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Immunomodulating agents interact with the immune system and alter the outcome of specific immune processes. As our understanding of the immune system continues to evolve, there is a growing effort to identify agents with immunomodulating applications to use therapeutically to treat various diseases. Mycobacterium w (Mw), a heat-killed mycobacterium, is an atypical mycobacterial species that possesses strong immunomodulatory properties. Mw was initially evaluated as an immune-therapeutic against leprosy, but since then Mw has generated a lot of interest and been studied for therapeutic applications across a host of diseases, such as pulmonary tuberculosis, tuberculous pericarditis, sepsis, lung cancer, and more. This article summarizes a large body of work published in the past five decades, describing various aspects of Mw and its potential for further therapeutic development. [ABSTRACT FROM AUTHOR]

Musculoskeletal (MSK) health impairments contribute substantially to the pain and disability burden in low- and middle-income countries (LMICs), yet health systems strengthening (HSS) responses are nascent in these settings. We aimed to explore the contemporary context, framed as challenges and opportunities, for improving population-level prevention and management of MSK health in LMICs using secondary qualitative data from a previous study exploring HSS priorities for MSK health globally and (2) to contextualize these findings through a primary analysis of health policies for integrated management of non-communicable diseases (NCDs) in select LMICs. Part 1: 12 transcripts of interviews with LMIC-based key informants (KIs) were inductively analysed. Part 2: systematic content analysis of health policies for integrated care of NCDs where KIs were resident (Argentina, Bangladesh, Brazil, Ethiopia, India, Kenya, Malaysia, Philippines and South Africa). A thematic framework of LMIC-relevant challenges and opportunities was empirically derived and organized around five meta-themes: (1) MSK health is a low priority; (2) social determinants adversely affect MSK health; (3) healthcare system issues de-prioritize MSK health; (4) economic constraints restrict system capacity to direct and mobilize resources to MSK health; and (5) build research capacity. Twelve policy documents were included, describing explicit foci on cardiovascular disease (100%), diabetes (100%), respiratory conditions (100%) and cancer (89%); none explicitly focused on MSK health. Policy strategies were coded into three categories: (1) general principles for people-centred NCD care, (2) service delivery and (3) system strengthening. Four policies described strategies to address MSK health in some way, mostly related to injury care. Priorities and opportunities for HSS for MSK health identified by KIs aligned with broader strategies targeting NCDs identified in the policies. MSK health is not currently prioritized in NCD health policies among selected LMICs. However, opportunities to address the MSK-attributed disability burden exist through integrating MSK-specific HSS initiatives with initiatives targeting NCDs generally and injury and trauma care. [ABSTRACT FROM AUTHOR]

Background: The burden of musculoskeletal conditions is growing worldwide. In low- and middle-income countries (LMIC), the burden cannot be fully estimated, due to paucity of credible data. Further, no attempt has been made so far to estimate surgical burden of musculoskeletal conditions. This is a difficult task and accurate estimation of what would constitute surgical burden out of the total musculoskeletal burden in LMIC is not possible, due to number of constraints. Methods: This review looks at current understanding of the musculoskeletal conditions, that can be measured in LMIC and the limitations based on previous studies and past global burden of diseases estimates. Results: An attempt has been made to identify major conditions where a range of surgical burden can be predicted. Conclusion: We conclude that there is huge scope for improvement in the current surveillance mechanism of surgical procedures undertaken for musculoskeletal conditions in LMIC so that the surgical burden can be more accurately predicted. Unless this burden can be highlighted, the attention to these conditions in LMIC will be limited. [ABSTRACT FROM AUTHOR]

Background: The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. Methods: The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Results: Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51; 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4; 95% CI 1.02–2.01; p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Conclusion: Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries. [ABSTRACT FROM AUTHOR]

Background: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. Methods: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. Results: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation ( p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. Conclusions: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings. [ABSTRACT FROM AUTHOR]

Background: We sought to assess the status of availability of technology for trauma care in a state in India and to identify factors contributing to both adequate levels of availability and to deficiencies. We also sought to identify potential solutions to deficiencies in terms of health system management and product development. Methods: Thirty-two technology-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. The status of these items was assessed at 43 small and large hospitals in Gujarat State. Site visits utilized direct inspection and interviews with administrative, clinical, and bioengineering staff. Results: Many specific individual items could be better supplied, including many that were very low cost (e.g., chest tubes). Many deficiencies arose because of mismatch of resources, such as availability of equipment in the absence of personnel trained to use it. Several locally manufactured items were fairly well supplied: pulse oximetry, image intensification, and X-ray machines. Ventilators were often deficient because of inadequate numbers of units and frequent breakdowns. Conclusions: Availability of a range of lower-cost items could be improved by better organization and planning, such as: better procurement and stock management; eliminating mismatch of resources, including optimizing training for use of existing resources; and by strengthening service contracts and in-house repair capabilities. From a product development viewpoint, there is a need for lower cost, more durable, and easier to repair ventilators. Promoting increased capacity for local manufacturing should also be considered as a potential method to decrease cost and increase availability of a range of equipment. [ABSTRACT FROM AUTHOR]

