The Current Status and Challenges of Prehospital Trauma Care in Low- and Middle-Income Countries: A Systematic Review.

BACKGROUND: This review aims to understand the present circumstances on the provision of prehospital trauma care in low- and middle-income countries (LMICs), particularly scoping the challenges experienced by LMICs in this regard. The objective is to systematically evaluate the currently available evidence on this topic. Based on the themes and challenges identified in the provision of prehospital trauma care in LMICs, we provide a series of recommendations and a knowledge base for future research in the field. METHODS: A systematic database search was conducted of original articles that explored and reported on prehospital trauma care in LMIC in EMBASE, MEDLINE, Cochrane database, and Google Scholar, from inception to March 2022. All original articles reporting on prehospital trauma care from 2010 to 2022 in LMICs were assessed, excluding case reports, small case series, editorials, abstracts, and pre-clinical studies; those with data inconsistencies that impede data extraction; and those with study populations fewer than ten. RESULTS: The literature search identified 2,128 articles, of which 29 were included in this review, featuring 27,848 participants from LMICs countries. Four main areas of focus within the studies were identified: (1) exploring emergency service systems, frameworks, and interconnected networks within the context of prehospital trauma care; (2) transportation of patients from the response site to hospital care; (3) medical education and the effects of first responder training in LMICs; and (4) cultural and social factors influencing prehospital trauma care-seeking behaviors. Due to overarching gaps in social and health care systems, significant barriers exist at various stages of providing prehospital trauma care in LMICs, particularly in injury identification, seeking treatment, transportation to hospital, and receiving timely treatment and post-intervention support. CONCLUSION: The provision of prehospital trauma care in LMICs faces significant barriers at multiple levels, largely dependent on wider social, geographic, economic, and political factors impeding the development of such higher functioning systems within health care. However, there have been numerous breakthroughs within certain LMICs in different aspects of prehospital trauma care, supported to varying degrees by international initiatives, that serve as case studies for widespread implementation and targets. Such experiential learning is essential due to the heterogenous landscapes that comprise LMICs.

Memory CD8+ T cells exhibit tissue imprinting and non-stable exposure-dependent reactivation characteristics following blood-stage Plasmodium berghei ANKA infections.

Experimental cerebral malaria (ECM) is a severe complication of Plasmodium berghei ANKA (PbA) infection in mice, characterized by CD8+ T-cell accumulation within the brain. Whilst the dynamics of CD8+ T-cell activation and migration during extant primary PbA infection have been extensively researched, the fate of the parasite-specific CD8+ T cells upon resolution of ECM is not understood. In this study, we show that memory OT-I cells persist systemically within the spleen, lung and brain following recovery from ECM after primary PbA-OVA infection. Whereas memory OT-I cells within the spleen and lung exhibited canonical central memory (Tcm) and effector memory (Tem) phenotypes, respectively, memory OT-I cells within the brain post-PbA-OVA infection displayed an enriched CD69+ CD103- profile and expressed low levels of T-bet. OT-I cells within the brain were excluded from short-term intravascular antibody labelling but were targeted effectively by longer-term systemically administered antibodies. Thus, the memory OT-I cells were extravascular within the brain post-ECM but were potentially not resident memory cells. Importantly, whilst memory OT-I cells exhibited strong reactivation during secondary PbA-OVA infection, preventing activation of new primary effector T cells, they had dampened reactivation during a fourth PbA-OVA infection. Overall, our results demonstrate that memory CD8+ T cells are systemically distributed but exhibit a unique phenotype within the brain post-ECM, and that their reactivation characteristics are shaped by infection history. Our results raise important questions regarding the role of distinct memory CD8+ T-cell populations within the brain and other tissues during repeat Plasmodium infections.

Increasing Brace Treatment for Pediatric Distal Radius Buckle Fractures: Using Quality Improvement Methodology to Implement Evidence-based Medicine.

