Burns in South Asia: Outcomes from South Asian Burn Registry (SABR).

BACKGROUND: South Asian region contributes 59 % to the global mortality due to burns. However, we find a paucity of literature on the outcomes of burns from low- and middle-income countries (LMICs). South Asian Burn Registry (SABR) is a facility-based burns registry that collected data on in-patient burn care. This study assesses factors associated with mortality, length of hospital stay at the burns center, and functional status of burn patients. METHODS: Prospective data was collected from two specialized public sector burn centers between September 2014 - January 2015 from Bangladesh and Pakistan. Multivariable logistic, linear, and ordinal logistic regression was conducted to assess factors associated with inpatient-mortality, length of hospital stay, and functional status at discharge, respectively. RESULTS: Data on 883 patients was analyzed. Increased association with mortality was observed with administration of blood product (OR:3, 95 % CI:1.18-7.58) and nutritional support (OR:4.32, 95 % CI:1.55-12.02). Conversely, antibiotic regimens greater than 8 days was associated with decreased mortality (OR:0.1, 95 % CI:0.03-0.41). Associated increase in length of hospital stay was observed in patients with trauma associated with their burn injury, history of seizures (CE:47.93, 95 % CI 12.05-83.80), blood product (CE:22.09, 95 % CI:0.83-43.35) and oxygen administration (CE:23.7, 95 % CI:7.34-40.06). Patients who developed sepsis (OR:6.89, 95 % CI:1.92-24.73) and received blood products during hospitalization (OR:2.55, 95 % CI:1.38- 4.73) were more likely to have poor functional status at discharge. CONCLUSION: This study identified multiple factors associated with worse clinical outcomes for burn patients in South Asia. Understanding these parameters can guide targeted efforts to improve the process and quality of burn care in LMICs.

Unfavorable social determinants of health and risk of mortality in adults with diabetes: findings from the National Health Interview Survey.

INTRODUCTION: Understanding the role of social determinants of health as predictors of mortality in adults with diabetes may help improve health outcomes in this high-risk population. Using population-based, nationally representative data, this study investigated the cumulative effect of unfavorable social determinants on all-cause mortality in adults with diabetes. RESEARCH DESIGN AND METHODS: We used data from the 2013-2018 National Health Interview Survey, linked to the National Death Index through 2019, for mortality ascertainment. A total of 47 individual social determinants of health were used to categorize participants in quartiles denoting increasing levels of social disadvantage. Poisson regression was used to report age-adjusted mortality rates across increasing social burden. Multivariable Cox proportional hazards models were used to assess the association between cumulative social disadvantage and all-cause mortality in adults with diabetes, adjusting for traditional risk factors. RESULTS: The final sample comprised 182 445 adults, of whom 20 079 had diabetes. In the diabetes population, mortality rate increased from 1052.7 per 100 000 person-years in the first quartile (Q1) to 2073.1 in the fourth quartile (Q4). In multivariable models, individuals in Q4 experienced up to twofold higher mortality risk relative to those in Q1. This effect was observed similarly across gender and racial/ethnic subgroups, although with a relatively stronger association for non-Hispanic white participants compared with non-Hispanic black and Hispanic subpopulations. CONCLUSIONS: Cumulative social disadvantage in individuals with diabetes is associated with over twofold higher risk of mortality, independent of established risk factors. Our findings call for action to screen for unfavorable social determinants and design novel interventions to mitigate the risk of mortality in this high-risk population.

Factors associated with emergency department disposition among burn injury patients: Analysis of prehospital and emergency care characteristics using South Asia Burn Registry (SABR) data.

INTRODUCTION: Improvement in burn injury data collections and the quality of databanks has allowed meaningful study of the epidemiologic trends in burn care. The study assessed factors associated with disposition of burn injury patients from emergency department accounting for pre-hospital care and emergency care. METHODS: This prospective observational pilot study of the South Asia Burn Registry project was conducted at selected public sector burn centers in Bangladesh and Pakistan (September 2014 - January 2015). All age groups with an initial presentation to the burn centers were enrolled. Descriptive and regression analysis is presented. RESULTS: A total of 2749 patients were enrolled. The mean age was 21.7 ± 18.0 years, 55.3% were males, and about a quarter were children < 5 years. About 46.9% of the females were housewives. Scald burns were common among children (67.6%) while flame burns were common among adults (44.3%). About 75% of patients were brought in via non-ambulance mode of transport. More than 55% of patients were referrals from other facilities or clinics. The most common first aid given pre-hospital was the use of water or oil. About 25% were admitted for further care. The adjusted odds of being admitted compared to being sent home were highest for children < 5 yrs, those with higher total body surface area burnt, having arrived via ambulance, scald and electrical burn, having an associated injury and inhalational injury. CONCLUSION: The study provides insight into emergency burn care and associated factors that influenced outcomes for patients with burn injuries.

