Descriptive Analysis of Outcomes After Onlay Ventral Hernia Repair in Obese Patients.

OBJECTIVE: To determine outcomes after on lay large ventral hernia repair in obese patients. INTRODUCTION: Large ventral hernia repairs (VHR) in obese patients remain a challenge. Obesity is a risk factor for intraoperative difficulties and postoperative complications. Recurrence rates after VHR in obese patients range between 12-50% versus 10% in nonobese patients. While results of laparoscopic techniques in VHR compare favorably to open, outcomes in correlation with obesity, technique, and defect size are less understood. METHODS: A single surgeon's experience of 329 consecutive VHR between 2013-2022 was retrospectively reviewed. Inclusion criteria were obesity (BMI >30) and large hernia defects (>5 cm). A modified onlay technique was used which included component release and a lightweight monofilament polypropylene mesh. Primary outcome measures were hernia recurrence and wound complications. RESULTS: A total of 56 patients met inclusion criteria. Patients were majority male (n=30, 54%), with a median age of 58.5 years (inter quartile range (IQR) 33-83), and median BMI of 36 kg/m2 (IQR: 30-72). Median hernia defect size was 8 cm (IQR: 5-15). Twenty patients had undergone prior mesh repairs. Median follow-up was 52 months (IQR: 6 months-9 years). Two patients experienced recurrence (3.6%) and four experienced wound complications (four seromas, one panniculitis, 8.9%). No patients suffered flap ischemia or necrosis. CONCLUSION: Obesity is a risk factor for poor outcomes after VHR. We developed a protocol for obese patients with large defects involving a modified onlay technique which demonstrates comparable results to other VHR techniques in obese patients.

Chronic Disease Comorbidities Among Injured Patients in Cameroon: A Retrospective Cohort Study.

INTRODUCTION: Chronic diseases are increasing but underdiagnosed in low-income and middle-income countries (LMICs), where injury mortality is already disproportionately high. We estimated prevalence of known chronic disease comorbidities and their association with outcomes among injured patients in Cameroon. MATERIALS AND METHODS: Injured patients aged ≥15 y presenting to four Cameroonian hospitals between October 2017 and January 2020 were included. Our explanatory variable was known chronic disease; prevalence was age-standardized. Outcomes were overall in-hospital mortality and admission or transfer from the emergency department (ED). Associations between known chronic disease and outcomes were evaluated using logistic regression adjusted for age, gender, estimated injury severity score (eISS), hospital, and household socioeconomic status. Unadjusted eISS-stratified and age-stratified outcomes were also compared via chi-squared tests. RESULTS: Of 7509 injured patients, 370 (4.9%) reported at least one known chronic disease; age-standardized prevalence was 8.4% (95% confidence interval [CI] 7.5%-9.2%). Patients with known chronic disease had higher mortality (4.6% versus 1.5%, adjusted odds ratio [aOR]: 2.61 [95% CI: 1.25-5.47], P = 0.011) and were more likely to be admitted or transferred from the ED (38.7% versus 19.8%, aOR: 1.40 [95% CI: 1.02-1.92], P = 0.038) compared to those without known comorbidities. Crude differences in mortality (11.3% versus 3.3%, P = 0.002) and hospital admission or transfer (63.8% versus 46.6%, P = 0.011) were most notable for patients with eISS 16-24. CONCLUSIONS: Despite underdiagnosis among Cameroonians, we demonstrated worse injury outcomes among those with known chronic diseases. Integrating chronic disease screening with injury care may help address underdiagnosis in Cameroon. Future work should assess whether chronic disease prevention in LMICs could improve injury outcomes.

Cardiovascular risk factors and comorbidities in people living with HIV: A cross-sectional multicenter study from Colombia comorbidities in a Colombian PLWHIV population.