BACKGROUND: Multiple randomized trials have showed equivalent outcomes and improved patient/family satisfaction using a removable brace to treat pediatric distal radius buckle fractures (DRBF). We tested the hypothesis that we could use quality improvement (QI) methodology to increase the proportion of patients with DRBF treated with removable braces at 2 tertiary care orthopaedic clinics from a baseline of 34.8% to 80%. METHODS: Clinic billing records were reviewed monthly to determine treatment (brace vs. cast) of DRBF and tracked using control charts (p-chart). Balance measures including correct application of the diagnostic criteria and algorithm were monitored. Process measures including the number of follow-up visits, radiographs obtained, and total cost of treatment were collected. Baseline data were obtained over a 3-month period, followed by a 12-month period of interventions using Plan-Do-Study-Act cycles targeting both individuals and groups of providers. RESULTS: The proportion of DRBF treated in a brace increased from a combined baseline of 34.8% to a combined 84% at the end of the study period. Following intervention, 83% (15/18) of providers began using braces for a majority of patients (defined as >67%), with only 1 provider continuing to use casts 100% of the time. Patient preference was cited as the most common reason for use of cast treatment. There was a significant decrease in the number of radiographs obtained at 1 of 2 institutions. The charges for brace treatment averaged $630 less per patient than for cast treatment, leading to an estimated medical-cost savings of $205,000 following intervention. CONCLUSIONS: Implementation of brace treatment for pediatric DRBF using QI methodology resulted in a shift toward brace treatment in the majority of patients, leading to substantial medical and nonmedical cost savings. Although patient preference was cited as the most common reason for persistent cast treatment, the data show the use of cast treatment to be more dependent upon individual provider preference. LEVEL OF EVIDENCE: Level II-therapeutic.

Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room: A Multicenter Perspective.

BACKGROUND: The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management). METHODS: A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded. RESULTS: In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P<0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P<0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group. CONCLUSIONS: There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures. LEVEL OF EVIDENCE: Level III.

Outcomes of salvage hip surgery in children with cerebral palsy.

This study compared the outcomes of four salvage procedures in treating painful dislocated hips in patients with cerebral palsy: Schanz osteotomy, Girdlestone, Castle, and McHale procedures. A retrospective review of cerebral palsy patients treated between 1990 and 2014 with minimum 6-month follow-up was carried out. Of 69 hips (62 patients), there were 36 McHales, 24 Castles, four Girdlestones, and five Schanz procedures at a mean age of 13.9 years. All four procedures provided pain relief. Proximal femoral migration was similar following the procedures, but heterotopic ossification was more common after the Castle procedure. Bone resorption and revision surgery were more frequent after the McHale procedure.

A Bundled Payment Model for Pediatric Distal Radius Fractures: Defining an Episode of Care.

BACKGROUND: Distal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. METHODS: We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. RESULTS: We identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs. CONCLUSIONS: Closed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices. LEVEL OF EVIDENCE: Level III-therapeutic.

Anatomy of the Volar Retinacular Elements of the Hand: A Unified Nomenclature.

Many investigators have described the anatomy of the volar retinacular structures of the hand over the last 60 years. As a result, multiple terms have been assigned to 1 anatomical structure and 1 name designated to more than 1 structure. Our purpose is to review the detailed anatomy and key components of the volar retinacular elements of the hand, their etymology, and their most recent descriptions. The objective also is to organize these structures into systems, which can be helpful for learners to assimilate into a practical anatomical guide. Lastly, the goal is to create a common nomenclature for identifying the volar retinacular structures of the hand in order to facilitate clear communication about them across languages.

Pediatric Metacarpal Fractures.

Metacarpal fractures account for 10% to 35% of all pediatric hand fractures. Pediatric metacarpal fractures commonly occur in patients aged 13 to 16 years, with most injuries sustained during sports activities. Pseudoepiphyses can be confused with metacarpal fractures; however, a careful physical examination can help physicians distinguish the two. Thumb metacarpal base fractures that involve the physis warrant special attention. Thumb metacarpal base fractures with lateral metaphyseal fragments and pediatric Bennett fracture variants (Salter-Harris type III and type IV fractures) are unstable and require surgical management. Finger metacarpal base fractures, especially those in young children, are often the result of high-energ y injuries and should increase a physician's concern for compartment syndrome. Metacarpal shaft fractures can result from a simple bending moment; however, they also can result from a rotational force, which may cause finger crossover that will not remodel and requires reduction. Metacarpal neck fractures account for three-fourths of all finger metacarpal fractures, and increasing acceptable alignment of the index finger through the little finger metacarpal necks (10°, 20°, 30°, and 40° across the digits, respectively) is commonly recommended. Metacarpal head fractures are rare intra-articular injuries that require anatomic fixation and may be underappreciated in children because of the complex geometry and largely cartilaginous nature of the metacarpal head.

