Predictors at 6 and 12 Months for Social Participation Outcome at 24 Months in the Adult Burn Injury Population: A Burn Model System National Database Study.

OBJECTIVE: To identify clinical factors (physical and psychological symptoms and post-traumatic growth) that predict social participation outcome at 24-month after burn injury. DESIGN: A prospective cohort study based on Burn Model System National Database. SETTING: Burn Model System centers. PARTICIPANTS: 181 adult participants less than 2 years after burn injury (N=181). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Demographic and injury variables were collected at discharge. Predictor variables were assessed at 6 and 12 months: Post-Traumatic Growth Inventory Short Form (PTGI-SF), Post-Traumatic Stress Disorder Checklist Civilian Version (PCL-C), Patient-Reported Outcomes Measurement Information System (PROMIS-29) Depression, Anxiety, Sleep Disturbance, Fatigue, and Pain Interference short forms, and self-reported Heat Intolerance. Social participation was measured at 24 months using the Life Impact Burn Recovery Evaluation (LIBRE) Social Interactions and Social Activities short forms. RESULTS: Linear and multivariable regression models were used to examine predictor variables for social participation outcomes, controlling for demographic and injury variables. For LIBRE Social Interactions, significant predictors included the PCL-C total score at 6 months (ß=-0.27, P<.001) and 12 months (ß=-0.39, P<.001), and PROMIS-29 Pain Interference at 6 months (ß=-0.20, P<.01). For LIBRE Social Activities, significant predictors consisted of the PROMIS-29 Depression at 6 months (ß=-0.37, P<.001) and 12 months (ß=-0.37, P<.001), PROMIS-29 Pain Interference at 6 months (ß=-0.40, P<.001) and 12 months (ß=-0.37, P<.001), and Heat Intolerance at 12 months (ß=-4.55, P<.01). CONCLUSIONS: Post-traumatic stress and pain predicted social interactions outcomes, while depression, pain and heat intolerance predicted social activities outcomes in people with burn injury.

Standardized trauma intake form with clinical decision support prompts improves care and reduces mortality for seriously injured patients in non-tertiary hospitals in Ghana: stepped-wedge cluster randomized trial.

BACKGROUND: The WHO Trauma Care Checklist improved key performance indicators (KPIs) of trauma care at tertiary hospitals. A standardized trauma intake form (TIF) with real-time clinical decision support prompts was developed by adapting the WHO Trauma Care Checklist for use in smaller low- and middle-income country hospitals, where care is delivered by non-specialized providers and without trauma teams. This study aimed to determine the effectiveness of the TIF for improving KPIs in initial trauma care and reducing mortality at non-tertiary hospitals in Ghana. METHODS: A stepped-wedge cluster randomized trial was conducted by stationing research assistants at emergency units of eight non-tertiary hospitals for 17.5 months to observe management of injured patients before and after introduction of the TIF. Differences in performance of KPIs in trauma care (primary outcomes) and mortality (secondary outcome) were estimated using generalized linear mixed regression models. RESULTS: Management of 4077 injured patients was observed (2067 before TIF introduction, 2010 after). There was improvement in 14 of 16 primary survey and initial care KPIs after TIF introduction. Airway assessment increased from 72.9 to 98.4 per cent (adjusted OR 25.27, 95 per cent c.i. 2.47 to 258.94; P = 0.006) and breathing assessment from 62.1 to 96.8 per cent (adjusted OR 38.38, 4.84 to 304.69; P = 0.001). Documentation of important clinical data improved from 52.4 to 76.7 per cent (adjusted OR 2.14, 1.17 to 3.89; P = 0.013). The mortality rate decreased from 17.7 to 12.1 per cent among 302 patients (186 before, 116 after) with impaired physiology on arrival (hypotension or decreased level of consciousness) (adjusted OR 0.10, 0.02 to 0.56; P = 0.009). CONCLUSION: The TIF improved overall initial trauma care and reduced mortality for more seriously injured patients. REGISTRATION NUMBER: NCT04547192 (http://www.clinicaltrials.gov).

Preliminary Exploration of Long-Term Patient Outcomes After Tracheostomy in Burns: A Burn Model System Study.