INTRODUCTION: HIV is an independent risk factor for cardiovascular diseases (CVD). There is insufficient information regarding comorbidities and cardiovascular risk factors in the Colombian HIV population. The aim of this study is to describe the prevalence of cardiovascular risk factors and comorbidities in patients from the HIV Colombian Group VIHCOL. METHODS: This is a multicenter, cross-sectional study conducted in the VIHCOL network in Colombia. Patients 18 years or older who had at least 6 months of follow-up were included. A stratified random sampling was performed to estimate the adjusted prevalence of cardiovascular risk factors and comorbidities. RESULTS: A total of 1616 patients were included. 83.2% were men, and the median age was 34 years. The adjusted prevalence for dyslipidemia, active tobacco use, hypothyroidism, and arterial hypertension was 51.2% (99% CI: 48.0%-54.4%), 7.6% (99% CI: 5.9%-9.3%), 7.4% (99% CI: 5.7%-9.1%), and 6.3% (99% CI: 4.8%-7.9%), respectively. CONCLUSIONS: In this Colombian HIV cohort, there is a high prevalence of modifiable CVD risk factors such as dyslipidemia and active smoking. Non-pharmacological and pharmacological measures for the prevention and management of these risk factors should be reinforced.

Anal cytology screening in men who have sex with men with HIV at a university hospital in Bogotá, Colombia.

BACKGROUND: Risk of anal squamous cell carcinoma (anal cancer) is greater among men who have sex with men (MSM) living with human immunodeficiency virus (HIV). We describe the frequency of and factors associated with abnormal anal cytology results in Colombian MSM living with HIV. METHODS: This retrospective observational cohort study included MSM ≥18 years old living with HIV screened with anal cytology at Hospital Universitario San Ignacio in Bogotá, Colombia between January 2019 and February 2020. A multivariable log-binomial regression model estimated associations with abnormal anal cytology. RESULTS: A total of 211 patients were included. Mean age was 35.6 years. Sixty-eight (32.3%) had an abnormal anal cytology result: ASC-US 33.8% (n = 23); LSIL 60.3% (n = 41); and HSIL 5.9% (n = 4). MSM with an STI diagnosis in the previous 12 months (RR 1.48, [95% CI 1.03-2.12], p = 0.032) or with a CD4+ T cell count <200 (RR 2.08 [95% CI 1.16-3.73], p = 0.014) were significantly more likely to have abnormal anal cytology. CONCLUSIONS: These data provide crucial information to guide scale up of anal cancer screening at select centers in Colombia. Our results also suggest STI prevention efforts and improved virological control among MSM living with HIV may have the secondary benefit of reducing the risk of anal cancer.

Association of research timing with surgery resident perceptions of operative autonomy and satisfaction: A multi-institutional study.

BACKGROUND: General surgery residents commonly engage in research years after the second (Post-postgraduate year 2 [PostPGY2]) or third (PostPGY3) clinical training year. The impact of dedicated research training timing on training experience is unknown. Our aim was to examine the progression of residents' perceived meaningful operative autonomy and evaluate career satisfaction, in relation to research timing. METHODS: Categorical surgery residents with 2-year research requirements were surveyed regarding perceived autonomy for laparoscopic appendectomy, laparoscopic cholecystectomy, and right hemicolectomy and satisfaction with the impact of dedicated research training on professional development. Meaningful operative autonomy was defined as Zwisch scores ≥3 (passive help or supervision only). RESULTS: Residents from 17 programs participated (n = 233, 30.6%); 48% were PostPGY2. PostPGY3 residents were more likely to perceive meaningful operative autonomy when starting dedicated research training (laparoscopic appendectomy: 98% vs 74%, P < .001; laparoscopic cholecystectomy: 87% vs 48%, P < .001; right hemicolectomy: 27% vs 3%, P < .001). Meaningful operative autonomy declined during dedicated research training but was still higher for PostPGY3 residents for laparoscopic appendectomy (84% vs 42%, P < .001) and laparoscopic cholecystectomy (68% vs 30%, P < .001). By PGY4, PostPGY2 residents reported rates of meaningful operative autonomy comparable to PostPGY3 through training completion. A higher proportion of PostPGY3 residents reported dedicated research training satisfaction (90% vs 78%, P = .01). Training at PostPGY3 programs (odds ratio, 3.06, 95% confidence interval, 1.38-6.80) and postresearch training stage (compared with preresearch residents, odds ratio, 3.25, 95% confidence interval, 1.06-10.0) were independently associated with satisfaction. CONCLUSION: Significant differences existed in the progression of perceived operative autonomy and dedicated research training satisfaction between PostPGY2 and PostPGY3 residents. These results could help surgical educators make individualized decisions regarding research timing to promote surgical skill acquisition and resident well-being.

