Dual-Lumen Stenting of Dissected Superior Mesenteric Artery During Fenestrated Branched Endovascular Repair of a Post-dissection Thoracoabdominal Aortic Aneurysm.

PURPOSE: Long-segment aortic branch dissections have been considered a relative contraindication for fenestrated-branched endovascular aneurysm repair (FB-EVAR). This case report describes a technique of dual-lumen stenting of a fully-dissected superior mesenteric artery (SMA) to preserve patency of the true and false lumens during FB-EVAR. CASE REPORT: A 67-year-old man presented with a 6.0 cm extent III chronic post-dissection thoracoabdominal aortic aneurysm. The patient had highly-complex anatomy including dissection of the entire SMA. The true and false lumens of the dissected SMA were noted to be supplying different branches, requiring preservation of both lumens. The patient underwent a staged physician-modified FB-EVAR. A modified endograft containing 5 fenestrations and 1 branch cuff was introduced and the celiac, true-lumen SMA, and 3 renal arteries were sequentially catheterized using staggered deployment of the modified endograft. The false lumen SMA stent was catheterized via the branch cuff. Molded parallel grafting ("eye-of-the-tiger") technique was used to achieve double D configuration between the true and false lumens of the SMA. CONCLUSION: This case demonstrates feasibility of dual-lumen stenting to incorporate dissected target vessels during FB-EVAR while preserving flow to both the true and false lumens and the second-order branches they supply. CLINICAL IMPACT: We report a novel technique that allows incorporation of branch vessels affected by long segment dissection during fenestrated branched endovascular aortic repairs. This has potential advantage of preserving flow to all secondary branches of the dissected target vessels, while reducing the risk of type Ic endoleak.

Functional recovery after cesarean delivery: a prospective cohort study in rural Rwanda.

INTRODUCTION: Women who deliver via cesarean section (c-section) experience short- and long-term disability that may affect their physical health and their ability to function normally. While clinical complications are assessed, postpartum functional outcomes are not well understood from a patient's perspective or well-characterized by previous studies. In Rwanda, 11% of rural women deliver via c-section. This study explores the functional recovery of rural Rwandan women after c-section and assesses factors that predict poor functionality at postoperative day (POD) 30. METHODS: Data were collected prospectively on POD 3, 11, and 30 from women delivering at Kirehe District Hospital between October 2019 and March 2020. Functionality was measured by self-reported overall health, energy level, mobility, self-care ability, and ability to perform usual activities; and each domain was rated on a 4-point likert scale, lower scores reflecting higher level of difficulties. Using the four functionality domains, we computed composite mean scores with a maximum score of 4.0 and we defined poor functionality as composite score of ≤ 2.0. We assessed functionality with descriptive statistics and logistic regression. RESULTS: Of 617 patients, 54.0%, 25.9%, and 26.8% reported poor functional status at POD3, POD11, and POD30, respectively. At POD30, the most self-reported poor functionality dimensions were poor or very poor overall health (48.1%), and inability to perform usual activities (15.6%). In the adjusted model, women whose surgery lasted 30-45 min had higher odds of poor functionality (aOR = 1.85, p = 0.01), as did women who experienced intraoperative complications (aOR = 4.12, 95% CI (1.09, 25.57), p = 0.037). High income patients had incrementally lower significant odds of poor physical functionality (aOR = 0.62 for every US$1 increase in monthly income, 95% CI (0.40, 0.96) p = 0.04). CONCLUSION: We found a high proportion of poor physical functionality 30 days post-c-section in this Rwandan cohort. Surgery lasting > 30 min and intra-operative complications were associated with poor functionality, whereas a reported higher income status was associated with lower odds of poor functionality. Functional status assessments, monitoring and support should be included in post-partum care for women who delivered via c-section. Effective risk mitigating intervention should be implemented to recover functionality after c-section, particularly among low-income women and those undergoing longer surgical procedures or those with intraoperative complications.

Analysis of authorship trends in vascular surgery demonstrates a sticky surgical floor for women.