Epidemiology of unintentional injuries among 15-24-year-old vocational school youth from Peshawar Pakistan: A cross-sectional survey.

Background: The burden of unintentional injuries among youth (15-24 years) is high. There is paucity of data on unintentional injuries in youth working in Vocational Training Institutes. Objective: To determine the incidence, characteristics, and risk factors of unintentional injuries among youth. Methods: Design:: A retrospective cross-sectional survey was conducted among select vocational school youth in Peshawar, Pakistan between February 2022 to October 2022.Participants:: A total of 547 study participants participated in the survey, 356 were males while 191 were females. Data were collected on using the World Health Organization community survey guide for injuries and violence. Multilevel Negative Binomial Regression model was used to report incidence rate ratios of all unitentional injuries. Results: A total of 503 injuries were reported by the youth, with road traffic injuries being the most common (n=197, 39%), followed by burns (n=89, 18%), falls (n=79, 16%) and poisonings (n=15, 3%), drownings (n=23, 7.1%). Occupational injuries reported during vocational training were (n=95, 18%). Males had a higher incidence rates of RTI 3.24[2.35-5.3], falls 1.30 [0.74-2.27], poisonings 2.14 [0.57-7.58] and drownings 2.46(0.84-7.21), while females had a higher incidence rate of burns 2.19 [1.785-3.46].Lack of education 4.6 [1.12 -18.91] (p=0.034), smoking 1.25 [1.05 -2.69] (p=0.049), lack of fathers education 4.71 [2.12 -10.49] (p=<0.001), carrying a gun 6.59 [2.54 -17.11] (p=<0.001), crowded families 3.59 [3.11 -5.07] (p=<0.001), lower family income 2.04 [1.04 -4.02](p=0.039*), lack of helmet use 4.54 [2.12 -9.76] (p=<0.001) and lack of seat belt use 1.3 [1.14 -1.69] (p= <0.001) were significant risk factors for unintentional injuries in youth. Conclusion Added value of the study: This study is one of the first research studies conducted in vocational school youth in Pakistan. It provides the recent rate of unintentional injuries among the youth of Pakistan. High occupational injuries among vocational school youth were reported which needs further research.

Unfavorable social determinants of health and mortality risk by cardiovascular disease status: Findings from a National Study of United States Adults.

BACKGROUND: The association between cumulative burden of unfavorable social determinants of health (SDoH) and all-cause mortality has not been assessed by atherosclerotic cardiovascular disease (ASCVD) status on a population level in the United States. METHODS: We assessed the association between cumulative social disadvantage and all-cause mortality by ASCVD status in the National Health Interview Survey, linked to the National Death Index. RESULTS: In models adjusted for established clinical risk factors, individuals experiencing the highest level of social disadvantage (SDoH-Q4) had over 1.5 (aHR = 1.55; 95%CI = 1.22, 1.96) and 2-fold (aHR = 2.21; 95% CI = 1.91, 2.56) fold increased risk of mortality relative to those with the most favorable social profile (SDoH-Q1), respectively for adults with and without ASCVD; those experiencing co-occurring ASCVD and high social disadvantage had up to four-fold higher risk of mortality (aHR = 3.81; 95%CI = 3.36, 4.32). CONCLUSIONS: These findings emphasize the importance of a healthcare model that prioritizes efforts to identify and address key social and environmental barriers to health and wellbeing, particularly in individuals experiencing the double jeopardy of clinical and social risk.

Which curve is better? A comparative analysis of trauma scoring systems in a South Asian country.

Objectives: A diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings. Methods: Data were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS). Results: The mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively). Conclusion: Trauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems. Level of evidence: Level III.