INTRODUCTION: Upper airway management is crucial to burn care. Endotracheal intubation is often performed in the setting of inhalation injury, burns of the face and neck, or large burns requiring significant resuscitation. Tracheostomy may be necessary in patients requiring prolonged ventilatory support. This study compares long-term, patient-reported outcomes in burn patients with and without tracheostomy. MATERIALS AND METHODS: Data from the Burn Model System Database, collected from 2013 to 2020, were analyzed. Demographic and clinical data were compared between those with and without tracheostomy. The following patient-reported outcomes, collected at 6-, 12-, and 24-mo follow-up, were analyzed: Veterans RAND 12-Item Health Survey (VR-12), Satisfaction with Life, Community Integration Questionnaire, Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure, employment status, and days to return to work. Regression models and propensity-matched analyses were used to assess the associations between tracheostomy and each outcome. RESULTS: Of 714 patients included in this study, 5.5% received a tracheostomy. Mixed model regression analyses demonstrated that only VR-12 Physical Component Summary scores at 24-mo follow-up were significantly worse among those requiring tracheostomy. Tracheostomy was not associated with VR-12 Mental Component Summary, Satisfaction with Life, Community Integration Questionnaire, or Patient-Reported Outcomes Measurement Information System 29-Item Profile Measure scores. Likewise, tracheostomy was not found to be independently associated with employment status or days to return to work. CONCLUSIONS: This preliminary exploration suggests that physical and psychosocial recovery, as well as the ability to regain employment, are no worse in burn patients requiring tracheostomy. Future investigations of larger scale are still needed to assess center- and provider-level influences, as well as the influences of various hallmarks of injury severity. Nonetheless, this work should better inform goals of care discussions with patients and families regarding the use of tracheostomy in burn injury.

Perioperative Risk Assessment in Humanitarian Settings: A Scoping Review.

BACKGROUND: No validated perioperative risk assessment models currently exist for use in humanitarian settings. To inform the development of a perioperative mortality risk assessment model applicable to humanitarian settings, we conducted a scoping review of the literature to identify reports that described perioperative risk assessment in surgical care in humanitarian settings and LMICs. METHODS: We conducted a scoping review of the literature to identify records that described perioperative risk assessment in low-resource or humanitarian settings. Searches were conducted in databases including: PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature, Web of Science, World Health Organization Catalog, and Google Scholar. RESULTS: Our search identified 1582 records. After title/abstract and full text screening, 50 reports remained eligible for analysis in quantitative and qualitative synthesis. These reports presented data from over 37 countries from public, NGO, and military facilities. Data reporting was highly inconsistent: fewer than half of reports presented the indication for surgery; less than 25% of reports presented data on injury severity or prehospital data. Most elements of perioperative risk models designed for high-resource settings (e.g., vital signs, laboratory data, and medical comorbidities) were unavailable. CONCLUSION: At present, no perioperative mortality risk assessment model exists for use in humanitarian settings. Limitations in consistency and quality of data reporting are a primary barrier, however, can be addressed through data-driven identification of several key variables encompassed by a minimum dataset. The development of such a score is a critical step toward improving the quality of care provided to populations affected by conflict and protracted humanitarian crises.

Systematic review of global hepatitis E outbreaks to inform response and coordination initiatives.

INTRODUCTION: Hepatitis E virus (HEV) is the most common cause of acute hepatitis. While symptoms are generally mild and resolve within weeks, some populations (e.g., pregnant women, immunocompromised adults) are at high-risk of severe HEV-related morbidity and mortality. There has not been a recent comprehensive review of contemporary HEV outbreaks, which limits the validity of current disease burden estimates. Therefore, we aimed to characterize global HEV outbreaks and describe data gaps to inform HEV outbreak prevention and response initiatives. METHODS: We performed a systematic review of peer-reviewed (PubMed, Embase) and gray literature (ProMED) to identify reports of outbreaks published between 2011 and 2022. We included (1) reports with ≥ 5 cases of HEV, and/or (2) reports with 1.5 times the baseline incidence of HEV in a specific population, and (3) all reports with suspected (e.g., clinical case definition) or confirmed (e.g., ELISA or PCR test) cases if they met criterium 1 and/or 2. We describe key outbreak epidemiological, prevention and response characteristics and major data gaps. RESULTS: We identified 907 records from PubMed, 468 from Embase, and 247 from ProMED. We screened 1,362 potentially relevant records after deduplication. Seventy-one reports were synthesized, representing 44 HEV outbreaks in 19 countries. The populations at risk, case fatalities, and outbreak durations were not reported in 66% of outbreak reports. No reports described using HEV vaccines. Reported intervention efforts included improving sanitation and hygiene, contact tracing/case surveillance, chlorinating boreholes, and advising residents to boil water. Commonly missing data elements included specific case definitions used, testing strategy and methods, seroprevalence, impacts of interventions, and outbreak response costs. Approximately 20% of HEV outbreaks we found were not published in the peer-reviewed literature. CONCLUSION: HEV represents a significant public health problem. Unfortunately, extensive data shortages and a lack of standardized reporting make it difficult to estimate the HEV disease burden accurately and to implement effective prevention and response activities. Our study has identified major gaps to guide future studies and outbreak reporting systems. Our results support the development of standardized reporting procedures/platforms for HEV outbreaks to ensure accurate and timely data distribution, including active and passive coordinated surveillance systems, particularly among high-risk populations.