OBJECTIVE: Prior research in vascular surgery has identified significant gender disparities in leadership positions, but few data exist regarding gender disparities in vascular publications. This study aims to evaluate authorship trends by gender in the three highest impact factor vascular surgery journals. METHODS: In this bibliometric analysis, PubMed was searched for articles published in the European Journal of Vascular and Endovascular Surgery, the Journal of Vascular Surgery, and Annals of Vascular Surgery from 2015 to 2019. The web-based application Genderize used predictive algorithms to classify names of first and last authors as male or female. Statistical analyses regarding trends in authorship were performed using Stata16. RESULTS: A total of 6457 articles were analyzed, with first author gender predicted with >90% confidence in 83% (4889/5796) and last author gender in 88% (5078/5796). Overall, 25% (1223/4889) of articles had women first authors, and 10% (501/5078) had women last authors. From 2015 to 2019, there was a slight increase in the proportion of articles written by women first authors (P = .001), but no increase in the proportion of articles written by women last authors (P = .204). The proportion of articles written by women last authors was lower than the proportion of active women vascular surgeons in 2015 (8% of articles vs 11% of surgeons; P = .015), 2017 (9% of articles vs 13% of surgeons; P < .001), and 2019 (11% of articles vs 15% of practicing surgeons; P < .001). The average number of last-author publications was higher for men (2.35 ± 3.76) than for women (1.62 ± 1.88, P = .001). The proportion of unique authors who were women was less than the proportion of active women vascular surgeons in 2017 (10% unique authors vs 13% surgeons; P = .047), but not in 2015 (9% unique authors vs 11% surgeons; P = .192) or 2019 (13% unique authors vs 15% surgeons; P = .345). Notably, a woman last author was associated with 1.45 higher odds of having a woman first author (95% confidence interval, 1.17-1.79; P = .001). CONCLUSIONS: Over the past 5 years, there has been no significant increase in women last authors among top-tier journals in vascular surgery. Women remain under-represented as last authors in terms of proportion of published articles, but not in terms of proportion of unique authors. Nevertheless, women last authors are more likely to publish with women first authors, indicating the importance of women-led mentorship in achieving publication gender equity. Support for women surgeons through grants and promotions is essential not only for advancing last authorship gender equity, but for advancing junior faculty and trainee academic careers.

Referral of Burn Patients in the Absence of Guidelines: A Rwandan Study.

INTRODUCTION: The management of severe burns and pediatric burns requires an organized system of care delivery, which includes referral guidelines. In Rwanda, the burn unit at the University Teaching Hospital of Kigali (CHUK) is the only dedicated burn unit in the country and admits patients of all ages referred from the other provinces. However, since there are no official referral guidelines, it is unknown whether patients with burns are appropriately referred. This study aims to analyze referral patterns among burn patients admitted at the CHUK burn unit and their adherence to the referral criteria listed by the American Burn Association (ABA), comparing patients transferred to the burn unit from facilities within Kigali and those referred from facilities outside Kigali. METHODS: This retrospective study included all patients with acute burns admitted to the CHUK burn unit with data available on the province of origin from 2005 to 2019. Patients with burns younger than 16 y were defined as pediatric burns, as per the CHUK routines. Characteristics of all burns referred from a facility within Kigali (Pat-K) and facilities outside Kigali (Pat-O) were compared using Fisher's exact test for categorical variables or Wilcoxon rank-sum test for continuous variables. The adherence to ABA referral criteria was assessed for variables with available data, which were total burnt surface area %, burn thickness, cause of burn, and age. RESULTS: The study population consisted of 1093 patients, of which 1064 had data regarding if they were referred from other facilities to CHUK. Overall, the median age was 3 y (2-16 y), with Pat-O being older than Pat-K (P < 0.001). Scalds were the dominant cause of injury in both groups; flame was more common among Pat-O than among Pat-K (in 25.5% versus 10.6%, P < 0.01). Burns of larger size and depth were more common among Pat-O, as compared to the Pat-K group [median total burnt surface area % = 19% versus 15.5%, respectively (P < 0.001); presence of full-thickness burns = 55.6% versus 29.7 %, respectively (P < 0.001)]. Hospitalization was longer and in-hospital mortality higher in Pat-O than in Pat-K [LOS = 42 d (interquartile range 11-164) versus 28 d (interquartile range 9-132), P < 0.05; in-hospital mortality = 18.9% versus 10.1%, P < 0.001]. Among Pat-O, 85% had characteristics that mirrored one or more of the analyzed ABA criteria. CONCLUSIONS: Although there are no clear guidelines, referral patterns indicate that patients are being appropriately referred for specialized burn care in Rwanda. Compared to patients from Kigali, rural patients had larger and more severe injuries, needed more surgical interventions, and had worse outcomes. Most of referred patients matched criteria listed among international referral guidelines. However, the statement of national referral criteria is essential to improve timely access to adequate care.