Pre-exposure prophylaxis use, HIV knowledge, and internalized homonegativity among men who have sex with men in Brazil: A cross-sectional study.

Background: Pre-exposure prophylaxis (PrEP) use in Brazil remains low despite free national access. We explored associations of HIV knowledge and internalized homonegativity with PrEP use among PrEP-eligible men who have sex with men (MSM). Methods: Brazilian Hornet users completed an online, cross-sectional survey in February-March 2020. We included cis-men ≥18 years old who reported recent sex with men and were PrEP-eligible per the following: condomless anal intercourse, partner(s) living with HIV, transactional sex, and/or sexually transmitted infection. Our outcome was current PrEP use, defined by the response, "I am currently taking PrEP." Key predictors included the HIV/AIDS Knowledge Assessment (HIV-KA) and Reactions to Homosexuality Scale (RHS); higher scores indicate greater knowledge and greater internalized homonegativity, respectively. Scales were standardized for analysis. Associations with current PrEP use were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). Findings: Among 2398 PrEP-eligible MSM, n = 370 (15·4%) reported current PrEP use. Increasing HIV-KA scores were associated with greater odds of PrEP use (aOR 1·70 [95%CI 1·41-2·04], p < 0·001), and increasing RHS scores with lower odds of PrEP use (aOR 0·83 [95%CI 0·73-0·96], p = 0·010). PrEP use was lower among 18-24 versus 40+-years-old MSM (aOR 0·43 [95%CI 0·27-0·69], p = 0·005), and in Black versus White/Asian respondents (aOR 0·51 [95%CI 0·31-0·85], p = 0·040). Interpretation: Among PrEP-eligible Brazilian MSM, HIV knowledge was associated with increased PrEP use and internalized homonegativity with decreased use. Wider dissemination of HIV prevention knowledge and addressing stigma experienced by MSM could promote increased PrEP use. Funding: National Institute of Mental Health, Fiocruz, Conselho Nacional de Desenvolvimento Científico e Tecnológico.

Introdução: O número de usuários da profilaxia pré-exposição (PrEP) no Brasil continua baixo, apesar do acesso gratuito pelo Sistema Único de Saúde. Exploramos as associações entre conhecimento sobre HIV e homonegatividade internalizada com o uso de PrEP entre homens que fazem sexo com homens (HSH) elegíveis para PrEP. Métodos: Brasileiros usuários do Hornet completaram uma pesquisa seccional online em fevereiro-março de 2020. Foram incluídos homens cis ≥18 anos, que reportaram sexo recente com homens e elegíveis para PrEP. O desfecho principal foi uso de PrEP, definido por: "Estou atualmente tomando PrEP." Os principais preditores incluíram escalas de Conhecimento em HIV/aids (HIV-KA) e de Reações à Homossexualidade (RHS); escores mais altos indicam maior conhecimento e maior homonegatividade internalizada, respectivamente. As escalas foram padronizadas para análise. Associações com uso da PrEP foram estimadas usando razões de chances ajustadas (aOR) com intervalos de confiança de 95% (IC95%). Resultados: Entre 2.398 HSH elegíveis para PrEP, 370 (15,4%) relataram o uso atual de PrEP. Maior conhecimento em HIV/AIDS foi associado a maior chance de uso de PrEP (aOR 1·70 [IC 95% 1·41­2·04], p < 0·001), e maior homonegatividade internalizada com menor chance de uso de PrEP (aOR 0·83 [95% IC 0·73­0·96], p = 0·010). Uso de PrEP foi menor entre HSH de 18­24 vs. 40+ anos (aOR 0·43 [IC95%:0·27­0·69], p = 0·005), e entre pretos versus brancos/asiáticos (aOR 0·51 [IC95% 0·31­0·85], p = 0·040). Interpretação: Entre brasileiros HSH elegíveis para a PrEP, o conhecimento do HIV foi associado ao aumento do uso da PrEP e homonegatividade internalizada com a diminuição do uso. Financiamento: National Institute of Mental Health, Fiocruz, Conselho Nacional de Desenvolvimento Científico e Tecnológico, Coordenação de Aperfeiçoamento¸ de Pessoal de Nível Superior.