Historical Patterns and Variation in Treatment of Injuries in NFL (National Football League) Players and NCAA (National Collegiate Athletic Association) Division I Football Players.

We conducted a study to identify and contrast patterns in the treatment of common injuries that occur in National Football League (NFL) players and National Collegiate Athletic Association (NCAA) Division I football players. Orthopedic team physicians for all 32 NFL and 119 NCAA Division I football teams were asked to complete a survey regarding demographics and preferred treatment of a variety of injuries encountered in football players. Responses were received from 31 (97%) of the 32 NFL and 111 (93%) of the 119 NCAA team physicians. Although patellar tendon autograft was the preferred graft choice for both groups of team physicians, the percentage of NCAA physicians who allowed return to football 6 months or less after anterior cruciate ligament reconstruction was significantly (P = .03) higher than that of NFL physicians. Prophylactic knee bracing, which may prevent medial collateral ligament injuries, was used at a significantly (P < .0001) higher rate by NCAA teams (89%) than by NFL teams (28%). Ketorolac injections were given by a significantly (P < .01) higher percentage of NFL teams (93%) than of NCAA teams (62%). Understanding the current trends in the management of these injuries is beneficial in designing studies that may help improve the treatment and prevention of injuries in football players.

Type I Open Fractures Benefit From Immediate Antibiotic Administration But Not Necessarily Immediate Surgery.

Pediatric open fractures are rare, occurring in approximately 2% to 9% of all pediatric fractures. Type I open fractures represent the most common type of open fractures seen in pediatrics and are commonly caused by low-energy mechanisms. The management of these injuries has been primarily dictated by the adult literature. Immediate antibiotic administration, specifically a first generation cephalosporin, has been shown to reduce infection rates. The duration of antibiotic treatment is less clear, but longer courses of antibiotics have not been significantly better than a shorter course. Retrospective case series have shown no difference in infection rates with nonoperative management of type I open fractures. However, concern regarding serious and even life-threatening infection continues to limit the universal adoption of nonoperative treatment protocols. A prospective randomized control trial is underway and will hopefully elucidate which open fractures can be safely managed with prompt antibiotic administration and nonoperative care.

A Modification to the McHale Procedure Reduces Operative Time and Blood Loss.

BACKGROUND: Treatment of symptomatic spastic hip dislocations in adolescent patients with cerebral palsy includes a variety of described salvage type procedures. In 1990, McHale and colleagues described a technique involving a femoral head resection, valgus-producing proximal femoral osteotomy, and advancement of the lesser trochanter into the acetabulum. We have modified this technique in 3 ways by: performing it in the lateral position with a more posterior approach, not advancing the lesser trochanter into the acetabulum, and closing the capsule over the acetabulum. The purpose of this paper is to describe our technique and to compare the results to Castle type procedures and McHale procedures performed as originally described. METHODS: We retrospectively reviewed all salvage type procedures performed at our institution for spastic hip dislocations in children with cerebral palsy from 2003 to 2013. Preoperative and postoperative pain, estimated blood loss, operative time, length of stay in the hospital, and postoperative pelvis radiographs were reviewed for heterotopic ossification formation and proximal femoral migration. RESULTS: Twenty-six patients with 30 hip procedures were reviewed. The modified McHale technique had shorter operative times when compared with the supine McHale technique and the Castle procedure (134, 171, and 139 min, respectively). There was a trend toward less blood loss in the modified McHale technique, but this was not significant. There was no difference in length of stay in the hospital. The majority of McHale patients (>63%) had pain relief postoperatively, where half of the Castle patients required a revision surgery for pain (4 of 8). There was less heterotopic ossification seen in the modified McHale technique (6.25%) when compared with supine McHale and Castle techniques (both 50%). However, there was more proximal femoral migration in the modified McHale group. CONCLUSIONS: The modified McHale technique is faster with otherwise equivocal results in the immediate operative periods. There is less heterotopic bone formation but more proximal femoral migration with this new technique. LEVEL OF EVIDENCE: Level IV-case series.

