A multi-state evaluation of the association between mental health and firearm storage practices.

Firearm storage method is a potentially modifiable risk factor for suicide. Using data from a large, multi-state survey, we sought to determine whether there is an association between mental health and household firearm storage practices, and characterize that association by state of residence. Participants who endorsed the presence of a household firearm and answered the mental health questions in the 2016-2017 Behavioral Risk Factor Surveillance System from eight states were included (n=26,949). Exposures were recent poor mental health (≥14 vs. 0-13 days/past month), and diagnosis of depression. Outcomes were household firearm storage practices (loaded, and both loaded and unlocked). Using Poisson regression, we calculated adjusted prevalence ratios (aPR) overall and stratified by state of residence. Of adults endorsing a household firearm, 35.1% reported storing a firearm loaded, and of those, 53.4% reported that the firearm was both loaded and unlocked. Neither recent poor mental health nor depression was associated with loaded (aPR 1.14 [95% CI: 0.95-1.37] and aPR 0.94 [95% CI 0.80-1.09], respectively) or loaded and unlocked (aPR 1.08 [95% CI 0.88-1.42] and aPR 1.04 [95% CI 0.88-1.22], respectively) firearm storage. In the setting of highly prevalent loaded firearm storage, no differences in storage practices by mental health indicators were observed across eight states despite disparate firearm policies and local culture. The lack of difference in storage practices by mental health indicators across several states highlights an opportunity to improve means safety counseling practices, and the need for dedicated evaluation of state-level firearm storage policies.

Optimal Timing of Tracheostomy in Injured Adolescents.

OBJECTIVES: To evaluate the optimal timing of tracheostomy for injured adolescents. DESIGN: Retrospective cohort study. SETTING: Trauma facilities in the United States. PATIENTS: Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point. CONCLUSIONS: For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.

Hemostatic Resuscitation of Pediatric Trauma Patients During Air Medical Transport: A Retrospective Matched Cohort Study.

OBJECTIVE: The objective of this study was to examine an academic air ambulance service's experience with prehospital transfusion of plasma and red blood cells in pediatric trauma for evidence of efficacy on the treatment of shock and coagulopathy. METHODS: All trauma patients < 18 years old transfused during transport by the University of Washington Airlift Northwest (Airlift) air medical transport service to Harborview Medical Center, Seattle, WA, were identified. Controls were matched 1:1 from pediatric trauma patients transported by Airlift before transfusion support became available. Demographics, injury scores, emergency department admission and interval laboratory values, blood product use, and hospital outcome measures were registered. RESULTS: Seventeen cases met the inclusion criteria and were matched by age and Injury Severity Score to 17 control patients (mean age = 10.5 vs. 10.9 years; New Injury Severity Score, 37 vs. 40.7). No significant differences in vital signs, shock index, or mortality were observed. Cases received less in-flight crystalloid (4.3 mL/kg vs. 16.9 mL/kg, P = .004), had higher admission fibrinogen levels (238 vs. 148mg/dL, P = .007), and shorter time to normalization of the international normalized ratio (6.4 vs. 19.1 hours, P = .04). CONCLUSIONS: In this small series, hemostatic resuscitation during air medical transport was associated with less crystalloid administration and better support of coagulation indices.

Laparoscopy Compared With Laparotomy for the Management of Pediatric Blunt Abdominal Trauma.

BACKGROUND: There is minimal evidence evaluating the risks and benefits of laparoscopy use in hemodynamically stable children with suspected abdominal injuries. The objective of this study was to evaluate postoperative outcomes in a large cohort of hemodynamically stable pediatric patients with blunt abdominal injury. METHODS: Using the 2015-2016 National Trauma Data Bank, all patients aged <18 y with injury severity score (ISS) ≤25, Glasgow coma scale ≥13, and normal blood pressure who underwent an abdominal operation for blunt abdominal trauma were included. Patients were grouped into three treatment groups: laparotomy, laparoscopy, and laparoscopy converted to laparotomy. Treatment effect estimation with inverse probability weighting was used to determine the association between treatment group and outcomes of interest. RESULTS: Of 720 patients, 504 underwent laparotomy, 132 underwent laparoscopy, and 84 underwent laparoscopy converted to laparotomy. The median age was 10 (IQR: 7-15) y, and the median ISS was 9 (IQR: 5-14). Mean hospital length of stay was 2.1 d shorter (95% confidence interval [CI]: 0.9-3.2 d) and mean intensive care unit length of stay was 1.1 d shorter (95% CI: 0.6-1.5 d) for the laparoscopy group compared with the laparotomy group. The laparoscopy group had a 2.0% lower mean probability of surgical site infection than the laparotomy group (95% CI: 1.0%-3.0%). CONCLUSIONS: In this cohort of hemodynamically stable pediatric patients with blunt abdominal injury, laparoscopy may have improved outcomes over laparotomy.

