Predictors of clinical deterioration and intensive care unit admission in trauma patients transferred from northern Quebec to a level 1 trauma centre: a retrospective cohort study.

BACKGROUND: Trauma care in Nunavik, Quebec, is highly challenging. Geographic distances and delays in transport can translate into precarious patient transfers to tertiary trauma care centres. The objective of this study was to identify predictors of clinical deterioration during transport and eventual intensive care unit (ICU) admission for trauma patients transferred from Nunavik to a tertiary trauma care centre. METHODS: This is a retrospective cohort study using the Montreal General Hospital (MGH) trauma registry. All adult trauma patients transferred from Nunavik and admitted to the MGH from 2010 to 2019 were included. Main outcomes of interest were hemodynamic and neurologic deterioration during transport and ICU admission. RESULTS: In total, 704 patients were transferred from Nunavik and admitted to the MGH during the study period. The median age was 33 (interquartile range [IQR] 23-47) years and the median Injury Severity Score was 10 (IQR 5-17). On multiple regression analysis, transport time from site of injury to the MGH (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.01-1.06), thoracic injuries (OR 1.75, 95% CI 1.03-2.99), and head and neck injuries (OR 3.76, 95% CI 2.10-6.76) predicted clinical deterioration during transfer. Injury Severity Score (OR 1.04, 95% CI 1.01-1.08), abnormal local Glasgow Coma Scale score (OR 2.57, 95% CI 1.34-4.95), clinical deterioration during transfer (OR 4.22, 95% CI 1.99-8.93), traumatic brain injury (OR 2.44, 95% CI 1.05-5.68), and transfusion requirement at the MGH (OR 4.63, 95% CI 2.35-9.09) were independent predictors of ICU admission. CONCLUSION: Our study identified several predictors of clinical deterioration during transfer and eventual ICU admission for trauma patients transferred from Nunavik. These factors could be used to refine triage criteria in Nunavik for more timely evacuation and higher level care during transport.

Surgical, trauma and telehealth capacity in Indigenous communities in Northern Quebec: a cross-sectional survey.

BACKGROUND: Delivering trauma and surgical care to Northern Quebec presents unique challenges owing to the region's remoteness, extreme weather and limited transport; the expansion of telehealth could help address these difficulties. We aimed to evaluate current surgical, trauma and telemedicine capacity in Nunavik, Quebec. METHODS: We used validated assessment tools, including the Personnel, Infrastructure, Procedures, Equipment and Supplies survey, the International Assessment of Capacity for Trauma index and the Maryland Health Care Commission Telemedicine Readiness tool to evaluate surgical, trauma and telemedicine capacity, respectively. We adapted these tools to the Northern Quebec context through discussions with local leadership. Data were collected in 2 regional hospitals - the Ungava Tulattavik Health Centre (UTHC) and the Inuulitsivik Health Centre (IHC) - and 12 Centres locaux de services communautaires (CLSCs; local community services centres) in 6 villages along the Hudson Bay coast and 6 villages along the Ungava Bay coast through iterative discussions with 4 chief nurses from each regional hospital and set of CLSCs; resources were confirmed through on-site evaluation by the respondents. We performed a descriptive analysis of the data. RESULTS: Surgical capacity was highest in the IHC (6.76) and lowest in the Ungava Bay CLSCs (5.52). Personnel (0%-0%) and procedures (13%-33%) were the least available resources. Trauma capacity was highest in the IHC (7.25) and lowest in the Hudson Bay CLSCs (5.58). Although equipment (90%-100%) and supplies (100%-100%) were readily available, personnel (0%-0%) and procedures (25%-56%) were lacking. The UTHC was most prepared for telehealth (67.80%), and the Ungava Bay CLSCs achieved a lower score (51.13%). Underdeveloped telehealth criteria included funding, administrative support, quality improvement and physical spaces (all 33%-67%). CONCLUSION: Acute care capacity in Nunavik appears heterogeneous, with readily available equipment and supplies, but a lack of personnel capable of performing lifesaving procedures. To address the need for telemedicine, future initiatives should focus on improving funding, administrative support, physical spaces and quality-improvement initiatives.