Anatomy of a transformation: a systematic effort to reduce mechanical restraints at a state psychiatric hospital.

OBJECTIVE: The authors describe efforts to reduce use of mechanical restraints at a state psychiatric hospital. METHODS: Data were collected for individuals admitted to the acute adult unit (AAU) (N=2,910) and the community transition unit (CTU) (N=334) over three years. Two strategies aimed to reduce mechanical restraint use. First, staff were trained in deescalation techniques, and a response team was formed for crisis situations. Second, a policy change required prior approval for use of mechanical restraint. RESULTS: Mechanical restraint was significantly reduced on both units after the first strategy. After the second, additional reduction was noted on AAU (98% total reduction) but not on CTU, where the practice had already been eliminated. No increase in assaults or injuries was noted. CONCLUSIONS: Reduction in mechanical restraint use is possible through deescalation skills training, use of a response team, and policy changes. Strong leadership, staff buy-in, provision of feedback, and quality monitoring were also instrumental.

Comparison of computerized and paper versions of the Western Ontario Rotator Cuff (WORC) Index.

BACKGROUND: The Western Ontario Rotator Cuff Index (WORC) is commonly used in orthopedic research to assess the effect of a rotator cuff injury. Questions in the WORC are presented in a visual analog scale format, which requires patients to place a pencil mark along a 10-cm line indicating their responses. The purpose of our study was to determine if a computerized version of a visual analog scale requiring patients drag a cursor along a line was comparable to data collected using the standard paper version of the WORC. MATERIALS AND METHODS: Administration of the WORC was randomized, with the first version given in the waiting room before the office visit, and the second immediately after the office visit, to ensure the participant's shoulder function had not significantly changed. RESULTS: Thirty-five patients with rotator cuff injury completed the paper and computerized versions of the WORC. There was no significant difference in mean scores for the WORC between the paper (1040.3) and computerized versions (1021.2, P = .488). The intraclass correlation coefficient for the 2 versions was 0.94. Similarly, there were no significant differences in scores between the subset of scores within the WORC (Physical Activity, Work, Sports, Lifestyle, and Emotion, P > .05), and each subset was highly correlated (intraclass correlation coefficient >0.80). CONCLUSIONS: There was no significant difference in scores for the WORC index when administered in a computerized format vs a paper format.

Promoting interdisciplinary care of patients and families: a classroom project.

Interdisciplinary educational experiences provide opportunities for nursing students to gain knowledge regarding the contributions of other healthcare providers in ensuring quality patient care. The project, part of a family health course, brought together students from 5 disciplines to heighten awareness of the necessity of, and the call for, interdisciplinary education. The authors discuss the project and its structure to provide ideas to other educators who may want to integrate an innovative interdisciplinary experience into their course.

Patient perspectives on antipsychotic treatments and their association with clinical outcomes.

This analysis examined patient-reported attitudes toward antipsychotic medication and the relationship of these attitudes with clinical outcomes and pharmacotherapy adherence. The analysis included three randomized, double-blind studies in patients with schizophrenia, schizoaffective disorder, or schizophreniform disorder diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders 4th Edition and randomly assigned to treatment with olanzapine 5-20 mg/day or another antipsychotic (haloperidol 2-20 mg/day, risperidone 2-10 mg/day, or ziprasidone 80-160 mg/day). Patient-reported improvements were significantly greater for olanzapine (n = 488) versus other treatments (haloperidol n = 145, risperidone n = 158, or ziprasidone n = 271) on multiple Drug Attitude Inventory items. A positive attitude toward medication reported by patients was significantly associated with greater clinical improvement on the Positive and Negative Syndrome Scale and lower discontinuation rates. These results suggest that patients' perceptions of treatment benefits are associated with objective clinical measures, including reduction of symptom severity and lower discontinuation rates. Furthermore, olanzapine may be associated with more positive treatment attitudes. These findings may contribute to a better understanding of reasons for treatment adherence from patients' own perspectives.

Housing preferences and choices among adults with mental illness and substance use disorders: a qualitative study.

