areas of KTS and other scores. Similar results were found when the analysis was limited to severe injuries. CONCLUSIONS: This comparison of KTS to other trauma scores supports the adoption of KTS for injury surveillance and triage in resource-limited settings. We show that the KTS is as effective as other scoring systems for predicting patient mortality.

Analysis of prospective trauma registry data in Francophone Africa: a pilot study from Cameroon.

INTRODUCTION: Injury rates in sub-Saharan Africa are among the highest in the world, but prospective, registry-based reports from Cameroon are limited. We aimed to create a prospective trauma registry to expand the data elements collected on injury at a busy tertiary center in Yaoundé Cameroon. METHODS: Details of the injury context, presentation, care, cost, and disposition from the emergency department (ED) were gathered over a 6-month period, by trained research assistants using a structured questionnaire. Bivariate and multivariate models were built to explore variable relationships and outcomes. RESULTS: There were 2,855 injured patients in 6 months, comprising almost half of all ED visits. Mean age was 30 years; 73 % were male. Injury mechanism was road traffic injury in 59 %, fall in 7 %, penetrating trauma in 6 %, and animal bites in 4 %. Of these, 1,974 (69 %) were discharged home, 517 (18 %) taken to the operating room, and 14 (1 %) to the intensive care unit. The body areas most severely injured were pelvis and extremity in 43 %, head in 30 %, chest in 4 %, and abdomen in 3 %. The estimated injury severity score (eISS) was <9 in 60 %, 9-24 in 35 %, and >25 in 2 %. Mortality was 0.7 %. In the multivariate analysis, independent predictors of mortality were eISS ≥9 and Glasgow Coma Score ≤12. Road traffic injury was an independent predictor for the need to have surgery. Trauma registry results were presented to the Ministry of Health in Cameroon, prompting the formation of a National Injury Committee. CONCLUSIONS: Injuries comprise a significant proportion of ED visits and utilization of surgical services in Yaoundé. A prospective approach allows for more extensive information. Thorough data from a prospective trauma registry can be used successfully to advocate for policy towards prevention and treatment of injuries.

Benchmarking of trauma care worldwide: the potential value of an International Trauma Data Bank (ITDB).

BACKGROUND: National trauma registries have helped improve patient outcomes across the world. Recently, the idea of an International Trauma Data Bank (ITDB) has been suggested to establish global comparative assessments of trauma outcomes. The objective of this study was to determine whether global trauma data could be combined to perform international outcomes benchmarking. METHODS: We used observed/expected (O/E) mortality ratios to compare two trauma centers [European high-income country (HIC) and Asian lower-middle income country (LMIC)] with centers in the North American National Trauma Data Bank (NTDB). Patients (≥16 years) with blunt/penetrating injuries were included. Multivariable logistic regression, adjusting for known predictors of trauma mortality, was performed. Estimates were used to predict the expected deaths at each center and to calculate O/E mortality ratios for benchmarking. RESULTS: A total of 375,433 patients from 301 centers were included from the NTDB (2002-2010). The LMIC trauma center had 806 patients (2002-2010), whereas the HIC reported 1,003 patients (2002-2004). The most important known predictors of trauma mortality were adequately recorded in all datasets. Mortality benchmarking revealed that the HIC center performed similarly to the NTDB centers [O/E = 1.11 (95% confidence interval (CI) 0.92-1.35)], whereas the LMIC center showed significantly worse survival [O/E = 1.52 (1.23-1.88)]. Subset analyses of patients with blunt or penetrating injury showed similar results. CONCLUSIONS: Using only a few key covariates, aggregated global trauma data can be used to adequately perform international trauma center benchmarking. The creation of the ITDB is feasible and recommended as it may be a pivotal step towards improving global trauma outcomes.

Facial modeling and measurement based upon homologous topographical features.