The true costs of cesarean delivery for patients in rural Rwanda: Accounting for post-discharge expenses in estimated health expenditures.

INTRODUCTION: While it is recognized that there are costs associated with postoperative patient follow-up, risk assessments of catastrophic health expenditures (CHEs) due to surgery in sub-Saharan Africa rarely include expenses after discharge. We describe patient-level costs for cesarean section (c-section) and follow-up care up to postoperative day (POD) 30 and evaluate the contribution of follow-up to CHEs in rural Rwanda. METHODS: We interviewed women who delivered via c-section at Kirehe District Hospital between September 2019 and February 2020. Expenditure details were captured on an adapted surgical indicator financial survey tool and extracted from the hospital billing system. CHE was defined as health expenditure of ≥ 10% of annual household expenditure. We report the cost of c-section up to 30 days after discharge, the rate of CHE among c-section patients stratified by in-hospital costs and post-discharge follow-up costs, and the main contributors to c-section follow-up costs. We performed a multivariate logistic regression using a backward stepwise process to determine independent predictors of CHE at POD30 at α ≤ 0.05. RESULTS: Of the 479 participants in this study, 90% were classified as impoverished before surgery and an additional 6.4% were impoverished by the c-section. The median out-of-pocket costs up to POD30 was US$122.16 (IQR: $102.94, $148.11); 63% of these expenditures were attributed to post-discharge expenses or lost opportunity costs (US$77.50; IQR: $67.70, $95.60). To afford c-section care, 64.4% borrowed money and 18.4% sold possessions. The CHE rate was 27% when only considering direct and indirect costs up to the time of discharge and 77% when including the reported expenses up to POD30. Transportation and lost household wages were the largest contributors to post-discharge costs. Further, CHE at POD30 was independently predicted by membership in community-based health insurance (aOR = 3.40, 95% CI: 1.21,9.60), being a farmer (aOR = 2.25, 95% CI:1.00,3.03), primary school education (aOR = 2.35, 95% CI:1.91,4.66), and small household sizes had 0.22 lower odds of experiencing CHE compared to large households (aOR = 0.78, 95% CI:0.66,0.91). CONCLUSION: Costs associated with surgical follow-up are often neglected in financial risk calculations but contribute significantly to the risk of CHE in rural Rwanda. Insurance coverage for direct medical costs is insufficient to protect against CHE. Innovative follow-up solutions to reduce costs of patient transport and compensate for household lost wages need to be considered.

Telemedicine for Surgical Site Infection Diagnosis in Rural Rwanda: Concordance and Accuracy of Image Reviews.