Associations between social determinants of health and interpersonal violence-related injury in Cameroon: a cross-sectional study.

INTRODUCTION: Risk factors for interpersonal violence-related injury (IPVRI) in low-income and middle-income countries (LMICs) remain poorly defined. We describe associations between IPVRI and select social determinants of health (SDH) in Cameroon. METHODS: We conducted a cross-sectional analysis of prospective trauma registry data collected from injured patients >15 years old between October 2017 and January 2020 at four Cameroonian hospitals. Our primary outcome was IPVRI, compared with unintentional injury. Explanatory SDH variables included education level, employment status, household socioeconomic status (SES) and alcohol use. The EconomicClusters model grouped patients into household SES clusters: rural, urban poor, urban middle-class (MC) homeowners, urban MC tenants and urban wealthy. Results were stratified by sex. Categorical variables were compared via Pearson's χ2 statistic. Associations with IPVRI were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI). RESULTS: Among 7605 patients, 5488 (72.2%) were men. Unemployment was associated with increased odds of IPVRI for men (aOR 2.44 (95% CI 1.95 to 3.06), p<0.001) and women (aOR 2.53 (95% CI 1.35 to 4.72), p=0.004), as was alcohol use (men: aOR 2.33 (95% CI 1.91 to 2.83), p<0.001; women: aOR 3.71 (95% CI 2.41 to 5.72), p<0.001). Male patients from rural (aOR 1.45 (95% CI 1.04 to 2.03), p=0.028) or urban poor (aOR 2.08 (95% CI 1.27 to 3.41), p=0.004) compared with urban wealthy households had increased odds of IPVRI, as did female patients with primary-level/no formal (aOR 1.78 (95% CI 1.10 to 2.87), p=0.019) or secondary-level (aOR 1.54 (95% CI 1.03 to 2.32), p=0.037) compared with tertiary-level education. CONCLUSION: Lower educational attainment, unemployment, lower household SES and alcohol use are risk factors for IPVRI in Cameroon. Future research should explore LMIC-appropriate interventions to address SDH risk factors for IPVRI.

Pre-exposure prophylaxis use, HIV knowledge, and internalized homonegativity among men who have sex with men in Brazil: A cross-sectional study

Introdução: O número de usuários da profilaxia pré-exposição (PrEP) no Brasil continua baixo, apesar do acesso gratuito pelo Sistema Único de Saúde. Exploramos as associações entre conhecimento sobre HIV e homonegatividade internalizada com o uso de PrEP entre homens que fazem sexo com homens (HSH) elegíveis para PrEP. Métodos: Brasileiros usuários do Hornet completaram uma pesquisa seccional online em fevereiro-março de 2020. Foram incluídos homens cis ≥18 anos, que reportaram sexo recente com homens e elegíveis para PrEP. O desfecho principal foi uso de PrEP, definido por: "Estou atualmente tomando PrEP." Os principais preditores incluíram escalas de Conhecimento em HIV/aids (HIV-KA) e de Reações à Homossexualidade (RHS); escores mais altos indicam maior conhecimento e maior homonegatividade internalizada, respectivamente. As escalas foram padronizadas para análise. Associações com uso da PrEP foram estimadas usando razões de chances ajustadas (aOR) com intervalos de confiança de 95% (IC95%). Resultados: Entre 2.398 HSH elegíveis para PrEP, 370 (15,4%) relataram o uso atual de PrEP. Maior conhecimento em HIV/AIDS foi associado a maior chance de uso de PrEP (aOR 1·70 [IC 95% 1·41­2·04], p < 0·001), e maior homonegatividade internalizada com menor chance de uso de PrEP (aOR 0·83 [95% IC 0·73­0·96], p = 0·010). Uso de PrEP foi menor entre HSH de 18­24 vs. 40+ anos (aOR 0·43 [IC95%:0·27­0·69], p = 0·005), e entre pretos versus brancos/asiáticos (aOR 0·51 [IC95% 0·31­0·85], p = 0·040). Interpretação: Entre brasileiros HSH elegíveis para a PrEP, o conhecimento do HIV foi associado ao aumento do uso da PrEP e homonegatividade internalizada com a diminuição do uso.