Measurement of human faces is fundamental to many applications from recognition to genetic phenotyping. While anthropometric landmarks provide a conventional set of homologous measurement points, digital scans are increasingly used for facial measurement, despite the difficulties in establishing their homology. We introduce an alternative basis for facial measurement, which 1) provides a richer information density than discrete point measurements, 2) derives its homology from shared facial topography (ridges, folds, etc.), and 3) quantifies local morphological variation following the conventions and practices of anatomical description. A parametric model that permits matching a broad range of facial variation by the adjustment of 71 parameters is demonstrated by modeling a sample of 80 adult human faces. The surface of the parametric model can be adjusted to match each photogrammetric surface mesh generally to within 1 mm, demonstrating a novel and efficient means for facial shape encoding. We examine how well this scheme quantifies facial shape and variation with respect to geographic ancestry and sex. We compare this analysis with a more conventional, landmark-based geometric morphometric (GMM) study with 43 landmarks placed on the same set of scans. Our multivariate statistical analysis using the 71 attribute values separates geographic ancestry groups and sexes with a high degree of reliability, and these results are broadly similar to those from GMM, but with some key differences that we discuss. This approach is compared with conventional, non-parametric methods for the quantification of facial shape, including generality, information density, and the separation of size and shape. Potential uses for phenotypic and dysmorphology studies are also discussed.

Increasing Injury Intensity among 6,500 Violent Deaths in the State of Maryland.

BACKGROUND: Anecdotal evidence strongly suggests there has been a rise in violent crimes. This study sought to examine trends in injury characteristics of homicide victims in Maryland. We hypothesized that there would be an increase in the severity of wound characteristics. STUDY DESIGN: The Office of the Chief Medical Examiner is a statewide agency designated by law to investigate all homicides, suicides, or unusual or suspicious circumstances. Using individual autopsy reports, we collected data among all homicides from 2005 to 2017, categorizing them into 3 time periods: 2005 to 2008 (early), 2009 to 2013 (mid), and 2014 to 2017 (late). Primary outcomes included the number of gunshots, stabs, and fractures from assaults. High-violence intensity outcomes included victims having 10 or more gunshots, 5 or more stabs, or 5 or more fractures from assaults. RESULTS: Of 6,500 homicides (annual range 403 to 589), the majority were from firearms (75%), followed by stabbings (14%) and blunt assaults (10%). Most homicide victims died in the hospital (60%). The average number of gunshots per victim was 3.9 (range 1 to 54), stabs per victim was 9.4 (range 1 to 563), and fractures from assaults per victim was 3.7 (range 0 to 31). The proportion of firearm victims with at least 10 gunshots nearly doubled from 5.7% in the early period to 10% (p < 0.01) in the late period. Similarly, the proportion with 5 or more stabbings increased from 39% to 50% (p = 0.02) and assault homicides with 5 or more fractures increased from 24% to 38% (p < 0.01). CONCLUSIONS: In Maryland, the intensity of violence increased across all major mechanisms of homicide. Further follow-up studies are needed to elucidate the root causes underlying this escalating trend.

Access to Health Services Among Forced Migrants in Tanzania: A Cluster Randomized Cross Sectional Study of 3560 Congolese and Burundian Refugees.

Despite significant advances in the understanding of the global burden of surgical disease, limited research focuses on access to health and surgical services among refugees, especially in east Africa. The goal of this study was to describe patterns of access to transportation to health services among Congolese and Burundian refugees in Tanzania. We utilized cluster random sampling to perform a large, cross-sectional study in Nyarugusu refugee camp, Tanzania using an adapted version of the Surgeon Overseas Assessment Tool (SOSAS). We randomly selected 132 clusters out of 1472 clusters, randomly selected two people from all households in those clusters. Data analysis was performed in STATA (Stata Version 16, College Station, TX). A total of 3560 participants were included in the study including 1863 Congolese refugees and 1697 Burundian refugees. The majority of refugees reported they were generally healthy (n = 2792, 79.3%). The most common period of waiting to be seen at the health center was between three and 5 h (n = 1502, 45.8%), and over half of all refugees waited between 3 and 12 h to be seen. There was heterogeneity in other intra-camp referral networks (e.g. to and from traditional healer and hospital). Finally, a low percentage (3%) of participants reported leaving the refugee camp to seek health care elsewhere, and Congolese refugees were more likely to pursue self-referral in this manner. To our knowledge, this is the largest study focused on access to transportation among refugees in Tanzania and sub-Saharan Africa. Most participants reported financial difficulty always affording transportation costs with significant wait times occurring once arrived at the hospital. Our study does suggest that some independent health care seeking did occur outside of the camp-based services. Future research may focus more specifically on barriers to timely servicing of patients and patterns of self-referral.Please confirm if the author names are presented accurately and in the correct sequence (given name, middle name/initial, family name). Author 1 Given name: [Zachary Obinna] Last Name [Enumah] and Author 2 Given name: [Mohamed Yunus] Last Name [Rafiq]. Also, kindly confirm the details in the metadata are correct.Confirmed.

Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery.