Cumulative social disadvantage and health-related quality of life: national health interview survey 2013-2017.

BACKGROUND: Evidence for the association between social determinants of health (SDoH) and health-related quality of life (HRQoL) is largely based on single SDoH measures, with limited evaluation of cumulative social disadvantage. We examined the association between cumulative social disadvantage and the Health and Activity Limitation Index (HALex). METHODS: Using adult data from the National Health Interview Survey (2013-2017), we created a cumulative disadvantage index by aggregating 47 deprivations across 6 SDoH domains. Respondents were ranked using cumulative SDoH index quartiles (SDoH-Q1 to Q4), with higher quartile groups being more disadvantaged. We used two-part models for continuous HALex scores and logistic regression for poor HALex (< 20th percentile score) to examine HALex differences associated with cumulative disadvantage. Lower HALex scores implied poorer HRQoL performance. RESULTS: The study sample included 156,182 respondents, representing 232.8 million adults in the United States (mean age 46 years; 51.7% women). The mean HALex score was 0.85 and 17.7% had poor HALex. Higher SDoH quartile groups had poorer HALex performance (lower scores and increased prevalence of poor HALex). A unit increase in SDoH index was associated with - 0.010 (95% CI [-0.011, -0.010]) difference in HALex score and 20% higher odds of poor HALex (odds ratio, OR = 1.20; 95% CI [1.19, 1.21]). Relative to SDoH-Q1, SDoH-Q4 was associated with HALex score difference of -0.086 (95% CI [-0.089, -0.083]) and OR = 5.32 (95% CI [4.97, 5.70]) for poor HALex. Despite a higher burden of cumulative social disadvantage, Hispanics had a weaker SDoH-HALex association than their non-Hispanic White counterparts. CONCLUSIONS: Cumulative social disadvantage was associated with poorer HALex performance in an incremental fashion. Innovations to incorporate SDoH-screening tools into clinical decision systems must continue in order to accurately identify socially vulnerable groups in need of both clinical risk mitigation and social support. To maximize health returns, policies can be tailored through community partnerships to address systemic barriers that exist within distinct sociodemographic groups, as well as demographic differences in health perception and healthcare experience.

Low educational attainment is associated with higher all-cause and cardiovascular mortality in the United States adult population.

INTRODUCTION: Educational attainment is an important social determinant of health (SDOH) for cardiovascular disease (CVD). However, the association between educational attainment and all-cause and CVD mortality has not been longitudinally evaluated on a population-level in the US, especially in individuals with atherosclerotic cardiovascular disease (ASCVD). In this nationally representative study, we assessed the association between educational attainment and the risk of all-cause and cardiovascular (CVD) mortality in the general adult population and in adults with ASCVD in the US. METHODS: We used data from the 2006-2014 National Death Index-linked National Health Interview Survey for adults ≥ 18 years. We generated age-adjusted mortality rates (AAMR) by levels of educational attainment (< high school (HS), HS/General Education Development (GED), some college, and ≥ College) in the overall population and in adults with ASCVD. Cox proportional hazards models were used to examine the multivariable-adjusted associations between educational attainment and all-cause and CVD mortality. RESULTS: The sample comprised 210,853 participants (mean age 46.3), representing ~ 189 million adults annually, of which 8% had ASCVD. Overall, 14.7%, 27%, 20.3%, and 38% of the population had educational attainment < HS, HS/GED, Some College, and ≥ College, respectively. During a median follow-up of 4.5 years, all-cause age-adjusted mortality rates were 400.6 vs. 208.6 and 1446.7 vs. 984.0 for the total and ASCVD populations for < HS vs ≥ College education, respectively. CVD age adjusted mortality rates were 82.1 vs. 38.7 and 456.4 vs 279.5 for the total and ASCVD populations for < HS vs ≥ College education, respectively. In models adjusting for demographics and SDOH, < HS (reference = ≥ College) was associated with 40-50% increased risk of mortality in the total population and 20-40% increased risk of mortality in the ASCVD population, for both all-cause and CVD mortality. Further adjustment for traditional risk factors attenuated the associations but remained statistically significant for < HS in the overall population. Similar trends were seen across sociodemographic subgroups including age, sex, race/ethnicity, income, and insurance status. CONCLUSIONS: Lower educational attainment is independently associated with increased risk of all-cause and CVD mortality in both the total and ASCVD populations, with the highest risk observed for individuals with < HS education. Future efforts to understand persistent disparities in CVD and all-cause mortality should pay close attention to the role of education, and include educational attainment as an independent predictor in mortality risk prediction algorithms.