Experiences of Alaska Native people living with burn injury and opportunities for health system strengthening.

BACKGROUND: Injuries are a leading cause of death and disability for Alaska Native (AN) people. Alaska Native Tribal Health Consortium (ANTHC) is supporting the development of a burn care system that includes a partnership between Alaska Native Medical Center (ANMC) in Anchorage, AK and UW Medicine Regional Burn Center at Harborview Medical Center (HMC) in Seattle, WA. We aimed to better understand the experiences of AN people with burn injuries across the care continuum to aid development of culturally appropriate care regionalization. METHODS: We performed focus groups with twelve AN people with burn injury and their caregivers. A multidisciplinary team of burn care providers, qualitative research experts, AN care coordinator, and AN cultural liaison led focus groups to elicit experiences across the burn care continuum. Transcripts were analyzed using a phenomenological approach and inductive coding to understand how AN people and families navigated the medical and community systems for burn care and areas for improvement. RESULTS: Three themes were identified: 1-Challenges with local burn care in remote communities including limited first aid, triage, pain management, and wound care, as well as long-distance transport to definitive care; 2-Divergence between cultural values and medical practices that generated mistrust in the medical system, isolation from their support systems, and recovery goals that were not aligned with their needs; 3-Difficulty accessing emotional health support and a survivor community that could empower their resilience. CONCLUSION: Participants reported modifiable barriers to culturally competent treatment for burn injuries among AN people. The findings can inform initiatives that leverage existing resources, including expansion of the Extension for Community Healthcare Outcomes (ECHO) telementoring program, promulgation of the Phoenix Society Survivors Offering Assistance in Recovery (SOAR) to AK, coordination of regionalized care to reduce time away from AK and provide more comfortable community reintegration, and define rehabilitation goals in terms that align with personal goals and subsistence lifestyle skills. Long-distance transport times are non-modifiable, but better pre-hospital care could be achieved by harnessing existing telehealth services and adapting principles of prolonged field care to allow for triage, initial care, and resuscitation in remote environments.

Global Survey of Demand-Side Factors and Incentives that Influence Advanced Trauma Life Support (ATLS) Promulgation.

BACKGROUND: We aimed to identify and describe demand-side factors that have been used to support ATLS global promulgation, as well as current gaps in demand-side incentives. METHODS: We performed a cross-sectional survey about demand-side factors that influence the uptake and promulgation of ATLS and other trauma-related CME courses. The survey was sent to each of the four global ATLS region chiefs and 80 ATLS country directors. Responses were described and qualitative data were analyzed using a content analysis framework. RESULTS: Representatives from 30 countries and each region chief responded to the survey (40% response rate). Twenty of 30 country directors (66%) reported that there were some form of ATLS verification requirements. ATLS completion, not current verification, was often the benchmark. Individual healthcare systems were the most common agency to require ATLS verification (37% of countries) followed by medical/surgical accreditation boards (33%), governments (23%), training programs (27%), and professional societies (17%). Multiple credentialing frameworks were reported including making ATLS verification a requirement for: emergency unit or trauma center designation (40%), contract renewal or promotion (37%); professional licensing (37%); training program graduation (37%); and increases in remuneration (3%). Unique demand-side incentives were reported including expansion of ATLS to non-physician cadre credentialing and use of subsidies. CONCLUSION: ATLS region chiefs and country directors reported a variety of demand-side incentives that may facilitate the promulgation of ATLS. Actionable steps include: (i) shift incentivization from ATLS course completion to maintenance of verification; (ii) develop an incentive toolkit of best practices to support implementation; and (iii) engage leadership stakeholders to use demand-side incentives to improve the training and capabilities of the providers they oversee to care for the injured.