Pre-exposure prophylaxis awareness, use, and intention to use in a regional sample of Latin American geosocial networking application users in 2018-2019.

Pre-exposure prophylaxis (PrEP) access is increasing in Latin America. We explored PrEP use among Spanish-speaking, Hornet geosocial networking application users from Latin American countries with limited PrEP data via an online survey completed between December 2018 and February 2019. A total of 718 Hornet users from 10 countries were included, of whom 72.1% reported PrEP awareness. Few (5.6%) were currently taking PrEP, though 32.1% intended to take PrEP in the subsequent 6 months. PrEP awareness was lower in 18-25 year olds compared to 26+ (62.4% vs. 75.6%, aOR 0.67, [95% CI 0.46-0.97]), and higher among those living in larger versus smaller cities (74.4% vs. 58.8%, aOR 1.96, [95% CI 1.25-3.07]) or countries with at least partial versus no PrEP policy adoption (79.1% vs. 60.8%, aOR 2.20, [95% CI 1.56-3.12]). Intention to use PrEP was higher among PrEP-eligible respondents (51.8% vs. 29.6%, aOR 2.26, [95% CI 1.26-4.07]) and those recently tested for a sexually transmitted infection (35.4% vs. 25.5%, aOR 1.58, [95% CI 1.01-2.48]). Efforts to expand PrEP use in Latin America should focus on national PrEP policy adoption, and research should explore barriers to awareness and use among young men who have sex with men.

Screening with Anal Cytology in Colombia: Initial Experience and Need for High-Resolution Anoscopy.

BACKGROUND: Men who have sex with men (MSM) living with human immunodeficiency virus (HIV) are at increased risk of anal cancer. Anal cytology can be used to screen for dysplasia, with high-resolution anoscopy (HRA) required for diagnostic confirmation. We describe the impact lack of HRA had on management of abnormal screening results in Bogotá, Colombia. MATERIAL AND METHODS: This retrospective cohort study includes MSM with HIV who underwent anal cytology screening between January 2019February 2020, with colorectal surgery (CRS) follow-up through July 2020. Cytology results included atypical squamous cells of undetermined significance (ASC-US), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (HSIL). Categorical and continuous variables were compared via Fisher's exact test and Wilcoxon rank-sum, respectively. RESULTS: Of 211 MSM screened, 68 had abnormal cytology: ASC-US (n = 23), LSIL (n = 41), HSIL (n = 4). Sixty (88.2%) were referred to CRS, and 51 (75.0%) attended ≥ 1 appointment. At initial assessment, 17 were referred for anal exam under anesthesia (EUA) for tissue resection, and 21 for rectosigmoidoscopy. Having perianal condyloma was associated with recommendation for EUA (P < 0.001), while cytology grade of dysplasia was not (P = 0.308). Eleven (16.2%) underwent EUA for condyloma resection. CONCLUSIONS: Few studies have described anal cancer screening in settings without HRA. We found lack of HRA limited management of abnormal cytology in Colombia. Those with condyloma underwent resection, but HRA remains necessary to localize and treat microscopic disease. Next steps include implementation of HRA in order to further develop the anal cancer screening program for MSM with HIV in Bogotá.

A pilot study of stored low titer group O whole blood + component therapy versus component therapy only for civilian trauma patients.

