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.

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.

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.

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.

Safety, efficiency, and cost-effectiveness of a multidisciplinary percutaneous tracheostomy program.

OBJECTIVE: The frequency of bedside percutaneous tracheostomies is increasing in intensive care medicine, and both safety and efficiency of care are critical elements in continuing success of this procedure. Prioritizing patient safety, a tracheostomy team was created at our institution to provide bedside expertise in surgery, anesthesiology, respiratory, and technical support. This study was performed to evaluate the metrics of patient outcome, efficiency of care, and cost-benefit analysis of the multidisciplinary Johns Hopkins Percutaneous Tracheostomy Program. DESIGN: A review was performed for patients who received tracheostomies in 2004, the year before the Johns Hopkins Percutaneous Tracheostomy Program was established, and those who received tracheostomies in 2008, the year following the program's establishment. Comparative outcomes were evaluated, including the efficiency of procedure and intensive care unit length of stay, complication rate including bleeding, hypoxia, loss of airway, and a financial cost-benefit analysis. SETTING: Single-center, major university hospital. PATIENTS: The sample consisted of 363 patients who received a tracheostomy in the years 2004 and 2008. MEASUREMENTS AND MAIN RESULTS: The number of percutaneous procedures increased from 59 of 126 tracheostomy patients in 2004, to 183 of 237 in 2008. There were significant decreases in the prevalence of procedural complications, particularly in the realm of airway injuries and physiologic disturbances. Regarding efficiency, the structured program reduced the time to tracheostomy and overall procedural time. The intensive care unit length of stay in nonpulmonary patients and improvement in intensive care unit and operating room back-fill efficiency contributed to an overall institutional financial benefit. CONCLUSIONS: An institutionally subsidized, multi-disciplinary percutaneous tracheostomy program can improve the quality of care in a cost-effective manner by decreasing the incidence of tracheostomy complications and improving both the time to tracheostomy, duration of procedure, and postprocedural intensive care unit stay.

Predictors of positive head CT scan and neurosurgical procedures after minor head trauma.

BACKGROUND: There continues to be an ongoing debate regarding the utility of head CT scans in patients with a normal Glasgow Coma Scale (GCS) after minor head injury. The objective of this study is to determine patient and injury characteristics that predict a positive head CT scan or need for a neurosurgical procedure (NSP) among patients with blunt head injury and a normal GCS. MATERIALS AND METHODS: Retrospective analysis of adult patients in the National Trauma Data Bank who presented to the ED with a history of blunt head injury and a normal GCS of 15. The primary outcomes were a positive head CT scan or a NSP. Multivariate logistic regression controlling for patient and injury characteristics was used to determine predictors of each outcome. RESULTS: Out of a total of 83,566 patients, 24,414 (29.2%) had a positive head CT scan and 3476 (4.2%) underwent a NSP. Older patients and patients with a history of fall (compared with a motor vehicle crash) were more likely to have a positive finding on a head CT scan. Male patients, African-Americans (compared with Caucasians), and those who presented with a fall were more likely to have a NSP. CONCLUSIONS: Older age, male gender, ethnicity, and mechanism of injury are significant predictors of a positive finding on head CT scans and the need for neurosurgical procedures. This study highlights patient and injury-specific characteristics that may help in identifying patients with supposedly minor head injury who will benefit from a head CT scan.

Patterns of referral for refugees in western Tanzania: a retrospective review.

Introduction: access to essential secondary and tertiary healthcare, including surgery and medical sub-specialties, is a challenge in low-and-middle income countries (LMICs), especially for displaced populations. Referrals from refugee camps are highly regulated and may pose barriers to accessing essential secondary healthcare in a timely manner. Refugee referral systems and the ways they interact with national systems are poorly understood. Such information is necessary for resource allocation and prioritization, optimizing patient outcomes, national-level planning, and investment in capacity-building. Methods: a retrospective review of referrals from Nyarugusu Refugee Camp in Tanzania to Kabanga Hospital between January 2016-May 2017 was conducted. Data was collected from logbooks on patient demographics, diagnosis, and reason for referral. Diagnoses and reasons for referral were further coded by organ system and specific referral codes, respectively. Results: there were 751 entries in the referral logbook between January 2016 and May 2017. Of these, 79 (10.5%) were excluded as they were caretakers or missing both diagnoses and reason for referral resulting in 672 (89.5%) total entries for analysis.The most common organ system of diagnosis was musculoskeletal (171, 25.5%) followed by head, ear, eye, nose and throat (n=164, 24.4%) and infectious disease (n=92, 13.7%). The most common reason for referral was imaging (n=250, 37.2%) followed by need for a specialist (n=214, 31.9%) and further management (n=116, 17.3%). X-ray comprised the majority of imaging referred (n=249, 99.6%). The most common specialties referred to were ophthalmology (n=104, 48.6%) followed by surgery (n=63, 29.4%), and otolaryngology (ENT) (n=17, 7.9%). Conclusion: given a large burden of referral for refugee patients and sharing of in and out-of-camp healthcare facilities with nationals, refugees should be included in national health care plans and have clear referral processes. Epidemiological data that include these intertwined referral patterns are necessary to promote efficient resource allocation, reduce unnecessary referrals, and prevent delays in care that could affect patient outcomes. International agencies, NGOs, and governments should conduct cost analyses to explore innovative capacity-building projects for secondary care in camp-based facilities.