BACKGROUND: In rural Africa where access to medical personnel is limited, telemedicine can be leveraged to empower community health workers (CHWs) to support effective postpartum home-based care after cesarean section (c-section). As a first step toward telemedicine, we assessed the sensitivity, specificity, and interrater reliability of image-based diagnosis of surgical site infections (SSIs) among women delivering via c-section at a rural Rwandan Hospital. METHODS: Women ≥18 years who underwent c-section from March to October 2017 at Kirehe District Hospital (KDH) were enrolled. On postoperative day 10 at KDH, participants underwent a physical examination by a general practitioner, who provided a diagnosis of SSI or no SSI. Trained CHWs photographed patients' incisions and the collected images were shown to six physicians, who upon review, assigned one of the following diagnoses to each image: definite SSI, suspected SSI, suspected no SSI, and definite no SSI, which were compared with the diagnoses based on physical exam. We report the sensitivity and specificity and assessed reviewer agreement using Gwet's AC1. RESULTS: 569 images were included, with 61 women (10.7%) diagnosed with an SSI. Of the 3414 image-reviews, 49 (1.4%) could not be assigned diagnoses due to image quality. The median sensitivity and specificity were 0.83 and 0.69, respectively. The Gwet's AC1 estimate for binary classification was 0.46. CONCLUSIONS: We demonstrate decent accuracy but only moderate consistency for photograph-based SSI diagnosis. Strategies to improve overall agreement include providing clinical information to accompany photographs, providing a baseline photograph for comparison, and implementing photograph-taking processes aimed at improving image quality.

What is Known About Burns in East Africa? A Scoping Review.

BACKGROUND: Burns are a global public health concern, with the majority of the disease burden affecting low- and middle-income countries. Yet, as suggested by previous publications, there is a widespread belief that literature about burns in low- and middle-income countries is lacking. Therefore, we aimed to assess with a scoping review, the extent of the literature output on burns in East Africa, and to investigate patient demographics, injury characteristics, treatment and outcomes, as reported from the existing publications. METHODS: Studies discussing burns in East Africa were identified by searching PubMed / Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO), and Global Index Medicus on December 12, 2019. Controlled vocabulary terms (i.e., MeSH, EMTREE, Global Health thesaurus terms) were included when available and appropriate. No year restrictions were applied. RESULTS: A total of 1,044 records were retrieved from the database searches, from which 40 articles from 6 countries published between 1993 and 2019 were included in the final review. No studies were found from five East African countries with the lowest GDP. Most papers focused on pediatric trauma patients or tertiary hospital settings. The total number of burn patients recorded was 44,369, of which the mean proportion of males was 56%. The most common cause of injury was scalds (61%), followed by open flame (17%). Mortality rate ranged from 0-67%. The mean length of stay in hospital was between 9-60 d. CONCLUSIONS: Burn data is limited in the East African region, with socio-economically weak countries being particularly underrepresented. This scoping review has identified the largest set of literature on burns in East Africa to date, indicating the importance of reviewing data at a regional or local level, as "global" studies tend to be dominated by high-income country data. Data collection in specific registries is needed to better characterize the exact burden of burn injuries in East Africa.

The helminth-derived peptide GK-1 induces an anti-tumoral CD8 T cell response associated with downregulation of the PD-1/PD-L1 pathway.

CD8 T cells can kill malignant cells in an antigen-specific manner. However, anti-tumoral responses are usually limited by suppressive factors that curb the effector responses of tumor-infiltrating CD8 T cells. Therapeutic strategies to overcome intra-tumoral T cell suppression, for example immune checkpoint inhibition, have been clinically effective in patients with cancer. Here, we provide data that demonstrates that GK-1, a peptide derived from the parasite Taenia crassiceps, promotes an anti-melanoma CD8 T cell response with heightened effector characteristics that leads to an increased amount of tumor-infiltrating CD44+ IFN-γ-producing CD8 T cells. The response induced by GK-1 was associated with a reduction in the expression of PD-1 and PD-L1 on tumor-infiltrating CD8 and dendritic cells, respectively, effects that led to a dramatic decrease in tumor burden. Our results suggest that the immunomodulatory properties of GK-1 may promote a CD8 T cell response that may be therapeutically useful in the setting of cancer.

Postoperative Development of Abdominal Compartment Syndrome among Patients Undergoing Endovascular Aortic Repair for Ruptured Abdominal Aortic Aneurysms.