Association of Blood Component Ratios With 24-Hour Mortality in Injured Children Receiving Massive Transfusion.

OBJECTIVES: To determine if higher fresh frozen plasma and platelet to packed RBC ratios are associated with lower 24-hour mortality in bleeding pediatric trauma patients. DESIGN: Retrospective cohort study using the Pediatric Trauma Quality Improvement Program Database from 2014 to 2016. SETTING: Level I and II pediatric trauma centers participating in the Trauma Quality Improvement Program PATIENTS:: Injured children (≤ 14 yr old) who received massive transfusion (≥ 40 mL/kg total blood products in 24 hr). Of 123,836 patients, 590 underwent massive transfusion, of which 583 met inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Ratios of fresh frozen plasma:packed RBC and platelet:packed RBC. Of the 583 patients, 60% were male and the median age was 5 years (interquartile range, 2-10 yr). Overall mortality was 19.7% (95% CI, 16.6-23.2%) at 24 hours. There was 51% (adjusted relative risk, 0.49; 95% CI, 0.27-0.87; p = 0.02) and 40% (adjusted relative risk, 0.60; 95% CI, 0.39-0.92; p = 0.02) lower risk of death at 24 hours for the high (≥ 1:1) and medium (≥ 1:2 and < 1:1) fresh frozen plasma:packed RBC ratio groups, respectively, compared with the low ratio group (< 1:2). Platelet:packed RBC ratio was not associated with mortality (adjusted relative risk, 0.94; 95% CI, 0.51-1.71; p = 0.83). CONCLUSIONS: Higher fresh frozen plasma ratios were associated with lower 24-hour mortality in massively transfused pediatric trauma patients. The platelet ratio was not associated with mortality. Although these findings represent the largest study evaluating blood product ratios in pediatric trauma patients, prospective studies are necessary to determine the optimum blood product ratios to minimize mortality in this population.

Pathogen reduction combined with rapid diagnostic tests to reduce the risk of transfusion-transmitted infections in Uganda.

BACKGROUND: Blood safety and transfusion-transmitted infections (TTIs) are a major concern in low-resource areas. Laboratory screening of donors, a key contributor to blood safety, is usually done by enzyme-linked immunosorbent assay (ELISA) methods, which use expensive reagents and necessitate complex instruments and sophisticated laboratory staff. Rapid diagnostic tests (RDTs) are less expensive and easier to perform but have less sensitivity. Pathogen reduction technology (PRT) reduces transfusion transmission of malaria and may be effective in decreasing other TTIs. We explored the potential to improve blood safety by combining PRT and RDTs in comparison with current ELISA testing. STUDY DESIGN AND METHODS: We identified the sensitivity of RDTs available in Uganda and the sensitivity of currently used ELISA. Data from a riboflavin-and-UV-based photochemical treatment PRT were used. Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), and malaria were studied. Probability models were developed for estimation of the number of infectious units of blood for each of these four infections using either current ELISA or the combination of RDT and PRT. RESULTS: Compared to currently used ELISA, the combination of RDTs and PRT could reduce the rate of infectious units by 100, 20, 98, and 83% for HIV, HBV, HCV, and malaria, respectively, and would prevent use of 758 units of infectious blood per 10,000 units transfused. CONCLUSION: The combination of RDTs and PRT may improve blood safety in low-resource areas.

Burden of Surgical Conditions in Uganda: A Cross-sectional Nationwide Household Survey.