Prehospital intravenous fluid administration is associated with higher mortality in trauma patients: a National Trauma Data Bank analysis.

OBJECTIVE: Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting. METHODS: We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score. RESULTS: A total of 776,734 patients were studied. Approximately half (49.3%) received prehospital IV. Overall mortality was 4.6%. Unadjusted mortality was significantly higher in patients receiving prehospital IV fluids (4.8% vs. 4.5%, P < 0.001). Multivariable analysis demonstrated that patients receiving IV fluids were significantly more likely to die (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.05­1.17). The association was identified in nearly all subsets of trauma patients. It is especially marked in patients with penetrating mechanism (OR 1.25, 95% CI 1.08­1.45), hypotension (OR 1.44, 95% CI1.29­1.59), severe head injury (OR 1.34, 95% CI 1.17­1.54), and patients undergoing immediate surgery (OR 1.35, 95% CI 1.22­1.50). CONCLUSIONS: The harm associated with prehospital IV fluid administration is significant for victims of trauma. The routine use of prehospital IV fluid administration for all trauma patients should be discouraged.

Multiple imputation in trauma disparity research.

BACKGROUND: Missing data has remained a major disparity in trauma outcomes research due to missing race and insurance data. Multiple imputation (M.IMP) has been recommended as a solution to deal with this major drawback. STUDY DESIGN: Using the National Data Trauma Bank (NTDB) as an example, a complete dataset was developed by deleting cases with missing data across variables of interest. An incomplete dataset was then created from the complete set using random deletion to simulate the original NTDB, followed by five M.IMP rounds to generate a final imputed dataset. Identical multivariate analyses were performed to investigate the effect of race and insurance on mortality in both datasets. RESULTS: Missing data proportions for known trauma mortality covariates were as follows: age-4%, gender-0.4%, race-8%, insurance-17%, injury severity score-6%, revised trauma score-20%, and trauma type-3%. The M.IMP dataset results were qualitatively similar to the original dataset. CONCLUSION: M.IMP is a feasible tool in NTDB for handling missing race and insurance data.

Patterns of injury and violence in Yaoundé Cameroon: an analysis of hospital data.

BACKGROUND: Injuries are quickly becoming a leading cause of death globally, disproportionately affecting sub-Saharan Africa, where reports on the epidemiology of injuries are extremely limited. Reports on the patterns and frequency of injuries are available from Cameroon are also scarce. This study explores the patterns of trauma seen at the emergency ward of the busiest trauma center in Cameroon's capital city. MATERIALS AND METHODS: Administrative records from January 1, 2007, through December 31, 2007, were retrospectively reviewed; information on age, gender, mechanism of injury, and outcome was abstracted for all trauma patients presenting to the emergency ward. Univariate analysis was performed to assess patterns of injuries in terms of mechanism, date, age, and gender. Bivariate analysis was used to explore potential relationships between demographic variables and mechanism of injury. RESULTS: A total of 6,234 injured people were seen at the Central Hospital of Yaoundé's emergency ward during the year 2007. Males comprised 71% of those injured, and the mean age of injured patients was 29 years (SD = 14.9). Nearly 60% of the injuries were due to road traffic accidents, 46% of which involved a pedestrian. Intentional injuries were the second most common mechanism of injury (22.5%), 55% of which involved unarmed assault. Patients injured in falls were more likely to be admitted to the hospital (p < 0.001), whereas patients suffering intentional injuries and bites were less likely to be hospitalized (p < 0.001). Males were significantly more likely to be admitted than females (p < 0.001) DISCUSSION: Patterns in terms of age, gender, and mechanism of injury are similar to reports from other countries from the same geographic region, but the magnitude of cases reported is high for a single institution in an African city the size of Yaoundé. As the burden of disease is predicted to increase dramatically in sub-Saharan Africa, immediate efforts in prevention and treatment in Cameroon are strongly warranted.

Global surgical package reimbursement and the acute care surgeon: a threat to optimal care.