Background: Quality Improvement (QI) programs have been shown to be a valuable tool to strengthen care of severely injured patients, but little is known about them in low and middle income countries (LMIC). We sought to explore opportunities to improve trauma QI activities in LMIC, focusing on the Asia-Pacific region. Methods: We performed a mixed methods research study using both inductive thematic analysis of a meeting convened at the Royal Australasian College of Surgeons, Melbourne, Australia, November 21-22, 2010 and a pre-meeting survey to explore experiences with trauma QI activities in LMIC. Purposive sampling was employed to invite participants with demonstrated leadership in trauma care to provide diverse representation of organizations and countries within Asia-Pacific. Results: A total of 22 experts participated in the meeting and reported that trauma QI activities varied between countries and organizations: morbidity and mortality conferences (56 %), monitoring complications (31 %), preventable death studies (25 %), audit filters (19 %), and statistical methods for analyzing morbidity and mortality (6 %). Participants identified QI gaps to include paucity of reliable/valid injury data, lack of integrated trauma QI activities, absence of standards of care, lack of training in QI methods, and varying cultures of quality and safety. The group highlighted barriers to QI: limited engagement of leaders, organizational diversity, limited resources, heavy clinical workload, and medico-legal concerns. Participants proposed establishing the Asia-Pacific Trauma Quality Improvement Network (APTQIN) as a tool to facilitate training and dissemination of QI methods, injury data management, development of pilot QI projects, and advocacy for quality trauma care. Conclusions: Our study provides the first description of trauma QI practices, gaps in existing practices, and barriers to QI in LMIC of the Asia-Pacific region. In this study we identified opportunities for addressing these challenges, and that work will be supported by APTQIN. [ABSTRACT FROM AUTHOR]

Background. Injury and other medical emergencies are becoming increasingly common in low- and middle-income countries (LMICs). Many to most of the deaths from these conditions occur outside of hospitals, necessitating the development of prehospital care. Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most LMICs. Objective. In order to better plan for development of prehospital care globally, this study sought to better understand the current status of prehospital care in a wide range of LMICs. Methods. A survey was conducted of emergency medical services (EMS) leaders and other key informants in 13 LMICs in Africa, Asia, and Latin America. Questions addressed methods of transport to hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to EMS development. Results. Prehospital care capabilities varied significantly, but in general were less developed in low-income countries and in rural areas, where utilization of formal EMS was often very low. Commercial drivers, volunteers, and other bystanders provided a large proportion of prehospital transport and occasionally also provided first aid in many locations. Although taxes and mandatory motor vehicle insurance provided supplemental funds to EMS in 85% of the countries, the most frequently cited barriers to further development of prehospital care was inadequate funding (36% of barriers cited). The next most commonly cited barriers were lack of leadership within the system (18%) and lack of legislation setting standards (18%). Conclusions. Expansion of prehospital care to currently underserved or unserved areas, especially in low-income countries and in rural areas, could make use of the already-existing networks of first responders, such as commercial drivers and laypersons. Efforts to increase their effectiveness, such as more widespread first-aid training, and better encompassing their efforts within formal EMS, are warranted. In terms of existing formal EMS, there is a need for increased and more regular funding, integration and coordination among existing services, and improved organization and leadership, as could be accomplished by making EMS administration and leadership a more desirable career path. [ABSTRACT FROM AUTHOR]

Background: Reducing the global burden of injury requires both injury prevention and improved trauma care. We sought to provide an estimate of the number of lives that could be saved by improvements in trauma care, especially in low income and middle income countries. Methods: Prior data showed differences in case fatality rates for seriously injured persons (Injury Severity Score ≥9) in three separate locations: Seattle, WA (high income; case fatality 35%); Monterrey, Mexico (middle income; case fatality 55%); and Kumasi, Ghana (low income; case fatality 63%). For the present study, total numbers of injury deaths in all countries in different economic strata were obtained from the Global Burden of Disease study. The number of lives that could potentially be saved from improvements in trauma care globally was calculated as the difference in current number of deaths from trauma in low income and middle income countries minus the number of deaths that would have occurred if case fatality rates in these locations were decreased to the case fatality rate in high income countries. Results: Between 1,730,000 and 1,965,000 lives could be saved in low income and middle income countries if case fatality rates among seriously injured persons could be reduced to those in high income countries. This amounts to 34-38% of all injury deaths. Conclusions: A significant number of lives could be saved by improvements in trauma care globally. This is another piece of evidence in support of investment in and greater attention to strengthening trauma care services globally. [ABSTRACT FROM AUTHOR]