Agreement between proxy- and self-report scores on PROMIS health-related quality of life domains in pediatric burn survivors: a National Institute on Disability, Independent Living, and Rehabilitation Research Burn Model System Study.

PURPOSE: To examine agreement between pediatric burn survivor self- and caregiver proxy-report on multiple PROMIS domains and examine factors associated with differences between self- and proxy-reports. METHODS: Children 8-17 years of age and their caregivers completed PROMIS measures (physical function, depression, peer relationships, pain interference, and anger) between 6 months and 15 years after injury. Self- and proxy-report scores were compared using Wilcoxon sign rank test, Cohen's effect size, and intraclass correlation coefficients (ICC) and by agreement across severity of symptoms based on recommended cutoffs. Ordinary least squares regression analyses examined child- (self-report score, age, gender, and ethnicity) and proxy-related (relationship to child) factors associated with score differences. RESULTS: Two hundred and seventy four child-caregiver pairs completed the PROMIS measures. Mean child age was 13.0 (SD:3) years. Caregivers reported significantly worse scores than the child on physical function, pain, and anger (all p ≤ 0.01). The effect sizes were small across all domains except physical function. Similarly, ICCs were all of moderate agreement. The percentage of dyads in agreement by severity groups was high with only 5%-9% of pairs discordant. Only higher self-report score was associated (all p < 0.05) with greater differences across all domains in regression analyses. CONCLUSIONS: This study supports the use of pediatric proxy PROMIS depression, physical function, peer relationships, pain interference, and anger scales in pediatric burn patients. Although agreement was moderate to good, assessing proxy-report alone as a surrogate should only be considered when self-report is not possible or practical. Caregivers typically report slightly worse severity of symptoms than children across all domains.

National health insurance and surgical care for injured people, Ghana.

OBJECTIVE: To determine the association between having government health insurance and the timeliness and outcome of care, and catastrophic health expenditure in injured patients requiring surgery at a tertiary hospital in Ghana. METHODS: We reviewed the medical records of injured patients who required surgery at Komfo Anokye Teaching Hospital in 2015-2016 and extracted data on sociodemographic and injury characteristics, outcomes and out-of-pocket payments. We defined catastrophic health expenditure as ≥ 10% of the ratio of patients' out-of-pocket payments to household annual income. We used multivariable regression analyses to assess the association between having insurance through the national health insurance scheme compared with no insurance and time to surgery, in-hospital mortality and experience of catastrophic health expenditure, adjusted for potentially confounding variables. FINDINGS: Of 1396 patients included in our study, 834 (60%) were insured through the national health insurance scheme. Time to surgery and mortality were not statistically different between insured and uninsured patients. Insured patients made smaller median out-of-pocket payments (309 United States dollars, US$) than uninsured patients (US$ 503; P < 0.001). Overall, 45% (443/993) of patients faced catastrophic health expenditure. A smaller proportion of insured patients (33%, 184/558) experienced catastrophic health expenditure than uninsured patients (60%, 259/435; P < 0.001). Insurance through the national health insurance scheme reduced the likelihood of catastrophic health expenditure (adjusted odds ratio: 0.27; 95% confidence interval: 0.20 to 0.35). CONCLUSION: The national health insurance scheme needs strengthening to provide better financial risk protection and improve quality of care for patients presenting with injuries that require surgery.

Epidemiology of Injuries Sustained by Civilians and Local Combatants in Contemporary Armed Conflict: An Appeal for a Shared Trauma Registry Among Humanitarian Actors.

BACKGROUND: Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. METHODS: We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. RESULTS: The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. CONCLUSIONS: Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements.

Sex Differences in Civilian Injury in Baghdad From 2003 to 2014: Results of a Randomized Household Cluster Survey.