OBJECTIVE: To quantify the burden of surgical conditions in Uganda. BACKGROUND: Data on the burden of disease have long served as a cornerstone to health policymaking, planning, and resource allocation. Population-based data are the gold standard, but no data on surgical burden at a national scale exist; therefore, we adapted the Surgeons OverSeas Assessment of Surgical Need survey and conducted a nation-wide, cross-sectional survey of Uganda to quantify the burden of surgically treatable conditions. METHODS: The 2-stage cluster sample included 105 enumeration areas, representing 74 districts and Kampala Capital City Authority. Enumeration occurred from August 20 to September 12, 2014. In each enumeration area, 24 households were randomly selected; the head of the household provided details regarding any household deaths within the previous 12 months. Two household members were randomly selected for a head-to-toe verbal interview to determine existing untreated and treated surgical conditions. RESULTS: In 2315 households, we surveyed 4248 individuals: 461 (10.6%) reported 1 or more conditions requiring at least surgical consultation [95% confidence interval (CI) 8.9%-12.4%]. The most frequent barrier to surgical care was the lack of financial resources for the direct cost of care. Of the 153 household deaths recalled, 53 deaths (34.2%; 95% CI 22.1%-46.3%) were associated with surgically treatable signs/symptoms. Shortage of time was the most frequently cited reason (25.8%) among the 11.6% household deaths that should have, but did not, receive surgical care (95% CI 6.4%-16.8%). CONCLUSIONS: Unmet surgical need is prevalent in Uganda. There is an urgent need to expand the surgical care delivery system starting with the district-level hospitals. Routine surgical data collection at both the health facility and household level should be implemented.

Geospatial Analysis of Unmet Surgical Need in Uganda: An Analysis of SOSAS Survey Data.

BACKGROUND: Globally, a staggering five billion people lack access to adequate surgical care. Sub-Saharan Africa represents one of the regions of greatest need. We sought to understand how geographic factors related to unmet surgical need (USN) in Uganda. METHODS: We performed a geographic information system analysis of a nationwide survey on surgical conditions performed in 105 enumeration areas (EAs) representing the national population. At the district level, we determined the spatial autocorrelation of the following study variables: prevalence of USN, hub distance (distance from EA to the nearest surgical center), area of coverage (geographic catchment area of each center), tertiary facility transport time (average respondent-reported travel time), and care availability (rate of hospital beds by population and by district). We then used local indicators of spatial association (LISA) and spatial regression to identify any significant clustering of these study variables among the districts. RESULTS: The survey enumerated 4248 individuals. The prevalence of USN varied from 2.0-45 %. The USN prevalence was highest in the Northern and Western Regions. Moran's I bivariate analysis indicated a positive correlation between USN and hub distance (p = 0.03), area of coverage (p = 0.02), and facility transport time (p = 0.03). These associations were consistent nationally. The LISA analysis showed a high degree of clustering among sets of districts in the Northern Sub-Region. CONCLUSIONS: This study demonstrates a statistically significant association between USN and the geographic variables examined. We have identified the Northern Sub-Region as the highest priority areas for financial investment to reduce this unmet surgical disease burden.

Quantifying the pediatric surgical need in Uganda: results of a nationwide cross-sectional, household survey.

PURPOSE: Little is known about the prevalence of pediatric surgical conditions in low- and middle-income countries. Many children never seek medical care, thus the true prevalence of surgical conditions in children in Uganda is unknown. The objective of this study was to determine the prevalence of surgical conditions in children in Uganda. METHODS: Using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey, we enumerated 4248 individuals in 2315 households in 105 randomly selected clusters throughout Uganda. Children aged 0-18 were included if randomly selected from the household; for those who could not answer for themselves, parents served as surrogates. RESULTS: Of 2176 children surveyed, 160 (7.4 %) reported a currently untreated surgical condition. Lifetime prevalence of surgical conditions was 14.0 % (305/2176). The predominant cause of surgical conditions was trauma (48.4 %), followed by wounds (19.7 %), acquired deformities (16.2 %), and burns (12.5 %). Of 90 pediatric household deaths, 31.1 % were associated with a surgically treatable proximate cause of death (28/90 deaths). CONCLUSION: Although some trauma-related surgical burden among children can be adequately addressed at district hospitals, the need for diagnostics, human resources, and curative services for more severe trauma cases, congenital deformities, and masses outweighs the current capacity of hospitals and trained pediatric surgeons in Uganda.