BACKGROUND: This pilot assessed transfusion requirements during resuscitation with whole blood followed by standard component therapy (CT) versus CT alone, during a change in practice at a large urban Level I trauma center. METHODS: This was a single-center prospective cohort pilot study. Male trauma patients received up to 4 units of cold-stored low anti-A, anti-B group O whole blood (LTOWB) as initial resuscitation followed by CT as needed (LTOWB + CT). A control group consisting of women and men who presented when LTOWB was unavailable, received CT only (CT group). Exclusion criteria included antiplatelet or anticoagulant medication and death within 24 hours. The primary outcome was total transfusion volume at 24 hours. Secondary outcomes were mortality, morbidity, and intensive care unit- and hospital-free days. RESULTS: Thirty-eight patients received LTOWB, with a median of 2.0 (interquartile range [IQR] 1.0-3.0) units of LTOWB transfused. Thirty-two patients received CT only. At 24 hours after presentation, the LTOWB +CT group had received a median of 2,138 mL (IQR, 1,275-3,325 mL) of all blood products. The median for the CT group was 4,225 mL (IQR, 1,900-5,425 mL; p = 0.06) in unadjusted analysis. When adjusted for Injury Severity Score, sex, and positive Focused Assessment with Sonography for Trauma, LTOWB +CT group patients received 3307 mL of blood products, and CT group patients received 3,260 mL in the first 24 hours (p = 0.95). The adjusted median ratio of plasma to red cells transfused was higher in the LTOWB + CT group (0.85 vs. 0.63 at 24 hours after admission; p = 0.043. Adjusted mortality was 4.4% in the LTOWB + CT group, and 11.7% in the CT group (p = 0.19), with similar complications, intensive care unit-, and hospital-free days in both groups. CONCLUSION: Beginning resuscitation with LTOWB results in equivalent outcomes compared with resuscitation with CT only. LEVEL OF EVIDENCE: Therapeutic (Prospective study with 1 negative criterion, limited control of confounding factors), level III.

PrEP Awareness, Use, Intention to Use, and Information Source Among Geosocial Networking Application Users in Mexico in 2018-2019.

Pre-exposure prophylaxis (PrEP) has limited availability across Latin America, though access is increasing. We explored PrEP uptake in Mexico via an online survey completed by Spanish-speaking, Hornet geosocial networking application (GSN app) users without HIV (n = 2020). Most (81.3%) had heard of PrEP, 3.5% were current users, and 34.2% intended to take PrEP within six months. Current PrEP use was associated with PrEP eligibility (aOR 26.07 [95%CI 13.05-52.09], p < 0.001), recent STI testing (aOR 3.79 [95%CI 1.10-13.11], p = 0.035), and recent chemsex (aOR 3.02 [95%CI 1.02-8.93], p = 0.046). Recent STI testing was associated with hearing about PrEP from a doctor (aOR 3.26 [95%CI 1.98-5.36], p < 0.001), and those who lived in large cities were less likely to have learned about PrEP via Hornet (aOR 0.52 [95%CI 0.32-0.85], p = 0.009). Interventions to increase PrEP uptake in Mexico should build upon existing health networks and utilize GSN apps for PrEP information dissemination, particularly in less populated areas.

RESUMEN: La profilaxis pre-exposición (PrEP) tiene disponibilidad limitada en América Latina, aunque su acceso está aumentando. Exploramos el uso de PrEP en México a través de una encuesta en línea para sujetos hispanohablantes sin VIH usuarios de la aplicación de redes geosociales (GSN app) Hornet (n=2020). La mayoría (81,3%) había escuchado sobre PrEP, el 3,5% eran usuarios actuales, y el 34,2% tenían intención de tomar PrEP en seis meses o menos. El uso actual de PrEP estuvo asociado con la elegibilidad de tomar PrEP (aOR 26.07 [95%CI 13.05­52.09], p < 0.001), tener prueba reciente para ITS (aOR 3.79 [95%CI 1.10­13.11], p = 0.035), y chemsex reciente (aOR 3.02 [95%CI 1.02­8.93], p = 0.046). Tener prueba reciente para ITS se asoció con escuchar sobre PrEP de un médico (aOR 3.26 [95%CI 1.98­5.36], p < 0.001), y quienes vivían en ciudades grandes tenían menos probabilidad de conocer acerca de PrEP a través de Hornet (aOR 0.52 [95%CI 0.32­0.85], p = 0.009). Las intervenciones para aumentar el uso de PrEP en México deberían basarse en redes de salud existentes y usar las GSN apps para difundir información sobre PrEP, particularmente en áreas menos pobladas.