Race, Social Determinants of Health, and Risk of All-Cause and Cardiovascular Mortality in the United States.

OBJECTIVE: To examine the independent and interdependent effects of race and social determinants of health (SDoH) and risk of all-cause and cardiovascular disease (CVD) mortality in the US. DATA SOURCE/STUDY DESIGN: Secondary analysis of pooled data for 252,218 participants of the 2006-2018 National Health Interview Survey, linked to the National Death Index. METHODS: Age-adjusted mortality rates (AAMR) were reported for non-Hispanic White (NHW) and non-Hispanic Black (NHB) individuals overall, and by quintiles of SDoH burden, with higher quintiles representing higher cumulative social disadvantage (SDoH-Qx). Survival analysis was used to examine the association between race, SDoH-Qx, and all-cause and CVD mortality. FINDINGS: AAMRs for all-cause and CVD mortality were higher for NHB and considerably higher at higher levels of SDoH-Qx, however, with similar mortality rates at any given level of SDoH-Qx. In multivariable models, NHB experienced 20-25% higher mortality risk relative to NHW (aHR = 1.20-1.26); however, no association was observed after adjusting for SDoH. In contrast, higher SDoH burden was associated with up to nearly threefold increased risk of all-cause (aHR, Q5 vs Q1 = 2.81) and CVD mortality (aHR, Q5 vs Q1 = 2.90); the SDoH effect was observed similarly for NHB (aHR, Q5:all-cause mortality = 2.38; CVD mortality = 2.58) and NHW (aHR, Q5:all-cause mortality = 2.87; CVD mortality = 2.93) subgroups. SDoH burden mediated 40-60% of the association between NHB race and mortality. CONCLUSIONS: These findings highlight the critical role of SDoH as upstream drivers of racial inequities in all-cause and CVD mortality. Population level interventions focused on addressing adverse SDoH experienced by NHB individuals may help mitigate persistent disparities in mortality in the US.

Estimating the Burden of Disability From Road Traffic Injuries in 5 Low- and Middle-Income Countries: Protocol for a Prospective Observational Study.

BACKGROUND: Road traffic injuries (RTIs) are a leading cause of death and unintentional injuries globally. They claim 1.35 million lives and produce up to 50 million injuries each year, causing a major drain on health systems. Despite this high burden, there is a lack of robust data on the long-term consequences of RTIs, specifically the level of disability experienced by many survivors and its impact on their everyday lives. OBJECTIVE: This study aims to characterize RTIs, disability level, and related consequences affecting adult road traffic crash survivors in 5 low- and middle-income countries (LMICs). In addition, this study estimates the role of demographic and crash- and treatment-related factors in predicting adverse outcomes and disability as well as examining the disability level among patients with RTIs, likelihood of return to normal life, and the environmental factors that may influence these outcomes after discharge from the hospital. METHODS: This prospective observational study was conducted at selected hospitals in Bangladesh, Cambodia, Ethiopia, Mexico, and Zambia. The study sample included all adult patients with RTIs admitted to the hospital for at least 24 hours. Consecutive sampling was performed until the minimum required sample size of 400 was reached for each participating country. Data were collected from patients or their caregivers using a hospital-based surveillance tool administered at the participating sites as well as a telephone-based follow-up instrument administered 1, 3, and 6 months after discharge. Descriptive analysis and multivariate models will be used to estimate the contribution of a range of factors in predicting adverse outcomes, disability, and return to normal life. RESULTS: Enrollment began in June 2021 and was completed in April 2022. Follow-up data collection ended in September 2022. Data analysis is currently underway, with results expected for publication in mid-2023. Expected results include estimates of disability among patients with RTIs as well as identifying the predictors of adverse outcomes, disability, and the likelihood of return to normal life. CONCLUSIONS: Research findings will help better understand the long-term burden of disability from RTIs in the 5 LMICs and the challenges facing survivors of road traffic crashes. They will be used to inform interventions aimed at improving the health care, social, physical, and policy conditions in LMICs that can facilitate recovery and rehabilitation for patients with RTIs, reduce the burden of disability, and enhance their participation in society. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/40985.