Blood utilization at a national referral hospital in sub-Saharan Africa.

BACKGROUND: A safe and adequate supply of blood is critical to improving health care systems in sub-Saharan Africa, where little is known about the current use of blood. The aim of this study was to comprehensively describe the use of blood at a tertiary care hospital to inform future efforts to strengthen blood programs in resource-limited settings. STUDY DESIGN AND METHODS: Data were collected from blood bank documentation for all units issued at Mulago Hospital Complex in Kampala, Uganda, from mid-January to mid-April 2014. RESULTS: A total of 6330 units (69% whole blood, 32% red blood cells, 6% platelets, 2% plasma) were issued over the 3-month study period to 3662 unique patients. Transfusion recipients were 58% female and median age was 27 years (interquartile range [IQR], 14-41). Median pretransfusion hemoglobin was 5.6 g/dL (IQR, 4.0-7.2 g/dL, n = 1090). Strikingly, cancer was the top indication for transfusion (33.5%), followed by pregnancy-related complications (12.4%) and sickle cell disease (6.9%). CONCLUSION: This study provides a comprehensive picture of blood use at a national referral hospital in sub-Saharan Africa. Noncommunicable diseases, particularly oncologic conditions, represent a large proportion of demand for transfusion services.

Surgeons OverSeas Assessment of Surgical Need (SOSAS) Uganda: Update for Household Survey.

INTRODUCTION: The first step in improving surgical care delivery in low- and middle-income countries (LMICs) is quantifying surgical need. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) is a validated household survey that has been previously implemented in three LMICs with great success. We implemented the SOSAS survey in Uganda, a medium-sized country with comparatively more language and ethnic group diversity. METHODS: The investigators partnered with the Performance Monitoring and Accountability 2020 (PMA2020) Uganda to access a data collection platform sampling 2520 households in 105 randomly selected enumeration areas. Due to geographic size consideration and language diversity, SOSAS's methodology was updated in three significant dimensions (1) technology, (2) staff management, and (3) questionnaire adaptations. RESULTS: The SOSAS survey was successfully implemented with non-medically trained but field proven research assistants. We sampled 2315 of 2402 eligible households (response rate 96.4 %) and 4248 of 4374 eligible individual respondents (response rate 97.1 %). The female-to-male ratio was 51.1-48.9 %. Total survey cost was USD 73,145 and data collection occurred in 14 days. DISCUSSION: SOSAS Uganda has demonstrated that non-medically trained, but university-educated, experienced researchers supervised by academic surgeons can successfully perform accurate data collection of SOSAS. SOSAS can be successfully implemented within larger and more diverse LMICs using existing national survey platforms, and SOSAS Uganda provides insights on how SOSAS can be executed specifically within other PMA2020 program countries.

Multisite validation of cryptococcal antigen lateral flow assay and quantification by laser thermal contrast.

Cryptococcal meningitis is common in sub-Saharan Africa. Given the need for data for a rapid, point-of-care cryptococcal antigen (CRAG) lateral flow immunochromatographic assay (LFA), we assessed diagnostic performance of cerebrospinal fluid (CSF) culture, CRAG latex agglutination, India ink microscopy, and CRAG LFA for 832 HIV-infected persons with suspected meningitis during 2006-2009 (n = 299) in Uganda and during 2010-2012 (n = 533) in Uganda and South Africa. CRAG LFA had the best performance (sensitivity 99.3%, specificity 99.1%). Culture sensitivity was dependent on CSF volume (82.4% for 10 µL, 94.2% for 100 µL). CRAG latex agglutination test sensitivity (97.0%-97.8%) and specificity (85.9%-100%) varied between manufacturers. India ink microscopy was 86% sensitive. Laser thermal contrast had 92% accuracy (R = 0.91, p<0.001) in quantifying CRAG titers from 1 LFA strip to within <1.5 dilutions of actual CRAG titers. CRAG LFA is a major advance for meningitis diagnostics in resource-limited settings.

Variation in tracheostomy placement and outcomes following pediatric trauma among adult, pediatric, and combined trauma centers.