Housing is a crucial issue for adults with severe mental illness and co-occurring substance use disorders, as this population is particularly susceptible to housing instability and homelessness. We interviewed 40 adults with dual disorders, living in either supervised or independent housing arrangements, to examine housing preferences, decision making processes surrounding housing choices, and perceived barriers to housing. We found that many clients indicated their housing preferences had changed over time, and some clients related housing preferences to recovery. Although the majority of clients preferred independent housing, many also described benefits of supervised housing. Clients' current living situations appeared to be driven primarily by treatment provider recommendations and availability of housing. Common barriers to obtaining desired housing were lack of income and information. These findings have implications for supported housing models and approaches to providing housing for clients.

Implementing the illness management and recovery program for consumers with severe mental illness.

OBJECTIVE: The primary purpose of this study was to evaluate the statewide implementation of the illness management and recovery program, a curriculum-based intervention for adults with severe mental illnesses. METHODS: Using knowledge gained from the National Evidence-Based Practices Project, the ACT Center of Indiana assisted seven community mental health centers with implementation of the illness management and recovery program. Implementation was conducted by trainers, who provided in-depth skills training, ongoing monitoring and supervision, and consultation as needed. At six and 12 months, the fidelity of implementation was assessed by use of the Illness Management and Recovery Fidelity Scale, and changes in illness self-management, hope, and satisfaction with services were assessed for 324 consumers with severe mental illness by use of the Illness Management and Recovery Scale, the Adult State Hope Scale, and the Satisfaction With Services Scale, respectively. RESULTS: The illness management and recovery program was successfully implemented at six of seven sites; five sites achieved high fidelity by 12 months and the sixth by 24 months. Self-reports of consumers and clinicians indicated significant changes in illness self-management. Consumers reported increased hope but no changes in satisfaction with services. CONCLUSIONS: The illness management and recovery program can be implemented with a high degree of fidelity and may be a meaningful way for mental health providers to promote recovery and provide an evidence-based intervention.

Success of nonoperative management of adductor longus tendon ruptures in National Football League athletes.

BACKGROUND: Acute complete ruptures of the proximal adductor longus tendon are rare but challenging injuries to treat. The limited literature supports operative treatment, but data from management of chronic groin pain in athletes indicate that anatomical attachment of the tendon to the pubis may not be required for high-level function. HYPOTHESIS: Nonoperative management of complete adductor rupture can provide equal results to surgical repair in terms of return to play in the National Football League. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Using the National Football League Injury Surveillance System, adductor tendon ruptures documented by magnetic resonance imaging were identified in 19 National Football League players from 1992 to 2004. The team physician for each respective player completed a survey with information about history, physical examination, magnetic resonance imaging findings, treatment, and outcomes. Statistics were analyzed with a Student unpaired t test. RESULTS: Fourteen players were treated nonoperatively, and 5 players were treated with surgical repair using suture anchors. In both groups, all players eventually returned to play in the National Football League. Mean time for return to play was 6.1 +/- 3.1 weeks (range, 3-12 weeks) for the nonoperative group and 12.0 +/- 2.5 weeks (range, 10-16 weeks) for the operative group (P = .001). One player in the operative group suffered the complication of a draining wound and heterotopic ossification. Players represented a variety of positions, and 12 of 19 (63%) had experienced prior symptoms or events. CONCLUSION: Nonoperative treatment of proximal adductor tendon rupture results in a statistically significantly faster return to play than does operative treatment in athletes competing in the National Football League and avoids the risks associated with surgery while providing an equal likelihood of return to play at the professional level.

Measuring illness management outcomes: a psychometric study of clinician and consumer rating scales for illness self management and recovery.

Psychometric properties of the Illness Management and Recovery (IMR) Scales (consumer and clinician versions), new 15-item instruments measuring illness self-management and pursuit of recovery goals, were evaluated in consumers with severe mental illness. Both versions had moderate internal consistency and high 2-week test-retest reliability. In addition, the consumer version was correlated with self-ratings of recovery and symptoms, and the clinician version was correlated with clinician ratings of community functioning, indicating convergent validity. The results suggest the IMR Scales have adequate psychometric properties and may be useful in treatment planning and assessing recovery in individuals with severe mental illness.