Surgical and Trauma Capacity Assessment in Rural Haryana, India.

Background: Trauma is a major global health problem and majority of the deaths occur in low- and middle-income countries (LMICs), at even higher rates in the rural areas. The three-delay model assesses three different delays in accessing healthcare and can be applied to improve surgical and trauma healthcare delivery. Prior to implementing change, the capacities of the rural India healthcare system need to be identified. Objective: The object of this study was to estimate surgical and trauma care capacities of government health facilities in rural Nanakpur, Haryana, India using the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT) tools. Methods: The PIPES and INTACT tools were administered at eight government health facilities serving the population of Nanakpur in June 2015. Data analysis was performed per tool subsection, and an overall score was calculated. Higher PIPES or INTACT indices correspond to greater surgical or trauma care capacity, respectively. Findings: Surgical and trauma care capacities increased with higher levels of care. The median PIPES score was significantly higher for tertiary facilities than primary and secondary facilities [13.8 (IQR 9.5, 18.2) vs. 4.7 (IQR 3.9, 6.2), p = 0.03]. The lower-level facilities were mainly lacking in personnel and procedures. Conclusions: Surgical and trauma care capacities at healthcare facilities in Haryana, India demonstrate a shortage of surgical resources at lower-level centers. Specifically, the Primary Health Centers were not operating at full capacity. These results can inform resource allocation, including increasing education, across different facility levels in rural India.

The Bolivian trauma patient's experience: A qualitative needs assessment.

BACKGROUND: Despite a significant burden of injury-related deaths, the Plurinational State of Bolivia (Bolivia), a lower- middle-income country in South America, lacks a formalized trauma system. This study sought to examine Bolivian trauma care from the patient perspective in order to determine barriers to care and targets for improvement. METHODS: Investigators conducted 15 semi-structured interviews with trauma patients admitted at four hospitals in Santa Cruz de la Sierra, Bolivia in June and July of 2016. Interviews were transcribed, translated, and analyzed through content and discourse analysis to identify key themes and perceptions of trauma care. RESULTS: Participants primarily presented with orthopedic injuries due to road traffic incidents and falls. Only one participant reported receiving first aid from a layperson at the scene of injury. Of the 15 participants, 12 did not know any number to contact emergency medical services (EMS). Participants expressed negative views of EMS as well as concerns for slow response times and inadequate personnel and training. Two thirds of participants were initially brought to a hospital without adequate resources to care for their injuries. Participants generally expressed positive views regarding healthcare workers involved in their hospital-based medical care. CONCLUSIONS: This region of Bolivia has a disorganized, underutilized, and distrusted trauma system. In order to increase survival, interventions should focus on improving prehospital trauma care. Potential interventions include the implementation of layperson trauma first responder courses, the establishment of a medical emergency hotline, the unification of EMS, the implementation of basic training requirements for EMS personnel, and public education campaigns to increase trust in EMS.

What is trauma? Qualitatively assessing stakeholder perceptions in Santa Cruz de la Sierra, Bolivia.

Addressing the burden of injury in low-resource settings requires development of trauma systems. This study aimed to describe perceptions of trauma in Santa Cruz, Bolivia to better inform strategies for trauma system development. In 2015-2016, we conducted 16 individual and 11 group interviews with key stakeholders involved with or exposed to trauma. A pile sorting activity showed participants pictures of injury mechanisms to explore perceptions of trauma. Responses were analysed for themes using content and discourse analysis. Among 27 interviews, six were with physicians, seven with first responders, three with community members, and 11 with trauma patients. Pictures commonly categorised as trauma depicted a road traffic incident (92.6%), fall (88.9%), gunshot wound (88.9%), and burn (85.2%). Fewer respondents stated intoxication (51.9%) or drowning (40.7%) were trauma. Coding of responses revealed five themes: trauma definition, mechanism, physical injury, management, and psychological trauma. Medical personnel focused more on trauma as mechanism, physical injury, and management, whereas laypersons commonly described trauma as psychological. Varied understanding of what represents trauma could influence trauma registry data collection. Laypersons' focus on psychological trauma may affect use of designated trauma care hospitals. These viewpoints must be considered when designing policies and interventions for trauma system strengthening.