BACKGROUND: Emergency surgery patients risk greater mortality and morbidity than elective patients undergoing the same procedure. However, the differential effort required for the care of emergency surgical patients is poorly defined. This study sought to characterize costs and outcomes of elective versus emergent right hemicolectomy. METHODS: 2006 Nationwide Inpatient Sample data were used to compare mortality, total charges, and length of stay (LOS) in patients undergoing emergency versus elective right hemicolectomy (International Classification of Diseases-9th procedure code 45.73). Mann-Whitney tests examined total costs and LOS; multivariable regression modeled inhospital mortality controlling for age, gender, insurance status, and comorbidities. RESULTS: Among 8,074,825 inpatient admissions, 7,767 emergent and 10,399 elective right hemicolectomies were identified. Emergent patients were similar in age (66.9 years vs. 67.6 years; p=0.129), more likely women (43.7% vs. 42.3%; p=0.048) and had greater comorbidity (Charlson score 3.37 vs. 3.01; p<0.001) compared with elective patients. Emergent patient LOS was approximately double that of elective patients (13 days vs. 7 days; p<0.001). Mean total charges were $78,118 for emergent versus $39,265 elective patients (p<0.001). Emergent patients had greater odds of inhospital mortality (odds ratio, 5.86; 95% confidence intervals, 4.80-7.14). CONCLUSIONS: Emergent right hemicolectomy patients have greater comorbidity, experience longer stays, accrue twice the charges, and have higher mortality risk. This reflects a heightened effort required to care for emergent patients unrecognized by Global Surgical Package reimbursement. The concentration of emergency surgical patients in acute care surgery services necessitates accounting for the additional effort associated with these predictable risks to ensure optimal care.

Do trauma safety-net hospitals deliver truly safe trauma care? A multilevel analysis of the national trauma data bank.

BACKGROUND: Patients treated at "safety-net hospitals," facilities that care for a high percentage of uninsured patients, are known to have worse outcomes. This study seeks to analyze whether care at "trauma safety-net hospitals" (TSNH) accounts for the known mortality disparity between uninsured and insured trauma patients. METHODS: A retrospective analysis of trauma patients (age, 18-64 years) in the National Trauma Data Bank (6.2; 2001-2005) with moderate to severe injury (Injury Severity Score ≥9) was performed. TSNH were defined as facilities treating ≥47% uninsured trauma patients. The main outcome measure was adjusted mortality of patients treated at TSNH versus non-TSNH. A multilevel analysis using multiple logistic regression and generalized estimating equations was performed to control for both hospital and patient-level characteristics (age, gender, insurance, injury severity, shock, and type and mechanism of injury). Subset analyses by hospital trauma level designation and patient injury severity and type were also performed. RESULTS: Collectively 343,053 trauma patients were treated at 46 TSNH and 413 non-TSNH. TSNH patients (n = 36,774) were more likely to be minorities (55% vs. 27%; p < 0.05) compared with non-TSNH patients (n = 306,279). Unadjusted mortality was greater in TSNH versus non-TSNH patients (6.8% vs. 4.6%; *p < 0.05). After controlling for patient- and hospital-level factors, patients at TSNH and non-TSNH facilities had equivalent odds ratio of death = 0.93 (95% confidence interval = 0.65-1.32). Similar results were obtained in all subset analyses. CONCLUSION: Patients treated at TSNH have equivalent mortality compared with those treated at non-TSNH. Disparate trauma outcomes due to insurance status are not explained by differences between trauma treating institutions.

Duplex ultrasound screening for deep vein thrombosis in asymptomatic trauma patients: a survey of individual trauma surgeon opinions and current trauma center practices.

BACKGROUND: Many national agencies have suggested that deep vein thrombosis (DVT) rates measure quality of hospital care. However, none provide recommendations for standardized screening. If screening practices vary among clinicians or hospitals, DVT rates could be biased-centers which perform more duplex ultrasounds report more DVTs. We hypothesized that trauma surgeons have varying opinions regarding duplex ultrasound screening for DVT in asymptomatic trauma patients, which result in varying practice patterns. METHODS: We conducted two web-based surveys regarding the use of duplex ultrasound screening for DVT in asymptomatic trauma patients. The first (individual provider level) surveyed members of two national trauma surgery organizations (American Association for the Surgery of Trauma and Eastern Association for the Surgery of Trauma). The second (trauma center level) surveyed practice patterns of National Trauma Data Bank hospitals. RESULTS: Three hundred seventeen individual surgeons completed surveys. There was wide variation in individual opinions regarding DVT screening in asymptomatic trauma patients (53% agree, 36% disagree, and 11% neither agree nor disagree). Two hundred thirteen National Trauma Data Bank hospitals completed surveys of which 28% (n=60) have a written guideline regarding DVT screening in asymptomatic trauma patients. The proportion of centers with a written protocol varied significantly by trauma center level (p<0.001) but not by teaching status. Opinions and practice patterns suggest that screening should start early and be performed weekly. The main risk factors used to suggest DVT screening are spinal cord injury and pelvic fracture. CONCLUSIONS: There are wide variations in trauma surgeons' opinions and trauma centers' practices regarding duplex ultrasound screening for DVT in asymptomatic trauma patients. This variability combined with the fact that performing more duplex ultrasounds finds more DVTs may influence reported DVT rates. DVT rates alone are biased and not reflective of true quality of trauma care.