OBJECTIVE: To examine sex differences in injury mechanisms, injury-related death, injury-related disability, and associated financial consequences in Baghdad since the 2003 invasion of Iraq to inform prevention initiatives, health policy, and relief planning. BACKGROUND: Reliable estimates of injury burden among civilians during conflict are lacking, particularly among vulnerable subpopulations, such as women. METHODS: A 2-stage, cluster randomized, community-based household survey was conducted in May 2014 to determine the civilian burden of injury in Baghdad since 2003. Households were surveyed regarding injury mechanisms, healthcare required, disability, deaths, connection to conflict, and resultant financial hardship. RESULTS: We surveyed 900 households (5148 individuals), reporting 553 injuries, 162 (29%) of which were injuries among women. The mean age of injury was higher among women compared with men (34 ±â€Š21.3 vs 27 ±â€Š16.5 years; P < 0.001). More women than men were injured while in the home [104 (64%) vs 82 (21%); P < 0.001]. Fewer women than men died from injuries [11 (6.8%) vs 77 (20%); P < 0.001]; however, women were more likely than men to live with reduced function [101 (63%) vs 192 (49%); P = 0.005]. Of intentional injuries, women had higher rates of injury by shell fragments (41% vs 26%); more men were injured by gunshots [76 (41%) vs 6 (17.6%); P = .011). CONCLUSIONS: Women experienced fewer injuries than men in postinvasion Baghdad, but were more likely to suffer disability after injury. Efforts to improve conditions for injured women should focus on mitigating financial and provisional hardships, providing counseling services, and ensuring access to rehabilitation services.

Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story.

OBJECTIVE: Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives. METHODS: A standardized surgical capacity assessment was performed at 37 hospitals nationwide using WHO guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability) for each hospital. Data regarding the number of essential operations performed over 1 year, surgical specialties available, hospital beds, and functional operating rooms were also collected. The relationship between capacity and output was explored. RESULTS: The median surgical capacity score was 37 [interquartile range (IQR) 29-48; range 20-56]. The median number of essential operations per year was 1480 (IQR 736-1932) at first-level hospitals; 1545 operations (IQR 984-2452) at referral hospitals; and 11,757 operations (IQR 3769-21,256) at tertiary hospitals. Surgical capacity and output were not correlated (p > 0.05). CONCLUSIONS: Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including demand-side factors; supply-side factors and process elements; and health administration and management factors.

Cleft-Related Infanticide and Abandonment: A Systematic Review of the Academic and Lay Literature.

OBJECTIVE: We aimed to describe the scope of cleft-related infanticide and identify issues that might inform prevention strategies. DESIGN: Systematic reviews of both academic (eg, PubMed, EBSCOhost) and lay literature (eg, LexisNexis Academic, Google) databases were performed to identify all primary reports of cleft-related infanticide. All languages were included. Records before 1985 were excluded. Reference lists of all included reports were screened for potentially relevant records. MAIN OUTCOME MEASURES: Country of origin and excerpts that pertained to the concepts surrounding cleft-related infanticide were extracted. Extracted excerpts were examined using a content analysis framework. RESULTS: Of the 1,151 records retrieved, 70 reports documented cleft-related infanticide from 27 countries. The largest number of reports was from China (14 reports; 48% of reports), followed by India (4; 14%) and Nigeria (4; 14%). However, 2 countries had 3 reports, 5 countries had 2 reports, and 17 countries had 1 report. Themes that emerged from excerpt analysis included stigma, lack of affordable cleft care, abandonment, orphanage overcrowding, and abuse and slavery. CONCLUSIONS: Cleft-related infanticide is a global problem. Initiatives to sensitize communities to cleft lip and/or cleft palate, provide timely and affordable cleft care, and build support systems for affected families may prove beneficial. Cleft care organizations have the opportunity to advocate for these initiatives, reduce the incidence of infanticide by providing or supporting timely and affordable cleft care, and demonstrate that children with successful cleft repairs reassimilate well into their communities.

Beyond a Moral Obligation: A Legal Framework for Emergency and Essential Surgical Care and Anesthesia.