BACKGROUND: Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults. METHODS: We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care. RESULTS: Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]). CONCLUSION: Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Utility of an orthopaedic trauma registry in Ghana.

In most low- and middle-income countries, trauma registries are uncommon. Although institutional registries for all trauma patients are ideal, it can be more practical to institute departmental registries for specific subsets of patients. Komfo Anokye Teaching Hospital (KATH) has started a locally developed, self-funded orthopaedic trauma registry. We describe methods and experiences for data collection and examine patient and injury characteristics, data quality, and the utility of the registry. Of 961 individuals in the registry, 67.9% were males, and the median age was 40 years. Motor vehicle collision (23.3%) was the most frequent mechanism of injury. Lower extremity fractures were the most common injury (60.6%), and 43.9% of injuries were managed operatively. Data quality was reasonable with missingness under 10% for 13 of 14 key variables, with inconsistencies of dates of injury, admission, treatment, and discharge in 9.1% of cases. However, the type of operation was missing for 73.2% of operative cases. Despite these limitations, the registry has been used for quality improvement and to successfully advocate for resources to improve trauma care. The registry has been improved by adding more detailed outcome variables, creating a standardised codebook of categorical variables, and adding more fields to allow for multiple injuries. In conclusion, it is practical and sustainable to institute a locally developed, self-funded orthopaedic trauma registry in Ghana that provides data with reasonable quality. Such a registry can be used to advocate for more resources to care for injured patients adequately and for quality improvement. Funding: None declared.

Nationwide enumeration of emergency operations performed in Ghana.

PURPOSE: To determine the population-based rate of emergency surgery performed in Ghana, categorized by hospital level. METHODS: Data on operations performed from June 2014 to May 2015 were obtained from a nationally representative sample of hospitals and scaled up to nationwide estimates. Operations were categorized as to: "emergency" or "elective" and as to "essential" (most cost-effective, highest population impact) or "other" according to the World Bank's Disease Control Priorities project. RESULTS: Of 232,776 (95% UI 178,004-287,549) total operations performed nationally, 48% were emergencies. 112,036 emergency operations (95% UI 92,105-131,967) were performed and the annual national rate was 416 per 100,000 population (95% UI 342-489). Most emergency operations (87%) were in the essential category. Of essential emergency procedures, 47% were obstetric and gynecologic, 22% were general surgery, and 31% were trauma. District (first-level) hospitals performed 54%, regional hospitals 10%, and tertiary hospitals 36% of all emergency operations. About half (54%) of district hospitals did not have a fully trained surgeon, however, these hospitals performed 36% of district hospital emergency operations and 20% of all emergency operations. CONCLUSIONS: Emergency operations make up nearly half of all operations performed in Ghana. Most are performed at district hospitals, many of which do not have fully trained surgeons. Obstetric procedures make up a large portion of emergency operations, indicating a need for improved provision of non-obstetric emergency surgical care. These data are useful for future benchmarking efforts to improve availability of emergency surgical care in Ghana and other low- and middle-income countries.

Surgeon choice in management of pediatric abdominal trauma.

BACKGROUND: No guidelines exist for management of hemodynamically stable children with suspected hollow viscus injury. We sought to determine factors contributing to surgeon management of these patients. METHODS: Surgeon members of the Eastern Association for the Surgery of Trauma and American Pediatric Surgical Association completed a survey on 3 blunt abdominal injury scenarios: (1) isolated, (2) with multisystem injury, and (3) with traumatic brain injury (TBI), and a penetrating injury scenario. Multivariable logistic regression was used to determine factors associated with initial management of observation vs. operation for blunt injury and observation vs. local wound exploration versus laparoscopy for penetrating injury. RESULTS: Of 394 surgeons (response rate 22.3%), 50.3% were pediatric surgeons. For scenarios 1-3, 32.2%, 49.3%, and 60.7% of surgeons chose operation over observation, respectively. Compared to isolated blunt injury, surgeons were more likely to choose operation for patients with multisystem injury (aOR 2.20, 95%CI: 1.78-2.72) or TBI (aOR 3.60, 95%CI: 2.79-4.66). Pediatric surgeons were less likely to choose operation (aOR 0.32, 95%CI: 0.22-0.44). For penetrating injury, 39.1%, 29.5%, and 31.5% of surgeons chose observation, local wound exploration, and laparoscopy, respectively. CONCLUSIONS: Large variation exists in management of hemodynamically stable children with suspected hollow viscus injury. Although patient injury characteristics account for some variation, surgeon factors such as type of surgeon also play a role. Evidence-based practice guidelines should be developed to standardize care. TYPE OF STUDY: Cross-Sectional Survey. LEVEL OF EVIDENCE: N/A.