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs. The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program. Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings. Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes. [ABSTRACT FROM AUTHOR]

On May 23, 2007, the World Health Assembly (WHA) adopted WHA Resolution 60.22, “Health Systems: Emergency Care Systems,” which called on the World Health Organization (WHO) and governments to adopt a variety of measures to strengthen trauma and emergency care services worldwide. This resolution constituted some of the highest level attention ever devoted to trauma care worldwide. This article reviews the background of this resolution and discusses how it can be of use to surgeons, emergency physicians, and others who care for the injured, especially in low- and middle-income countries. [ABSTRACT FROM AUTHOR]

The article cites a review which offers a public health perspective on the musculoskeletal injury in low and middle-income countries. It discusses the delivery of care of musculoskeletal trauma, highlights inadequacies in resources for health care, and delineates approaches to training and teaching. It also predicts the effect of skeletal injuries to the world's burden of disability. Further, it suggests the needs to have an exchange of information between resource providers in the countries.

Background: We sought to identify affordable and sustainable methods to strengthen trauma care capabilities globally, especially in developing countries, using the Guidelines for Essential Trauma Care. These guidelines were created by the World Health Organization (WHO) and the International Society of Surgery and provide recommendations on elements of trauma care that should be in place at the range of health facilities globally. Methods: The guidelines were used as a basis for needs assessments in 4 countries selected to represent the world's range of geographic and economic conditions: Mexico (middle income; Latin America); Vietnam (low income; east Asia); India (low income; south Asia); and Ghana (low income; Africa). One hundred sites were assessed, including rural clinics (n = 51), small hospitals (n = 34), and large hospitals (n = 15). Site visits utilized direct inspection and interviews with administrative and clinical staff. Results: Resources were partly adequate or adequate at most large hospitals, but there were gaps that could be improved, especially in low-income settings, such as shortages of airway equipment, chest tubes, and trauma-related medications; and prolonged periods where critical equipment (e.g., X-ray, laboratory) were unavailable while awaiting repairs. Rural clinics everywhere had difficulties with basic supplies for resuscitation even though some received significant trauma volumes. In all settings, there was a dearth of administrative functions to assure quality trauma care, including trauma registries, trauma-related quality improvement programs, and regular in-service training. Conclusions: This study identified several low-cost ways in which to strengthen trauma care globally. It also has demonstrated the usefulness of the Guidelines for Essential Trauma Care in providing an internationally applicable, standardized template by which to assess trauma care capabilities. [ABSTRACT FROM AUTHOR]

The planning and development of trauma care systems in India has yet to gain attention and priority from the government, even though trauma is a major public health problem. Several efforts are under way to improve the delivery of trauma care for the injured. Guidelines for Essential Trauma Care has proved to be an ideal tool with which to begin the process of development for building a national system for the care of the injured in one of the most populous countries in the world, and one with a high burden of trauma deaths and disability. This article focuses on the impact of the Guidelines for Essential Trauma Care in efforts for improvement of the system in India. [ABSTRACT FROM AUTHOR]

The Essential Trauma Care (EsTC) Project represents an effort to set reasonable, affordable, minimum standards for trauma services worldwide and to define the resources necessary to actually provide these services to every injured person, even in the lowest-income countries. An emphasis is improved organization and planning, at minimal cost. The EsTC Project is a collaborative effort of the World Health Organization and the International Association for Trauma Surgery and Intensive Care, an integrated society within the International Society of Surgery-Société Internationale de Chirurgie. A milestone of the project has been the release of Guidelines for Essential Trauma Care. This establishes 11 core Essential Trauma Care services that can be considered “The Rights of the Injured.” To assure these services, Guidelines delineates 260 items of human and physical resources that should be in place at the spectrum of health facilities globally. These are delineated in a series of flexible resource tables, to be adjusted based on an individual country’s circumstances. Guidelines is intended to serve as both a planning guide and an advocacy statement. It has been used to catalyze improvements in trauma care in several countries. It has stimulated five national-level consultation meetings on trauma care, which constituted the highest governmental attention yet devoted to trauma care in those countries. At these meetings, the EsTC resource templates were adjusted to local circumstances and implementation strategies developed. Future efforts need to emphasize more on-the-ground implementation in individual countries, greater linkages with prehospital care, and wider political endorsement, such as by passage of a World Health Assembly resolution. [ABSTRACT FROM AUTHOR]