BACKGROUND: Access to quality and timely emergency and essential surgical care and anesthesia (EESCA) is an integral component of the right to health as reinforced by the ratification of the World Health Assembly Resolution 68.15. However, this resolution is merely a guideline and has not been able to bolster the necessary political will to promote EESCA. Our objective was to evaluate international treaties, which carry legal obligations, for EESCA-related text, and develop a human rights-based framework to support EESCA advancement and advocacy. METHODS: We conducted a comprehensive review of all the UN Treaty Collection-Certified True Copies (CTCs) of multilateral treaties database from December 2015 to April 2016. The relevant text was manually searched to abstract and analyze to identify major themes supporting a human rights-based approach to EESCA. RESULTS: Multiple treaties in the UN database addressed EESCA in the areas of human rights, refugees and stateless persons, health, penal matters, and disarmament. A total of 13 treaties containing 23 articles had language that endorsed aspects of EESCA. The three major themes, supported by the phraseology in the treaties, included: (1) equal access to EESCA (eight articles); (2) timely care of injured and those with emergency surgical conditions (eight articles); and (3) protection, rehabilitation, psychosocial support, and social security (seven articles). CONCLUSIONS: A number of United Nations multilateral treaties support available and equitable EESCA. These findings can be used to galvanize support and encourage signatory Member States to promote and implement EESCA development initiatives.

The Correlation Between Poverty and Access to Essential Surgical Care in Ghana: A Geospatial Analysis.

BACKGROUND: Surgical disease burden falls disproportionately on individuals in low- and middle-income countries. These populations are also the least likely to have access to surgical care. Understanding the barriers to access in these populations is therefore necessary to meet the global surgical need. METHODS: Using geospatial methods, this study explores the district-level variation of two access barriers in Ghana: poverty and spatial access to care. National survey data were used to estimate the average total household expenditure (THE) in each district. Estimates of the spatial access to essential surgical care were generated from a cost-distance model based on a recent surgical capacity assessment. Correlations were analyzed using regression and displayed cartographically. RESULTS: Both THE and spatial access to surgical care were found to have statistically significant regional variation in Ghana (p < 0.001). An inverse relationship was identified between THE and spatial access to essential surgical care (ß -5.15 USD, p < 0.001). Poverty and poor spatial access to surgical care were found to co-localize in the northwest of the country. CONCLUSIONS: Multiple barriers to accessing surgical care can coexist within populations. A careful understanding of all access barriers is necessary to identify and target strategies to address unmet surgical need within a given population.

Rectal bleeding and endoscopy need in Sierra Leone: results of a nationwide, community-based survey.

BACKGROUND: Low-income and middle-income countries (LMICs) face a large burden of gastrointestinal diseases that benefit from prompt endoscopic diagnosis and treatment. This study aimed to estimate the prevalence of gross rectal bleeding among adults in Sierra Leone. METHODS: A cluster randomised, cross-sectional household survey using the SOSAS tool was undertaken in Sierra Leone. 75 clusters of 25 households with two randomly selected respondents in each were sampled to estimate the prevalence of and disability from rectal bleeding. Barriers to care were also assessed. FINDINGS: 3645 individuals responded to the survery, 15 with rectal bleeding. Nine responders (64%) had been bleeding for more than a year. The prevalence of rectal bleeding was 412 per 100 000 people. In view of these findings, an estimated 24 604 individuals with rectal bleeding are in need of evaluation in Sierra Leone. Eight (53%) of the 15 people with rectal bleeding sought care from a traditional healer. If medical care was not sought, the most common reason was absence of financial resources (ten people; 77%), followed by no capable facility availability (two; 15%), and inability to leave work or family for the time needed (one; 8%). Seven (54%) of those with rectal bleeding reported some form of disability, including five (39%) that had bleeding that prevented usual work. INTERPRETATION: The high prevalence of rectal bleeding identified in Sierra Leone represents a major unmet health-care need. This study did not examine the cause of bleeding. However, the high prevalence, chronicity, and disability among respondents with bleeding suggest a substantial burden of disease. Additionally, because microscopic haematochezia was not assessed, these data represent a bare-minimum estimate of rectal bleeding in need of evaluation and treatment. In view of the substantial burden of conditions that can be diagnosed, treated, or palliated with timely endoscopic therapy, it is appropriate to consider endoscopy among efforts to develop health system capacity in LMICs. FUNDING: Surgeons OverSeas, the Thompson Family Foundation, and the Fogarty International Center.

Surgical need in an ageing population: a cluster-based household survey in Nepal.