Excited electronic states of AuF.

We have recorded laser excitation spectra of transitions from the ground X(1)Sigma(+) state of gaseous gold fluoride (AuF) into three excited electronic states in the visible region. We prepared the sample in a dc electric discharge by flowing a dilute mixture of SF(6) in argon through a hollow gold cathode. Two of these electronic states give rise to the previously reported yellow bands of the molecule, for which a rotational analysis is given here for the first time. We have analyzed the (0,0), (1,1), (0,1), and (1,2) bands of these two transitions, which we identify as [17.8]0(+)-X(1)Sigma(+) and [17.7]1-X(1)Sigma(+); their red-degraded (0,0) band heads lie at 563.0 and 566.2 nm, respectively. The (0,0) band of a new, red-degraded [14.0]1-X(1)Sigma(+) transition at 715.1 nm has also been recorded and analyzed. An accurate set of molecular constants of the three excited states as well as the ground state has been determined by least-squares fitting all of the optical data together with measurements made by other workers of the pure rotational spectrum of AuF in its ground state. These constants include the electronic term energies, vibrational frequencies, rotational constants, and Omega-doubling constants. We discuss the nature of these three excited electronic states in terms of the ionic Au(+)F(-) electronic configurations from which they are derived.

Electronic spectrum of AuF: hyperfine structure of the [17.7]1 state.

The [17.7]1-X(1)Sigma(+) (0,0) band of AuF at 566 nm has been studied by laser excitation spectroscopy. The molecule was prepared in a dc electric discharge by flowing a dilute mixture of SF(6) in argon through a hollow gold cathode. The rotational structure of the band has been analyzed for the first time, yielding accurate values for the rotational and Omega-type doubling constants of the upper state. Hyperfine splittings arising from both the (197)Au and (19)F nuclei have been resolved by recording the spectrum at sub-Doppler resolution using the technique of intermodulated fluorescence spectroscopy. The hyperfine structure is dominated by the (197)Au magnetic dipole interaction in the [17.7]1 state, with the (197)Au magnetic hyperfine constant determined to be h(1) = -543(4) MHz. It is demonstrated that the negative value of this constant implies that the [17.7]1 state has significant (3)Delta(1) character and that spin-orbit mixing with a (1)Pi(1) state may be providing the transition intensity to the ground electronic state.

Optimizing Care for Ugandans with Untreated Abdominal Surgical Conditions.

BACKGROUND: Abdominal operations account for a majority of surgical volume in low-income countries, yet population-level prevalence data on surgically treatable abdominal conditions are scarce. OBJECTIVE: In this study, our objective was to quantify the burden of surgically treatable abdominal conditions in Uganda. METHODS: In 2014, we administered a two-stage cluster-randomized Surgeons OverSeas Assessment of Surgical Need survey to 4,248 individuals in 105 randomly selected clusters (representing the national population of Uganda). FINDINGS: Of the 4,248 respondents, 185 reported at least one surgically treatable abdominal condition in their lifetime, giving an estimated lifetime prevalence of 3.7% (95% CI: 3.0 to 4.6%). Of those 185 respondents, 76 reported an untreated condition, giving an untreated prevalence of 1.7% (95% CI: 1.3 to 2.3%). Obstructed labor (52.9%) accounted for most of the 238 abdominal conditions reported and was untreated in only 5.6% of reported conditions. In contrast, 73.3% of reported abdominal masses were untreated. CONCLUSIONS: Individuals in Uganda with nonobstetric abdominal surgical conditions are disproportionately undertreated. Major health system investments in obstetric surgical capacity have been beneficial, but our data suggest that further investments should aim at matching overall surgical care capacity with surgical need, rather than focusing on a single operation for obstructed labor.