BACKGROUND: Hemorrhage control surgery is an essential trauma center function. Airway management of the unstable bleeding patient in the emergency department (ED) presents a challenge. Premature intubation in the ED can exacerbate shock and precipitate extremis. We hypothesized that ED versus operating room intubation of patients requiring urgent hemorrhage control surgery is associated with adverse outcomes at the patient and hospital-levels. METHODS: Patients who underwent hemorrhage control within 60 minutes of arrival at level 1 or 2 trauma centers were identified (National Trauma Data Bank 2017-2019). To minimize confounding, patients dead on arrival, undergoing ED thoracotomy, or with clinical indications for intubation (severe head/neck/face injury or Glasgow Coma Scale score of ≤8) were excluded. Two analytic approaches were used. First, hierarchical logistic regression measured the risk-adjusted association between ED intubation and mortality. Secondary outcomes included ED dwell time, units of blood transfused, and major complications (cardiac arrest, acute respiratory distress syndrome, acute kidney injury, sepsis). Second, a hospital-level analysis determined whether hospital tendency ED intubation was associated with adverse outcomes. RESULTS: We identified 9,667 patients who underwent hemorrhage control surgery at 253 trauma centers. Patients were predominantly young men (median age, 33 years) who suffered penetrating injuries (71%). The median initial Glasgow Coma Scale and systolic blood pressure were 15 and 108 mm Hg, respectively. One in five (20%) of patients underwent ED intubation. After risk-adjustment, ED intubation was associated with significantly increased odds of mortality, longer ED dwell time, greater blood transfusion, and major complications. Hospital-level analysis identified significant variation in use of ED intubation between hospitals not explained by patient case mix. After risk adjustment, patients treated at hospitals with high tendency for ED intubation (compared with those with low tendency) were significantly more likely to suffer in-hospital cardiac arrest (6% vs. 4%; adjusted odds ratio, 1.46; 95% confidence interval, 1.04-2.03). CONCLUSION: Emergency department intubation of patients who require urgent hemorrhage control surgery is associated with adverse outcomes. Significant variation in ED intubation exists between trauma centers not explained by patient characteristics. Where feasible, intubation should be deferred in favor of rapid resuscitation and transport to the operating room. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

Patterns, procedures, and indications for pediatric surgery in a Tanzanian Refugee Camp: a 20-year experience.

Background: There are 103 million displaced people worldwide, 41% of whom are children. Data on the provision of surgery in humanitarian settings are limited. Even scarcer is literature on pediatric surgery performed in humanitarian settings, particularly protracted humanitarian settings. Methods: We reviewed patterns, procedures, and indications for pediatric surgery among children in Nyarugusu Refugee Camp using a 20-year retrospective dataset. Results: A total of 1221 pediatric surgical procedures were performed over the study period. Teenagers between the ages of 12 and 17 years were the most common age group undergoing surgery (n=991; 81%). A quarter of the procedures were performed on local Tanzanian children seeking care in the camp (n=301; 25%). The most common procedures performed were cesarean sections (n=858; 70%), herniorrhaphies (n=197; 16%), and exploratory laparotomies (n=55; 5%). Refugees were more likely to undergo exploratory laparotomy (n=47; 5%) than Tanzanian children (n=7; 2%; p=0.032). The most common indications for exploratory laparotomy were acute abdomen (n=24; 44%), intestinal obstruction (n=10; 18%), and peritonitis (n=9; 16%). Conclusions: There is a significant volume of basic pediatric general surgery performed in the Nyarugusu Camp. Services are used by both refugees and local Tanzanians. We hope this research will inspire further advocacy and research on pediatric surgical services in humanitarian settings worldwide and illuminate the need for including pediatric refugee surgery within the growing global surgery movement.

Unintentional injuries: magnitude, prevention, and control.

The World Health Organization estimates injuries accounted for more than 5 million deaths in 2004, significantly impacting the global burden of disease. Nearly 3.9 million of these deaths were due to unintentional injury, a cause also responsible for more than 138 million disability-adjusted life years (DALYs) lost in the same year. More than 90% of the DALYs lost occur in low- and middle-income countries (LMICs), highlighting the disproportionate burden that injuries place on developing countries. This article examines the health and social impact of injury, injury data availability, and injury prevention interventions. By proposing initiatives to minimize the magnitude of death and disability due to unintentional injuries, particularly in LMICs, this review serves as a call to action for further investment in injury surveillance, prevention interventions, and health systems strengthening.