BACKGROUND: Abdominal compartment syndrome (ACS) has a reported incidence of 9%-14% among trauma patients. However, in patients with similar hemodynamic changes, the incidence of ACS remains unclear. Our aim was to determine the incidence of ACS among patients undergoing endovascular aortic repair (EVAR) for ruptured abdominal aortic aneurysms (rAAAs) and to identify associated risk factors. METHODS: A retrospective review was performed for consecutive patients who underwent EVAR for rAAA from March 2010 to November 2016 at our institution. The development of ACS was diagnosed based on a variety of factors, including bladder pressure, laboratory abnormalities, hemodynamic monitoring, and clinical evaluation. Previously validated risk factors for ACS development in trauma and EVAR patients (preoperative hypotension, aggressive fluid resuscitation, postoperative anemia, use of an aorto-uniiliac graft, and placement of an aortic occlusive balloon) were analyzed. Association between patient characteristics and ACS development was analyzed using the Fisher's exact test. RESULTS: During the study period, 25 patients had image-confirmed rAAA and underwent emergent EVAR. Mortality rate was 28% (n = 7), and ACS incidence was 12% (n = 3). Of the analyzed risk factors, hypotension on arrival (P = 0.037), transfusion of 3 or more units of packed red blood cells (P = 0.037), and postoperative anemia (P = 0.02) were all significantly associated with postoperative ACS development. In addition, having greater than 3 of the studied risk factors was associated with increased odds of developing ACS (P = 0.015), and having greater than 4 of the studied risk factors showed the strongest association with ACS development (P = 0.0017). CONCLUSIONS: Overresuscitation should be avoided in patients with rAAA. In addition, patients who present with multiple risk factors for ACS should be monitored very closely with serial bladder pressures and may require decompression laparotomy immediately after EVAR.

Synthesis, photophysical, electrochemical and electrochemiluminescence properties of A2B2 zinc porphyrins: the effect of π-extended conjugation.

The synthesis of two A2B2 porphyrins, {5,15-bis-[4-(octyloxy)phenyl]-porphyrinato}zinc(ii) () and {5,15-bis-(carbazol-3-yl-ethynyl)-10,20-bis-[4-(octyloxy)phenyl]-porphinato}-zinc(ii) (), is reported. Their photophysical properties were studied by steady-state absorption and emission. Substituting the carbazolylethynyl moieties at two of the meso positions results in a large bathochromic shift of all the absorption bands, a notable increase in the absorption coefficient of the Q(0,0) band, and higher fluorescence quantum yield compared to porphyrin , with two unsubstituted meso positions. Cyclic voltammetry and digital simulation show that electrogenerated radical ions of are more stable than those of . The lack of substituents at the meso positions of leads to dimerization reactions of the radical cation. Despite this, the annihilation reaction of and produces very similar electrogenerated chemiluminescence (ECL) intensity. Spectroelectrochemical experiments demonstrate that the electroreduction of leads to a strong absorption band that might quench the ECL.

In situ laser fenestration of aortic septum to bridge false and true lumen during endovascular repair of aortic dissection.

Fenestration of the septum between the true and false lumen might be necessary after aortic dissection. We report the technical aspects of in situ laser fenestration of the aortic dissection septum. Two illustrative cases are provided: a 56-year-old man with false lumen deployment of a frozen elephant trunk graft, and a 67-year-old man who underwent fenestrated endovascular aortic repair with a target branch vessel off the false lumen. In both cases, the septum was crossed using in situ laser fenestration. This technique is a precise option to enable passage between true and false lumens during endovascular repair of an aortic dissection.

Estimating mortality risk in burn patients admitted at Rwanda's largest referral hospital.