The burden of injuries in Zambia: A call to research and action.

Injuries are predicted to become a greater cause of mortality than communicable diseases in sub-Saharan Africa by 2030, signaling a public health dilemma for governments and citizens in each country. This article uses epidemiological estimates of injuries in Zambia, considers the socio-economic impact of injuries, examines current policies for prevention, and provides a rapid situation analysis to help develop an action and research agenda for injury prevention in the country. It calls for better epidemiological data, capacity building for human resources, and adoption of evidence-based targets and interventions. For Zambia to reduce its burden of injuries, funding for research and training should be integral to the future of its national health agenda.

Cumulative Social Disadvantage and All-Cause Mortality in the United States: Findings from a National Study.

The extent to which cumulative social disadvantage-defined as aggregate social risk resulting from multiple co-occurring adverse social determinants of health (SDOH)-affects the risk of all-cause mortality, independent of demographic and clinical risk factors, is not well understood. The objective of this study was to examine the association between cumulative social disadvantage, measured using a comprehensive 47-factor SDOH framework, and mortality in a nationally representative sample of adults in the United States. The authors conducted secondary analysis of pooled data for 63,540 adult participants of the 2013-2015 National Death Index-linked National Health Interview Survey. Age-adjusted mortality rates (AAMRs) were reported by quintiles of aggregate SDOH burden, with higher quintiles denoting greater social disadvantage. Cox proportional hazards models were used to examine the association between cumulative social disadvantage and risk of all-cause mortality. AAMR increased significantly with greater SDOH burden, ranging from 631 per 100,000 person-years (PYs) for participants in SDOH-Q1 to 1490 per 100,000 PYs for those in SDOH-Q5. In regression models adjusted for demographics, being in SDOH-Q5 was associated with 2.5-fold higher risk of mortality, relative to Q1 (adjusted hazard ratio [aHR] = 2.57 [95% confidence interval, CI = 1.94-3.41]); the observed association persisted after adjusting for comorbidities, with over 2-fold increased risk of mortality for SDOH-Q5 versus Q1 (aHR = 2.02 [95% CI = 1.52-2.67]). These findings indicate that cumulative social disadvantage is associated with increased risk of all-cause mortality, independent of demographic and clinical factors. Population level interventions focused on improving individuals' social, economic, and environmental conditions may help reduce the burden of mortality and mitigate persistent disparities.

Unfavorable social determinants of health are associated with higher burden of financial toxicity among patients with atherosclerotic cardiovascular disease in the US: findings from the National Health Interview Survey.

BACKGROUND: Atherosclerotic cardiovascular disease (ASCVD) is a major cause of financial toxicity, defined as excess financial strain from healthcare, in the US. Identifying factors that put patients at greatest risk can help inform more targeted and cost-effective interventions. Specific social determinants of health (SDOH) such as income are associated with a higher risk of experiencing financial toxicity from healthcare, however, the associations between more comprehensive measures of cumulative social disadvantage and financial toxicity from healthcare are poorly understood. METHODS: Using the National Health Interview Survey (2013-17), we assessed patients with self-reported ASCVD. We identified 34 discrete SDOH items, across 6 domains: economic stability, education, food poverty, neighborhood conditions, social context, and health systems. To capture the cumulative effect of SDOH, an aggregate score was computed as their sum, and divided into quartiles, the highest (quartile 4) containing the most unfavorable scores. Financial toxicity included presence of: difficulty paying medical bills, and/or delayed/foregone care due to cost, and/or cost-related medication non-adherence. RESULTS: Approximately 37% of study participants reported experiencing financial toxicity from healthcare, with a prevalence of 15% among those in SDOH Q1 vs 68% in SDOH Q4. In fully-adjusted regression analyses, individuals in the 2nd, 3rd and 4th quartiles of the aggregate SDOH score had 1.90 (95% CI 1.60, 2.26), 3.66 (95% CI 3.11, 4.35), and 8.18 (95% CI 6.83, 9.79) higher odds of reporting any financial toxicity from healthcare, when compared with participants in the 1st quartile. The associations were consistent in age-stratified analyses, and were also present in analyses restricted to non-economic SDOH domains and to 7 upstream SDOH features. CONCLUSIONS: An unfavorable SDOH profile was strongly and independently associated with subjective financial toxicity from healthcare. This analysis provides further evidence to support policies and interventions aimed at screening for prevalent financial toxicity and for high financial toxicity risk among socially vulnerable groups.