SOSAS Study in Rural India: Using Accredited Social Health Activists as Enumerators.

BACKGROUND: Global estimates show five billion people lack access to safe, quality, and timely surgical care. The wealthiest third of the world's population receives approximately 73.6% of the world's total surgical procedures while the poorest third receives only 3.5%. This pilot study aimed to assess the local burden of surgical disease in a rural region of India through the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey and the feasibility of using Accredited Social Health Activists (ASHAs) as enumerators. MATERIAL AND METHODS: Data were collected in June and July 2015 in Nanakpur, Haryana from 50 households with the support of Indian community health workers, known as ASHAs. The head of household provided demographic data; two household members provided personal surgical histories. Current surgical need was defined as a self-reported surgical problem present at the time of the interview, and unmet surgical need as a surgical problem in which the respondent did not access care. RESULTS: One hundred percent of selected households participated, totaling 93 individuals. Twenty-eight people (30.1%; 95% CI 21.0-40.5) indicated they had a current surgical need in the following body regions: 2 face, 1 chest/breast, 1 back, 3 abdomen, 4 groin/genitalia, and 17 extremities. Six individuals had an unmet surgical need (6.5%; 95% CI 2.45%-13.5%). CONCLUSIONS: This pilot study in Nanakpur is the first implementation of the SOSAS survey in India and suggests a significant burden of surgical disease. The feasibility of employing ASHAs to administer the survey is demonstrated, providing a potential use of the ASHA program for a future countrywide survey. These data are useful preliminary evidence that emphasize the need to further evaluate interventions for strengthening surgical systems in rural India.

Assessment of Surgical and Trauma Capacity in Potosí, Bolivia.

BACKGROUND: Scaling up surgical and trauma care in low- and middle-income countries could prevent nearly 2 million annual deaths. Various survey instruments exist to measure surgical and trauma capacity, including Personnel, Infrastructure, Procedures, Equipment, and Supplies (PIPES) and International Assessment of Capacity for Trauma (INTACT). OBJECTIVE: We sought to evaluate surgical and trauma capacity in the Bolivian department of Potosí using a combined PIPES and INTACT tool, with additional questions to further inform intervention targets. METHODS: In June and July 2014 a combined PIPES and INTACT survey was administered to 20 government facilities in Potosí with a minimum of 1 operating room: 2 third-level, 10 second-level, and 8 first-level facilities. A surgeon, head physician, director, or obstetrician-gynecologist completed the survey. Additional personnel responded to 4 short-answer questions. Survey items were divided into subsections, and PIPES and INTACT indices calculated. Medians were compared via Wilcoxon rank sum and Kruskal-Wallis tests. FINDINGS: Six of 20 facilities were located in the capital city and designated urban. Urban establishments had higher median PIPES (8.5 vs 6.7, P = .11) and INTACT (8.5 vs 6.9, P = .16) indices compared with rural. More than half of surgeons and anesthesiologists worked in urban hospitals. Urban facilities had higher median infrastructure and procedure scores compared with rural. Fifty-three individuals completed short-answer questions. Training was most desired in laparoscopic surgery and trauma management; less than half of establishments reported staff with trauma training. CONCLUSIONS: Surgical and trauma capacity in Potosí was most limited in personnel, infrastructure, and procedures at rural facilities, with greater personnel deficiencies than previously reported. Interventions should focus on increasing the number of surgical and anesthesia personnel in rural areas, with a particular focus on the reported desire for trauma management training. Results have been made available to key stakeholders in Potosí to inform targeted quality improvement interventions.

Surgical and trauma care in low- and middle-income countries: a review of capacity assessments.

BACKGROUND: Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool. MATERIALS AND METHODS: Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included. RESULTS: Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration. CONCLUSIONS: Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.