Humanitarian surgical service utilization by a host country population: comparing surgery patterns between refugees and Tanzanians using an interrupted time-series analysis.

BACKGROUND: While current estimates suggest that up to three million additional surgical procedures are needed to meet the needs of forcibly displaced populations, literature on surgical care for refugee or forced migrant populations has often focused on acute phase and war-related trauma or violence with insufficient attention to non-war related pathologies. To our knowledge, no study has compared refugee versus host population utilization of surgical services in a refugee camp-based hospital over such an extended period of twenty years. The aim of this paper is to first describe the patterns of surgical care by comparing refugee and host population utilization of surgical services in Nyarugusu refugee camp between 2000 and 2020, then evaluate the impact of a large influx of refugees in 2015 on refugee and host population utilization. METHODS: The study was based on a retrospective review of surgical logbooks in Nyarugusu refugee camp (Kigoma, Tanzania) between 2000 and 2020. We utilized descriptive statistics and multiple group, interrupted time series methodology to assess baseline utilization of surgical services by a host population (Tanzanians) compared to refugees and trends in utilization before and after a large influx of Burundian refugees in 2015. RESULTS: A total of 10,489 operations were performed in Nyarugusu refugee camp between 2000 and 2020. Refugees underwent the majority of procedures in this dataset (n = 7,767, 74.0%) versus Tanzanians (n = 2,722, 26.0%). The number of surgeries increased over time for both groups. The top five procedures for both groups included caesarean section, bilateral tubal ligation, herniorrhaphy, exploratory laparotomy and hysterectomy. In our time series model, refugees had 3.21 times the number of surgeries per quarter at baseline when compared to Tanzanians. The large influx of Burundian refugees in 2015 impacted surgical output significantly with a 38% decrease (IRR = 0.62, 95% CI 0.46-0.84) in surgeries in the Tanzanian group and a non-significant 20% increase in the refugee group (IRR = 1.20, 95% CI 0.99-1.46). The IRR for the difference-in-difference (ratio of ratios of post versus pre-intervention slopes between refugees and Tanzanians) was 1.04 (95% CI 1.00-1.07), and this result was significant (p=0.028). CONCLUSIONS: Surgical care in conflict and post-conflict settings is not limited to war or violence related trauma but instead includes a large burden of obstetrical and general surgical pathology. Host population utilization of surgical services in Nyarugusu camp accounted for over 25% of all surgeries performed, suggesting some host population benefit of the protracted refugee situation in western Tanzania. Host population utilization of surgical services was apparently different after a large influx of refugees from Burundi in 2015.

Motorcycle helmets save lives, but not limbs: a National Trauma Data Bank analysis of functional outcomes after motorcycle crash.

BACKGROUND: The incidence of motorcycle fatalities over the last 10 y has nearly doubled. There is considerable evidence that motorcycle helmets save lives, but there are little data regarding the impact that helmets have on functional outcomes after a motorcycle crash. The objective of this study was to determine the difference between helmeted and non-helmeted motorcyclists in the odds of developing a functional deficit at discharge in three domains: speech, locomotion, and feeding. METHODS: Reviewed cases in the National Trauma Databank v7.0 involved in motorcycle collisions. Multiple logistic regression was used to analyze the effect of helmets on mortality and functional outcomes, adjusting for age, race, gender, insurance status, anatomic and physiologic injury severity, and head injury. RESULTS: The adjusted odds of mortality (0.75; 95% CI 0.65-0.86) and functional deficits in speech (0.82; 95% CI 0.69-0.97), locomotion (1.19; 95% CI 1.11-1.29), and feeding (0.96 95% CI 0.84-1.08) among helmeted riders was compared with non-helmeted motorcyclists with equivalent injuries. CONCLUSION: Helmeted motorcyclists are less likely to die and develop a deficit in speech after a motorcycle collision. These data support that motorcycle helmets are important in preventing functional deficits related to head injury.