BACKGROUND: With an ageing global population comes major non-communicable disease burden, especially in low-income and middle-income countries. An unknown proportion of this burden is treatable or palliated with surgery. This study aimed to estimate the surgical needs of individuals aged 50 years or older in Nepal. METHODS: A two-stage, 30 randomised cluster by 30 households, community-based survey was performed in Nepal with the validated Surgeons OverSeas Assessment of Surgical Need (SOSAS). Respondents aged older than 50 years were included. After verbal informed consent was obtained, SOSAS collected household demographics, completed a verbal autopsy, and randomly selected household members for verbal head-to-toe examinations for surgical conditions. The Nepal Health Research Council in Kathmandu and the Nationwide Children's Hospital in Columbus, OH, USA, granted ethical approval. FINDINGS: The survey sampled 1350 households, totalling 2695 individuals (97% response rate); 49% were aged 50-59 years, 33% were 60-69 years, and 17% were 70 years and older. Of these, 273 surgical conditions were reported by 507 individuals. A growth or mass (including hernias and goiters) was the most commonly reported potentially surgical condition (25%), injuries and fractures were also common and had the greatest disability. Acquired deformities (13%), incontinence (11%), non-injury wounds (9%), and pelvic organ prolapse were also prevalent. Together, head and neck (24%) and back and extremity conditions (32%) were responsible for more than half of the conditions potentially treatable with surgery. These were followed by genitourinary (28%), abdominal (14%) and chest and breast conditions (2%). Extrapolated nationwide, roughly 1·25 million elderly individuals have a surgically treatable condition (32 150 per 100 000 people). There were 108 deaths in the year before to the survey. 20 (19%) were potentially preventable with surgery. Half of the deaths were due to a growth or mass, 20% to injury, 20% to abdominal pain or distension, and 10% to a non-injury wound. The age-standardised death rate of those with a potentially surgical condition was 24 per 1000 persons for individuals in their 6th decadte, 60 per 1000 for those in their 7th, and 44 per 1000 for those in their 8th. One in five deaths were potentially treatable or palliated by surgery. Literacy and distance to secondary and tertiary health facilities were associated with not receiving care for surgical conditions (p<0·05). INTERPRETATION: Surgical need is largely unmet among elderly individuals in Nepal. Literacy and distance from a capable health facility are the greatest barriers to care. Although verbal examination findings were used as proxies for surgical conditions, the survey tool has been previously validated. Also, there is potential for recall bias with overestimation of tragic deaths and underestimation of unknown or forgotten surgical causes of death and disease. However, this is the most comprehensive evaluation of surgical need in a developing country among the elderly. As the global population ages, there is an increasing need to improve access to surgical services and strengthen health systems to care for this group. FUNDING: The Association for Academic Surgery, Surgeons OverSeas, and the Fogarty International Center.

Care of surgical infections by Médecins Sans Frontières Operations Centre Brussels in 2008-14.

BACKGROUND: Surgical infections represent a substantial yet undefined burden of disease in low-income and middle-income countries (LMICs). Médecins Sans Frontières (MSF) provides surgical care in LMICs and collects data useful to describe the operative epidemiology of surgical need that would otherwise be unmet by national health services. We aimed to describe the experience of MSF Operations Centre Brussels surgery for infections during crisis; aid effective resource allocation; prepare humanitarian surgical staff; and further characterise unmet surgical needs in LMICs. METHODS: We reviewed all procedures undertaken in operating theatres at facilities run by the MSF Operations Centre Brussels between July, 2008, and June, 2014. Projects providing only specialty care were excluded. Procedures for infections were quantified, related to demographics and reason for humanitarian response was described. FINDINGS: 96 239 operations were undertaken at 27 MSF Operations Centre Brussels sites in 15 countries. Of 61 177 general operations, 7762 (13%) were for infections. Operations for skin and soft tissue infections were the most common (64%), followed by intra-abdominal (26%), orthopaedic (6%), and tropical infections (3%). The proportion of operations for skin and soft tissue infections was highest during natural disaster missions, intra-abdominal infections during hospital support missions, and orthopaedic infections during conflict missions. Most procedures for skin and soft tissue infections were minor (76%), whereas most operations for intra-abdominal infections were major (98%). INTERPRETATION: Surgical infections are among the most common causes for operation in LMICs. Although many procedures were minor, they represent substantial use of perioperative resources. Growing evidence shows the need for improved perioperative capacity to aptly care for the volume and variety of conditions comprising the global burden of surgical disease. FUNDING: Médecins Sans Frontières.