BACKGROUND: Burns is a disease of poverty, disproportionately affecting populations in low- and middle-income countries, where most of the injuries and the deaths caused by burns occurs. In Sub-Saharan Africa, it is estimated that one fifth of burn victims die from their injuries. Mortality prediction indexes are used to estimate outcomes after provided burn care, which has been used in burn services of high-income countries over the last 60 years. It remains to be seen whether these are reliable in low-income settings. This study aimed to analyze in-hospital mortality and to apply mortality estimation indexes in burn patients admitted to the only specialized burn unit in Rwanda. METHODS: This retrospective study included all patients with burns admitted at the burn unit (BU) of the University Teaching Hospital in Kigali (CHUK) between 2005 and 2019. Patient data were collected from the BU logbook. Descriptive statistics were calculated with frequency (%) and median (interquartile range, IQR). Association between burns characteristics and in-hospital mortality was calculated with Fisher's exact test, and Wilcoxon rank, as appropriate. Mortality estimation analysis, including Baux score, Lethal Area 50 (LA50), and point of futility, was calculated in those patients with complete data on age and TBSA. LA50 and point-of-futility were calculated using logistic regression. RESULTS: Among the 1093 burn patients admitted at the CHUK burn unit during the study period, 49% (n=532) had complete data on age and TBSA. Their median age, TBSA, and Baux score were 3.4 years (IQR 1.9-17.1), 15% (IQR 11-25), and 24 (IQR 16-38), respectively. Overall, reported in-hospital mortality was 13% (n=121/931), LA50 for Baux score was 89.9 (95% CI 76.2-103.7), and the point-of-futility was at a Baux score of 104. CONCLUSION: Mortality estimation indexes based on age and TBSA are feasible to use in low-income settings. However, implementation of systematic data collection would contribute to a more accurate calculation of the mortality risk.

Description of advanced third-stage larvae of Gnathostoma lamothei Bertoni-Ruiz et al. 2005 (Nematoda: Gnathostomatidae) from experimental hosts and contributions to its life cycle.

The advanced third-stage larvae (AdvL(3)) of Gnathostoma lamothei was obtained from experimental hosts. Frogs Lithobates heckscheri and snakes Nerodia fasciata pictiventris were compatible hosts allowing optimal larval development. AdvL(3) are 4,487.94 µm long, have two lateral cervical papillae between rows 10 and 16 and an excretory pore at row 23. The average counts of the cephalic bulb hooklets from the four rows are 39.3, 43.3, 44.2, and 47.3. Larvae show an esophagus that represents 40 % of the body width. These findings indicate that amphibians and reptiles could be involved as G. lamothei natural hosts; nevertheless, their role as etiological agents of human gnathostomiasis is uncertain. This paper reports for the first time the taxonomic description of G. lamothei AdvL(3) obtained from experimental hosts and contributes to the understanding of its life cycle.

Use of retrograde left subclavian branch portal of Gore TAG thoracic branch endoprosthesis for physician-modified fenestrated branched endovascular repair of thoracoabdominal aortic aneurysm.

A 75-year-old man who had undergone zone 2 thoracic endovascular repair of a symptomatic penetrating aortic ulcer using a Gore TAG thoracic branch endoprosthesis (TBE) device (W.L. Gore & Associates) 5 years before had presented with an enlarging extent I thoracoabdominal aortic aneurysm. A physician-modified five-vessel fenestrated-branched endograft repair was performed using preloaded wires. The visceral renal vessels were sequentially catheterized from the left brachial access via the TBE portal, and the endograft was deployed in staggered fashion. At 1 year of follow-up, imaging studies demonstrated a stable aneurysm sac, patent visceral renal branches, and no endoleak. The retrograde portal of Gore TAG TBE can facilitate fenestrated-branched endovascular repair of thoracoabdominal aortic aneurysms.

mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda.

BACKGROUND: Surgical site infections (SSIs) cause a significant global public health burden in low and middle-income countries. Most SSIs develop after patient discharge and may go undetected. We assessed the feasibility and diagnostic accuracy of an mHealth-community health worker (CHW) home-based telemedicine intervention to diagnose SSIs in women who delivered via caesarean section in rural Rwanda. METHODS: This prospective cohort study included women who underwent a caesarean section at Kirehe District Hospital between September 2019 and March 2020. At postoperative day 10 (±3 days), a trained CHW visited the woman at home, provided wound care and transmitted a photo of the wound to a remote general practitioner (GP) via WhatsApp. The GP reviewed the photo and made an SSI diagnosis. The next day, the woman returned to the hospital for physical examination by an independent GP, whose SSI diagnosis was considered the gold standard for our analysis. We describe the intervention process indicators and report the sensitivity and specificity of the telemedicine-based diagnosis. RESULTS: Of 787 women included in the study, 91.4% (n=719) were located at their home by the CHW and all of them (n=719, 100%) accepted the intervention. The full intervention was completed, including receipt of GP telemedicine diagnosis within 1 hour, for 79.0% (n=623). The GPs diagnosed 30 SSIs (4.2%) through telemedicine and 38 SSIs (5.4%) through physical examination. The telemedicine sensitivity was 36.8% and specificity was 97.6%. The negative predictive value was 96.4%. CONCLUSIONS: Implementation of an mHealth-CHW home-based intervention in rural Rwanda and similar settings is feasible. Patients' acceptance of the intervention was key to its success. The telemedicine-based SSI diagnosis had a high negative predictive value but a low sensitivity. Further studies must explore strategies to improve accuracy, such as accompanying wound images with clinical data or developing algorithms using machine learning.

Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review.

Purpose of Review: Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings: A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager's four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public-private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary: Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information: The online version contains supplementary material available at 10.1007/s40719-022-00229-1.

The Use of Mobile Thermal Imaging and Deep Learning for Prediction of Surgical Site Infection.

The ability to detect surgical site infections (SSI) is a critical need for healthcare worldwide, but is especially important in low-income countries, where there is limited access to health facilities and trained clinical staff. In this paper, we present a new method of predicting SSI using a thermal image collected with a smart phone. Machine learning algorithms were developed using images collected as part of a clinical study that included 530 women in rural Rwanda who underwent cesarean section surgery. Thermal images were collected approximately 10 days after surgery, in conjunction with an examination by a trained doctor to determine the status of the wound (infected or not). Of the 530 women, 30 were found to have infected wounds. The data were used to develop two Convolutional Neural Net (CNN) models, with special care taken to avoid overfitting and address the problem of class imbalance in binary classification. The first model, a 6-layer naïve CNN model, demonstrated a median accuracy of AUC=0.84 with sensitivity=71% and specificity=87%. The transfer learning CNN model demonstrated a median accuracy of AUC=0.90 with sensitivity =95% and specificity=84%. To our knowledge, this is the first successful demonstration of a machine learning algorithm to predict surgical infection using thermal images alone.Clinical Relevance- This work establishes a promising new method for automated detection of surgical site infection.

Recording Patient Data in Burn Unit Logbooks in Rwanda: Who and What Are We Missing?

Systematic data collection in high-income countries has demonstrated a decreasing burn morbidity and mortality, whereas lack of data from low- and middle-income countries hinders a global overview of burn epidemiology. In low- and middle-income countries, dedicated burn registries are few. Instead, burn data are often recorded in logbooks or as one variable in trauma registries, where incomplete or inconsistently recorded information is a known challenge. The University Teaching Hospital of Kigali hosts the only dedicated burn unit in Rwanda and has collected data on patients admitted for acute burn care in logbooks since 2005. This study aimed to assess the data registered between January 2005 and December 2019, to evaluate the extent of missing data, and to identify possible factors associated with "missingness." All data were analyzed using descriptive statistics, Fisher's exact test, and Wilcoxon Rank Sum test. In this study, 1093 acute burn patients were included and 64.2% of them had incomplete data. Data completeness improved significantly over time. The most commonly missing variables were whether the patient was referred from another facility and information regarding whether any surgical intervention was performed. Missing data on burn mechanism, burn degree, and surgical treatment were associated with in-hospital mortality. In conclusion, missing data is frequent for acute burn patients in Rwanda, although improvements have been seen over time. As Rwanda and other low- and middle-income countries strive to improve burn care, ensuring data completeness will be essential for the ability to accurately assess the quality of care, and hence improve it.