High-flow nasal oxygen as first-line therapy for COVID-19-associated hypoxemic respiratory failure: a single-centre historical cohort study.

PURPOSE: The optimal noninvasive modality for oxygenation support in COVID-19-associated hypoxemic respiratory failure and its association with healthcare worker infection remain uncertain. We report here our experience using high-flow nasal oxygen (HFNO) as the primary support mode for patients with COVID-19 in our institution. METHODS: We conducted a single-centre historical cohort study of all COVID-19 patients treated with HFNO for at least two hours in our university-affiliated and intensivist-staffed intensive care unit (Jewish General Hospital, Montreal, QC, Canada) between 27 August 2020 and 30 April 2021. We report their clinical characteristics and outcomes. Healthcare workers in our unit cared for these patients in single negative pressure rooms wearing KN95 or fit-tested N95 masks; they underwent mandatory symptomatic screening for COVID-19 infection, as well as a period of asymptomatic screening. RESULTS: One hundred and forty-two patients were analysed, with a median [interquartile range (IQR)] age of 66 [59-73] yr; 71% were male. Patients had a median [IQR] Sequential Organ Failure Assessment Score of 3 [2-3], median [IQR] oxygen saturation by pulse oximetry/fraction of inspired oxygen ratio of 120 [94-164], and a median [IQR] 4C score (a COVID-19-specific mortality score) of 12 [10-14]. Endotracheal intubation occurred in 48/142 (34%) patients, and overall hospital mortality was 16%. Barotrauma occurred in 21/142 (15%) patients. Among 27 symptomatic and 139 asymptomatic screening tests, there were no cases of HFNO-related COVID-19 transmission to healthcare workers. CONCLUSION: Our experience indicates that HFNO is an effective first-line therapy for hypoxemic respiratory failure in COVID-19 patients, and can be safely used without significant discernable infection risk to healthcare workers.

RéSUMé: OBJECTIF: La modalité non invasive optimale pour le soutien en oxygène lors d'insuffisance respiratoire hypoxémique liée à la COVID-19 et son association avec l'infection des travailleurs de la santé restent incertaines. Nous rapportons ici notre expérience avec l'utilisation de canules nasales à haut débit (CNHD) comme principale modalité de soutien pour les patients atteints de COVID-19 dans notre établissement. MéTHODE: Nous avons mené une étude de cohorte historique monocentrique de tous les patients atteints de COVID-19 traités par CNHD pendant au moins deux heures dans notre unité de soins intensifs affiliée à l'université et dotée d'intensivistes (Hôpital général juif, Montréal, QC, Canada) entre le 27 août 2020 et le 30 avril 2021. Nous rapportons leurs caractéristiques cliniques et leurs résultats. Les travailleurs de la santé de notre unité ont soigné ces patients dans des chambres individuelles à pression négative en portant des masques KN95 ou N95 ajustés; ils ont subi un dépistage symptomatique obligatoire de l'infection à la COVID-19, ainsi qu'un dépistage en période asymptomatique. RéSULTATS: Cent quarante-deux patients ont été analysés, avec un âge médian [écart interquartile (ÉIQ)] de 66 [59-73] ans; 71 % étaient des hommes. Les patients avaient un score SOFA (Sequential Organ Failure Assessment) médian [ÉIQ] de 3 [2, 3], un ratio médian [ÉIQ] de saturation en oxygène par oxymétrie de pouls/fraction d'oxygène inspiré de 120 [94-164], et un score 4C (un score de mortalité spécifique à la COVID-19) médian [ÉIQ] de 12 [10­14]. Dans l'ensemble, 48/142 patients (34 %) ont reçu une intubation endotrachéale, et la mortalité hospitalière globale était de 16 %. Un barotraumatisme est survenu chez 21/142 (15 %) patients. Parmi les 27 tests de dépistage symptomatiques et 139 tests asymptomatiques, aucun cas de transmission de COVID-19 liée aux CNHD aux travailleurs de la santé n'a été observé. CONCLUSION: Notre expérience indique que les CNHD constituent un traitement de première intention efficace pour l'insuffisance respiratoire hypoxémique chez les patients atteints de COVID-19 qui peut être utilisé en toute sécurité, sans risque d'infection significatif discernable pour les travailleurs de la santé.

Trauma in northern Quebec, 2005-2014: epidemiologic features, transfers and patient outcomes.

BACKGROUND: The Inuit people residing in Nunavik, Quebec, are vulnerable to major trauma owing to environmental and social factors; however, there is no systematic data collection for trauma in Nunavik, and, apart from data regarding patients who are transferred to tertiary care centres, no data enter the Quebec trauma registry directly from Nunavik. We performed a study to characterize the epidemiologic features of trauma in Nunavik, and describe indications for transfer and outcomes of patients referred to the tertiary trauma centre. METHODS: We collected data retrospectively for all patients with trauma admitted to the Centre de santé Tulattavik de l'Ungava in Kuujjuaq from 2005 to 2014. Sociodemographic, injury and health services data were extracted. The data were analyzed in conjunction with coroners' reports on death from trauma in Nunavik. RESULTS: A total of 797 trauma cases were identified. The most common causes of injury were motor vehicle collisions (258 cases [32.4%]), falls (137 [17.2%]) and blunt assault (95 [11.9%]). One-third of patients (262 [32.9%]) were transferred to the tertiary care centre in Montréal. The incidence rate of major trauma (Injury Severity Score > 12) was 18.1 and 21.7 per 10 000 person-years in the Kuujjuaq region and the Puvirnituq region, respectively, which translates to a relative risk (RR) of 4 compared to the Quebec population. The disparity observed in trauma mortality rate was even greater, with an RR of 47.6 compared to the Quebec population. CONCLUSION: The study showed major disparity in trauma incidence and mortality rate between Nunavik and the province of Quebec. Our findings allow for a better understanding of the burden of injury and regional trauma mortality in Nunavik, and recommendations for optimization of the trauma system in this unique setting.

The Financial Burden of Road Traffic Injuries in Mozambique: A Hospital-Related Cost-of-Illness Study of Maputo Central Hospital.

BACKGROUND: Road traffic injuries (RTIs) are increasingly being recognized for their significant economic impact. Mozambique, like other low-income countries, suffers staggering rates of road traffic collisions. To our knowledge, this is the first study to estimate direct hospital costs of RTIs using a bottom-up, micro-costing approach in the Mozambican context. This study aims to calculate the direct, inpatient costs of RTIs in Mozambique and compare it to the financial capacity of the Mozambican public health care system. METHODS: This was a retrospective, single-centre study. Charts of all patients with RTIs admitted to Maputo Central Hospital over a period of 2 months were reviewed. The costs were recorded and analysed based on direct costs, human resource costs, and overhead costs. Costs were calculated using a micro-costing approach. RESULTS: In total, 114 patients were admitted and treated for RTIs at Maputo Central Hospital during June-July 2015. On average, the hospital cost per patient was US$ 604.28 (IQR 1033.58). Of this, 44% was related to procedural costs, 23% to diagnostic imaging costs, 17% to length-of-stay costs, 9% to medication costs, and 7% to laboratory test costs. The average annual inpatient cost of RTIs in Mozambique was almost US$ 116 million (0.8% of GDP). CONCLUSION: The financial burden of RTIs in Mozambique represents approximately 40% of the annual public health care budget. These results help highlight the economic impact of trauma in Mozambique and the importance of an organized trauma system to reduce such costs.

Burden of road traffic injuries in Nepal: results of a countrywide population-based survey.

BACKGROUND: Road traffic injury has emerged as a leading cause of mortality, contributing to 2·1% of deaths globally and is predicted to be the third highest contributor to the global burden of mortality by 2020. This major public health problem disproportionately affects low-income and middle-income countries, where such incidents are too often underreported. Our study aims to explore the epidemiology of road traffic injurys in Nepal at a population level via a countrywide study. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a cluster randomised, cross-sectional nationwide survey, was conducted in Nepal between May 25, and June 12, 2014. Two-stage cluster sampling was performed: 15 of 75 districts were chosen randomly proportional to population; within each district, after stratification for urban and rural, and three clusters were randomly chosen. Questions were structured anatomically and designed around a representative spectrum of surgical conditions. Road traffic injury-related results were reported. FINDINGS: 1350 households and 2695 individuals were surveyed with a response rate of 97%. 75 road traffic injuries were reported in 72 individuals (2·67% [95% CI 2·10-3·35] of the study population), with a mean age of 33·2 years (SD 1·85). The most commonly affected age group was 30-44 years, with females showing significantly lower odds of sustaining a road traffic injury than men (crude odds ratio 0·29 [95% CI 0·16-0·52]). Road traffic injuries composed 19·8% of the injuries reported. Motorcycle crashes were the most common road traffic injuries (48·0%), followed by car, truck, or bus crashes (26·7%), and pedestrian or bicycle crashes (25·3%). The extremity was the most common anatomic site injured (74·7%). Of the 80 deaths reported in the previous year, 7·5% (n=6) were due to road traffic injuries. INTERPRETATION: This study provides the epidemiology of road traffic injuries at a population-based level in the first countrywide surgical needs assessment in Nepal. WHO reported that mortality due to road traffic injuries in Nepal in 2011 was 1·7%, whereas our study reported 7·5%, consistent with the concept of underreporting of deaths in police and hospital level data noted in previous literature. Road traffic injuries continue to be a significant problem in Nepal, probably greater than previously reported; future efforts should focus on addressing this growing epidemic through preventive and mitigating strategies. FUNDING: The Association for Academic Surgery and Surgeons OverSeas.

Injury assessment in three low-resource settings: a reference for worldwide estimates.

BACKGROUND: Trauma has become a worldwide pandemic. Without dedicated public health interventions, fatal injuries will rise 40% and become the 4th leading cause of death by 2030, with the burden highest in low-income and middle-income countries (LMICs). The aim of this study was to estimate the prevalence of traumatic injuries and injury-related deaths in low-resource countries worldwide, using population-based data from the Surgeons OverSeas Assessment of Surgical Need (SOSAS), a validated survey tool. METHODS: Using data from three resource-poor countries (Nepal, Rwanda, and Sierra Leone), a weighted average of injury prevalence and deaths due to injury was calculated and extrapolated to low-resource countries worldwide. Injuries were defined as wounds from road traffic injuries (bus, car, truck, pedestrian, and bicycle), gunshot or stab or slash wounds, falls, work or home incidents, and burns. The Nepal study included a visual physical examination that confirmed the validity of the self-reported data. Population and annual health expenditure per capita data were obtained from the World Bank. Low-resource countries were defined as those with an annual per capita health expenditure of US$100 or less. FINDINGS: The overall prevalence of lifetime injury for these three countries was 18·03% (95% CI 18·02-18·04); 11·64% (95% CI 11·53-11·75) of deaths annually were due to injury. An estimated prevalence of lifetime injuries for the total population in 48 low-resource countries is 465·7 million people; about 2·6 million fatal injuries occur in these countries annually. INTERPRETATION: The limitations of this observational study with self-reported data include possible recall and desirability bias. About 466 million people at a community level (18%) sustain at least one injury during their lifetime and 2·6 million people die annually from trauma in the world's poorest countries. Trauma care capacity should be considered a global health priority; the importance of integrating a coordinated trauma system into any health system should not be underestimated. FUNDING: None.

Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities.

BACKGROUND: Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures. METHODS: The authors conducted a retrospective analysis of anesthetic procedures performed at Médecins Sans Frontières facilities from July 2008 to June 2014. The authors collected data on patient demographics, procedural characteristics, and patient outcome. The factors associated with perioperative mortality were analyzed. RESULTS: Over the 6-yr period, 75,536 anesthetics were provided to adult patients. The most common anesthesia techniques were spinal anesthesia (45.56%) and general anesthesia without intubation (33.85%). Overall perioperative mortality was 0.25%. Emergent procedures (0.41%; adjusted odds ratio [AOR], 15.86; 95% CI, 2.14 to 115.58), specialized surgeries (2.74%; AOR, 3.82; 95% CI, 1.27 to 11.47), and surgical duration more than 6 h (9.76%; AOR, 4.02; 95% CI, 1.09 to 14.88) were associated with higher odds of mortality than elective surgeries, minor surgeries, and surgical duration less than 1 h, respectively. Compared with general anesthesia with intubation, spinal anesthesia, regional anesthesia, and general anesthesia without intubation were associated with lower perioperative mortality rates of 0.04% (AOR, 0.10; 95% CI, 0.05 to 0.18), 0.06% (AOR, 0.26; 95% CI, 0.08 to 0.92), and 0.14% (AOR, 0.29; 95% CI, 0.18 to 0.45), respectively. CONCLUSIONS: A wide range of anesthetics can be carried out safely in resource-limited settings. Providers need to be aware of the potential risks and the outcomes associated with anesthesia administration in these settings.

Trauma care and referral patterns in Rwanda: implications for trauma system development.

BACKGROUND: Trauma remains a leading cause of death worldwide. The development of trauma systems in low-resource settings may be of benefit. The objective of this study was to describe operative procedures performed for trauma at a tertiary care facility in Kigali, Rwanda, and to evaluate geographical variations and referral patterns of trauma care. METHODS: We retrospectively reviewed all prospectively collected operative cases performed at the largest referral hospital in Rwanda, the Centre Hospitalier Universitaire de Kigali (CHUK), between June 1 and Dec. 1, 2011, for injury-related diagnoses. We used the Pearson χ² and Fisher exact tests to compare cases arising from within Kigali to those transferred from other provinces. Geospatial analyses were also performed to further elucidate transfer patterns. RESULTS: Over the 6-month study period, 2758 surgical interventions were performed at the CHUK. Of these, 653 (23.7%) were for trauma. Most patients resided outside of Kigali city, with 337 (58.0%) patients transferred from other provinces and 244 (42.0%) from within Kigali. Most trauma procedures were orthopedic (489 [84.2%]), although general surgery procedures represented a higher proportion of trauma surgeries in patients from other provinces than in patients from within Kigali (28 of 337 [8.3%] v. 10 of 244 [4.1%]). CONCLUSION: To our knowledge, this is the first study to highlight geographical variations in access to trauma care in a low-income country and the first description of trauma procedures at a referral centre in Rwanda. Future efforts should focus on maturing prehospital and interfacility transport systems, strengthening district hospitals and further supporting referral institutions.

CONTEXTE: Les traumatismes demeurent l'une des principales causes de décès dans le monde. La mise au point de systèmes de traumatologie dans des milieux défavorisés pourrait toutefois contribuer à améliorer la situation. Notre étude avait pour objectif de décrire les interventions chirurgicales pratiquées sur les victimes de traumatismes dans un établissement de soins tertiaires de Kigali, au Rwanda, et d'évaluer les variations géographiques et les habitudes d'orientation des patients dans le domaine de la traumatologie. MÉTHODES: Nous avons évalué rétroactivement les données recueillies de façon prospective sur l'ensemble des interventions réalisées au plus grand centre hospitalier régional du Rwanda, le Centre hospitalier universitaire de Kigali (CHUK), du 1er juin au 1er décembre 2011 pour les diagnostics liés à des blessures. Nous avons eu recours au test χ² de Pearson et au test exact de Fisher pour comparer les cas issus de la province de Kigali à ceux provenant d'autres provinces. Nous avons en outre effectué des analyses géospatiales afin de mieux comprendre les habitudes d'orientation des patients. RÉSULTATS: Au cours des 6 mois de l'étude, 2758 interventions chirurgicales ont été pratiquées au CHUK, dont 653 (23,7 %) pour des traumatismes. La majorité des patients résidaient à l'extérieur de la capitale : 337 (58,0 %) d'entre eux avaient été transférés d'autres provinces, et 244 (42,0 %), d'ailleurs dans la province. Si la plupart des interventions chirurgicales étaient orthopédiques (489, soit 84,2 %), les patients d'autres provinces ont plus souvent subi des interventions générales que leurs compatriotes de la province de Kigali (28 sur 337, soit 8,3 %, par rapport à 10 sur 244, soit 4,1 %). CONCLUSION: À notre connaissance, il s'agit de la première étude mettant en lumière les variations géographiques de l'accès aux soins en traumatologie dans un pays à faible revenu et de la première description des interventions chirurgicales pratiquées sur des victimes de traumatismes dans un centre régional du Rwanda. Les travaux à venir devraient être axés sur le développement des systèmes de transport avant l'hospitalisation et entre les établissements, le renforcement des hôpitaux de district et l'augmentation du soutien aux centres régionaux.

Prioritizing injury care: a review of trauma capacity in low and middle-income countries.

BACKGROUND: Trauma is a large contributor to the global burden of disease, particularly in low and middle-income countries (LMICs). This study aimed to summarize the literature assessing surgical capacity in LMICs to provide a current assessment of trauma capacity, which will help guide future efforts. MATERIALS AND METHODS: The MEDLINE database was queried via PubMed to identify studies assessing baseline surgical capacity in individual LMICs. Data were collected from each study by extracting the relevant information from the full-published text or tables. Trauma capacity was evaluated using 12 surrogate criteria of trauma care, including laparotomy, cricothyroidotomy and chest tube insertion capabilities, and accessibility to a blood bank. RESULTS: Seventeen studies were reviewed, documenting data from 531 hospitals in seventeen countries. None of the countries had access to all twelve trauma criteria in all their hospitals. Endotracheal intubation and cricothyrotomy or tracheostomy were available at 48% (107/222) and 41% (163/418) of facilities, respectively. Bag mask valves were available at 61% (234/383) of the institutions. Although 87% (193/221) of facilities responded that they were able to provide initial resuscitation, only 48% (169/349) of them had access to a blood bank and 70% (191/271) had access to intravenous fluids. A third or less of district hospitals had access to basic resuscitation (33%; 8/24), endotracheal tubes (32%; 31/97), blood banks (31%; 32/102), and cricothyrotomies and/or tracheostomies (32%; 30/95). CONCLUSIONS: Deficiencies in trauma capacity in LMICs remain widespread. This study provides specific avenues for improved evaluations of trauma capacity and for strengthening trauma systems in LMICs.

Recommendations for including surgery on the public health agenda.

BACKGROUND: Surgical care has made limited inroads on the public health and global health agendas despite increasing data showing the enormous need. The objective of this study was to survey interested members of a global surgery community to identify patterns of thought regarding barriers to political priority. MATERIALS AND METHODS: All active members of the nongovernmental organization Surgeons OverSeas were surveyed and asked why surgical care is not receiving recognition and support on the public health and global health agenda. Responses were categorized using the Shiffman framework on determinants of political priority for global initiatives by two independent investigators, and the number of responses for each of the 11 factors was calculated. RESULTS: Seventy-five Surgeons OverSeas members replied (75 of 176; 42.6% response rate). A total of 248 individual reasons were collected. The most common responses were related to external frame, defined as public portrayals of the issue (60 of 248; 24.2%), and lack of effective interventions (48 of 248; 19.4%). Least cited reasons related to global governance structure (4 of 248; 2.4%) and policy window (4 of 248; 1.6%). CONCLUSIONS: This survey of a global surgery community identified a number of barriers to the recognition of surgical care on the global health agenda. Recommendations include improving the public portrayal of the problem; developing effective interventions and seeking strong and charismatic leadership.

Prevalence of surgical conditions in individuals aged more than 50 years: a cluster-based household survey in Sierra Leone.

BACKGROUND: With the demographic transition disproportionately affecting developing nations, the healthcare burden associated with the elderly is likely to be compounded by poor baseline surgical capacity in these settings. We sought to assess the prevalence of surgical disease and disability in the elderly population of Sierra Leone to guide future development strategies. METHODS: A cluster randomized, cross-sectional household survey was carried out countrywide in Sierra Leone from January 9th to February 3rd 2012. Using a standardized questionnaire, household member demographics, deaths occurring during the previous 12 months, and presence of any current surgical condition were elucidated. A retrospective analysis of individuals aged 50 and over was performed. RESULTS: The survey included 1,843 households with a total of 3,645 respondents. Of these, 13.6 % (496/3,645) were aged over 50 years. Of the elderly individuals in our sample, 301 (60.7 %) reported a current surgical condition. Of current surgical disease identified among elderly individuals (n = 530), 349 (65.8 %) described it as disabling, and 223 (42.1 %) sought help from traditional medicine practitioners. Women (odds ratio [OR] 0.60; 95 % confidence interval [CI] 0.40-0.90) and individuals living in urban settings (OR 0.44, 95 % CI 0.26-0.75) were less likely to report a current surgical problem. Of the 230 elderly deaths in the previous year, 83 (36.1 %) reported a surgical condition in the week prior. CONCLUSIONS: The unmet burden of surgical disease is prevalent in the elderly in low-resource settings. This patient population is expected to grow significantly in the coming years, and more resources should be allocated to address their surgical needs.

Operative procedures in the elderly in low-resource settings: a review of Médecins Sans Frontières facilities.

BACKGROUND: As the demographic transition occurs across developing countries, an increasing number of elderly individuals are affected by disasters and conflicts. This study aimed to evaluate the elderly population that underwent an operative procedure at MSF facilities. METHODS: A retrospective review of prospectively collected operative cases performed at MSF-Operational Centre Brussels (MSF-OCB) facilities between June 2008 and December 2012 was completed. Baseline demographic data, American Society of Anesthesiologists (ASA) physical status and surgical indications were collected for each patient. For each procedure, the degree of urgency, anesthesia type, and intra-operative mortality were noted. All patients aged 50 and over at the time of the procedure were considered elderly, as proposed by the World Health Organization (WHO). Comparisons were made with the 18-49 age group in order to elucidate differences between older and younger individuals. RESULTS: We reviewed a total of 93,385 procedures performed on 83,911 patients in 21 different countries. Patients aged 50 and over comprised 11.5% (9,628/83,911) of all patients. While most procedures (57.6%) in the comparison group were urgent, this proportion decreased substantially in the elderly. Intra-operative mortality was considerably lower in the 50-59 group (0.12%) but increased with each age stratum. The most commonly performed surgical procedures in the elderly included herniorrhaphies, simple and extensive wound debridements, abscess incision and drainages, minor tumorectomies, and urological procedures. CONCLUSIONS: In light of the increasing elderly population in developing countries, efforts should be made to better quantify and address their surgical needs.

Preparing for Euro 2012: developing a hazard risk assessment.

INTRODUCTION: Risk assessment is a vital step in the disaster-preparedness continuum as it is the foundation of subsequent phases, including mitigation, response, and recovery. HYPOTHESIS/PROBLEM: To develop a risk assessment tool geared specifically towards the Union of European Football Associations (UEFA) Euro 2012. METHODS: In partnership with the Donetsk National Medical University, Donetsk Research and Development Institute of Traumatology and Orthopedics, Donetsk Regional Public Health Administration, and the Ministry of Emergency of Ukraine, a table-based tool was created, which, based on historical evidence, identifies relevant potential threats, evaluates their impacts and likelihoods on graded scales based on previous available data, identifies potential mitigating shortcomings, and recommends further mitigation measures. RESULTS: This risk assessment tool has been applied in the vulnerability-assessment-phase of the UEFA Euro 2012. Twenty-three sub-types of potential hazards were identified and analyzed. Ten specific hazards were recognized as likely to very likely to occur, including natural disasters, bombing and blast events, road traffic collisions, and disorderly conduct. Preventative measures, such as increased stadium security and zero tolerance for impaired driving, were recommended. Mitigating factors were suggested, including clear, incident-specific preparedness plans and enhanced inter-agency communication. CONCLUSION: This hazard risk assessment tool is a simple aid in vulnerability assessment, essential for disaster preparedness and response, and may be applied broadly to future international events.

Scarcity of protective items against HIV and other bloodborne infections in 13 low- and middle-income countries.

OBJECTIVE: To assess protection of surgical healthcare workers against HIV and other bloodborne infections in low- and middle-income countries (LMICs). METHODS: Literature review based on recent studies assessing baseline surgical capacity in LMICs using the WHO Situational Analysis of Access to Emergency and Essential Surgical Care, the Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey and the Harvard Humanitarian Initiative survey tools. The availability of protective eyewear, sterile gloves and sterilisers was assessed. RESULTS: Thirteen individual country studies with relevant data were identified documenting items from 399 hospitals. The countries included Afghanistan, Bolivia, Gambia, Ghana, Liberia, Mongolia, Nigeria, Sierra Leone, Solomon Islands, Somalia, Sri Lanka, Tanzania and Zambia. Overall, only 29% (79/270) of hospitals always had eye protection. Sterilisers were only available at 64% (244/383) of facilities. Sterile gloves were the most available item, available at 75% of facilities (256/340). CONCLUSION: Surgical healthcare worker protection for bloodborne infections continues to be deficient in LMICs. Improved documentation of these items should be incorporated into future surgical capacity studies. Policy makers and clinicians should work together to secure resources and interventions that will protect this vital workforce.

The International Assessment of Capacity for Trauma (INTACT): an index for trauma capacity in low-income countries.

BACKGROUND: Injury remains a leading cause of death worldwide with a disproportionate impact in the developing world. Capabilities for trauma care remain limited in these settings. We propose the implementation of the International Assessment of Capacity for Trauma (INTACT) index to provide a standardized way of assessing a health care facility's capacity to provide adequate trauma care. MATERIALS AND METHODS: A retrospective review of the trauma capacity of 10 government hospitals (district, secondary, regional, maternity, and tertiary facilities) in Sierra Leone was performed using data collected during on-site visits in August 2011. The index incorporates 40 key elements, including resuscitation, laparotomy, chest tube insertion, fracture repair, and burn management capabilities. The INTACT index was calculated on a scale of 0-10 and compared with a previously published index of surgical capacity, the personnel, infrastructure, equipment, and supplies (PIPES) index. RESULTS: Connaught Hospital, the only tertiary referral center, had the highest index (9.0), consistent with it being the best equipped and staffed of the country. The three district hospitals assessed had the lowest scores from 3.5 to 4.3. INTACT and PIPES scores were correlated overall (r = 0.88). The proportionate difference compared with the PIPES survey was 30% for the maternity hospital and 1% for the tertiary center, suggesting that the INTACT index may be specific for trauma. Deficiencies are especially prominent in personnel, imaging, fracture repair, and burn management. CONCLUSIONS: The INTACT index is a simple tool designed to specifically assess trauma capacity from initial resuscitation to definitive care. Shortcomings in trauma capacity remain prominent and the INTACT index could be used to assess trauma care deficiencies in developing countries.