A school of public health responds to the pandemic: A case study from Washington D.C.

The emergence of COVID-19 immediately affected higher education, and the closure of campuses at the start of the pandemic in March of 2020 forced educational institutions to quickly adapt to changing circumstances. Schools of public health faced challenges not only of shifting to remote learning and work environments, but also uniquely redirecting public health research and service efforts toward COVID-19. This paper offers a case study of how the Milken Institute School of Public Health at the George Washington University (GWSPH), the only school of public health in the nation's capital, initially adapted to the COVID-19 pandemic. Using a modified version of the Public Health Preparedness and Response Core Competency Model created by the Association of Schools and Programs of Public Health and the Centers for Disease Control and Prevention, we analyze how GWSPH worked in three areas-research, education, service/operations. We reviewed this initial response across four domains: model leadership; communication and management of information; planning and improving practice; and protecting worker (and student) health and safety. The adaptation of the model and the analysis of GWSPH's initial response to the pandemic can be useful to other schools of public health and health sciences in the United States and beyond, in preparing for all hazards. We hope that such analysis also informs the current concerns of schools such as return to in-person education as well as planning for future public health crises.

Evaluating industry attempts to influence public health: Applying an ethical framework in understanding commercial determinants of health.

Objectives: This paper explores industry influence on public health using a specific case study and applies an established ethical framework based on eleven principles to explore Commercial Determinants of Health (CDoH). It demonstrates an application of these principles to evaluate the ethical integrity of industry strategies and practices and their impacts on public health. Methods: Using eleven a priori, deductive, ethical principles as codes, this paper conducted an in-depth analysis of 19 e-mail chains and accompanying documents made publicly available through the Freedom of Information Act (FOIA) from U.S. Right to Know (USRTK) sent between Coca-Cola representatives, lobbyists, academics, and the International Life Sciences Institute (ILSI), founded by former Coca-Cola executives. Results: The three principles violated most frequently amongst the documents were consumer sovereignty (n = 22), evidence-informed actions (n = 21), and transparency (n = 20). Similarly, codes that featured most regularly across documents were transparency (13 out of 19 documents), consumer sovereignty (13 out of 19 documents), evidence-informed actions (9 out of 19 documents), and social justice and equity (9 out of 19 documents). All eleven principles were applied at least four times throughout the documents; however, responsiveness (z = 12), moral responsibility (z = 16), and holism (z = 30) were the least relevant to the data set. Conclusions: This case study of Coca-Cola demonstrates the usefulness of this ethics framework in reviewing actions of corporate actors in the promotion of products that are harmful to human health. It shows that the industry at times has low ethical integrity in their various strategies and practices to promote their products despite the negative impacts of these products on public health.

Peace and health: exploring the nexus in the Americas.

The relationship between peace and health is complex, multifactorial and fraught with challenges of definitions, measurements and outcomes. This exploratory commentary on this nexus within a focus on the Americas posits this challenge clearly and calls for more scholarship and empirical work on this issue from an interdisciplinary perspective. The overall goal of this paper is to try and explore the elements that impact the relationship between peace and health with a focus on the Americas (defined as countries spanning from Canada to Argentina) in the post-Cold war period. Focusing on the 1990s and onwards, we seek to underscore why violence continues to permeate these societies despite a third and lasting wave of democratisation in the hemisphere. We hope this will allow a more robust dialogue on peace and health in the regional and global health literature.

Improvement in trauma care for road traffic injuries: an assessment of the effect on mortality in low-income and middle-income countries.

Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (>145 000 lives saved) and instituting and improving trauma teams (>115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (>200 000 excess deaths to >200 000 lives saved per year). For clinical interventions, damage control resuscitation (>60 000 lives saved per year) and institution of interventional radiology (>50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions.