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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., (© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Background:  Alzheimer's disease and related dementias (ADRDs) pose a major public health challenge in older adults. In sub-Saharan Africa, the burden of ADRD is projected to escalate amidst ill-equipped healthcare workers (HCWs)., Aim:  This study aimed to assess ADRD knowledge amongst Ghanaian HCWs and improve gaps identified through a workshop., Setting:  Study was conducted among HCWs attending a workshop in Kumasi, Ghana., Methods:  On 18 August 2021, a workshop on ADRD was organised in Kumasi, Ghana, which was attended by 49 HCWs comprising doctors, nurses, pharmacists, social workers and nutritionists. On arrival, they answered 30 pre-test questions using the Alzheimer's Disease Knowledge Scale (ADKS). A post-test using the same questionnaire was conducted after participants had been exposed to a 4-h in-person educational content on ADRD delivered by facilitators from family medicine, neurology, geriatrics, psychiatry and public health., Results:  The mean age of participants was 34.6 (± 6.82), mean years of practice was 7.7 (± 5.6) and 38.8% (n = 19) were nurses. The mean score of participants' overall knowledge was 19.8 (± 4.3) at pre-test and 23.2 (± 4.0) at post-test. Participants' pre-test and post-test scores improved in all ADKS domains. Factors associated with participants' knowledge at baseline were profession, professional rank and the highest level of education attained. After adjusting for age and sex, participant's rank, being a specialist (adjusted β = 14.44; 95% confidence interval [CI] = 7.03, 21.85; p  0.001) was an independent predictor of knowledge on Alzheimer's disease., Conclusion:  Existing knowledge gaps in ADRD could be improved via continuous medical education interventions of HCWs to prepare healthcare systems in Africa for the predicted ADRD epidemic.

Background and Objectives: Limbic-predominant age-related Tar DNA binding protein 43 (TDP-43) encephalopathy neuropathologic change (LATE-NC) is present in ≈25% of older persons' brains and is strongly associated with cognitive impairment. Hippocampal sclerosis (HS) pathology is often comorbid with LATE-NC, but the clinical and pathologic correlates of HS in LATE-NC are not well understood., Methods: This retrospective autopsy cohort study used data derived from the National Alzheimer's Coordinating Center Neuropathology Data Set, which included neurologic status, medical histories, and neuropathologic results. All autopsies were performed in 2014 or later. Among participants with LATE-NC, those who also had HS pathology were compared with those without HS with regard to candidate risk factors or common underlying diseases. Statistical significance was set at nominal p < 0.05 in this exploratory study., Results: A total of 408 participants were included (n = 221 were LATE-NC+/HS-, n = 145 were LATE-NC+/HS+, and n = 42 were LATE-NC-/HS+). Most of the included LATE-NC+ participants were severely impaired cognitively (83.3% with dementia). Compared to HS- participants, LATE-NC+ participants with HS trended toward having worse cognitive status and scored lower on the Personal Care and Orientation domains (both p = 0.03). Among LATE-NC+ participants with Braak neurofibrillary tangle (NFT) stages 0 to IV (n = 88), HS+ participants were more impaired in the Memory and Orientation domains (both p = 0.02). There were no differences (HS+ compared with HS-) in the proportion with clinical histories of seizures, stroke, cardiac bypass procedures, diabetes, or hypertension. The HS+ group lacking TDP-43 proteinopathy (n = 42) was relatively likely to have had strokes ( p = 0.03). When LATE-NC+ participants with or without HS were compared, there were no differences in Alzheimer disease neuropathologies (Thal β-amyloid phases or Braak NFT stages) or Lewy body pathologies. However, the HS+ group was less likely to have amygdala-restricted TDP-43 proteinopathy (LATE-NC stage 1) and more likely to have neocortical TDP-43 proteinopathy (LATE-NC stage 3) ( p < 0.001). LATE-NC+ brains with HS also tended to have more severe circle of Willis atherosclerosis and arteriolosclerosis pathologies., Discussion: In this cohort skewed toward participants with severe dementia, LATE-NC+ HS pathology was not associated with seizures or with Alzheimer-type pathologies. Rather, the presence of comorbid HS pathology was associated with more widespread TDP-43 proteinopathy and with more severe non-β-amyloid vessel wall pathologies., (© 2022 American Academy of Neurology.)

Background: Road construction work has specific risks and safety issues which have not been adequately addressed in most low- and middle-income countries, especially Africa. The objective of this study was to determine the prevalence of personal protective equipment (PPE) use during road construction activities by workers in foreign- owned against locally-owned road construction companies in Ghana., Methods: An institution-based cross-sectional survey was undertaken during January - March, 2020 to study 389 road construction workers who were actively working on site. They were unobtrusively observed to capture whether or not they wore the appropriate PPE at the time of the survey. The PPE of interest were: hard hat, goggles, shoes, nose masks, hearing protection, gloves and reflective vests/apparel. On-site posted PPE signage was also checked., Results: Majority of workers were males (96.9%) and labourers (53.5%). Similar numbers of workers in locally-owned (195) and foreign-owned (194) companies were studied. Use of PPE varied considerably by type: shoes (78.7%), reflective vest (44.5%), gloves (30.6%), hard hat (27.0%), nose mask (17.2%), goggles (11.3%) and hearing protection (10.8%). For all types of PPE, use was higher for workers in foreign-owned companies compared with locally-owned companies: goggles (Odds ratio [OR] 55.2), hearing protection (OR 52.0), gloves (OR 23.7), hard hat (OR 20.2), nose mask (OR 17.8), reflective vest (OR 5.3) and shoes (OR 4.1), (p<0.001 for all ORs). No site had any signage to promote PPE use., Conclusions: Majority of workers used shoes. Less than half of workers used other types of PPE and use of some types (goggles and hearing protection) was minimal. Workers in foreign-owned companies were significantly more likely to use all the seven types of PPE than locally-owned companies. Although there is still room for improvement in foreign-owned companies, locally-owned companies should be able to attain similar PPE use to that in foreign-owned companies. Necessary PPE should be provided and site supervisors should encourage workers to wear PPE when on site., (© 2021. The Author(s).)

Transactive response DNA-binding protein 43 kDa (TDP-43) is aberrantly aggregated and phosphorylated in frontotemporal lobar degeneration of the TDP-43 type (FTLD-TDP), and in limbic-predominant age-related TDP-43 encephalopathy neuropathologic change (LATE-NC). We examined data from the National Alzheimer's Coordinating Center to compare clinical features of autopsy-confirmed LATE-NC and FTLD-TDP. A total of 265 LATE-NC and 92 FTLD-TDP participants were included. Cognitive and behavioral symptoms were compared, stratified by level of impairment based on global clinical dementia rating (CDR) score. LATE-NC participants were older at death, more likely to carry APOE ε4, more likely to have Alzheimer disease neuropathology, and had lower (i.e. less severe) final CDR global scores than those with FTLD-TDP. Participants with FTLD-TDP were more likely to present with primary progressive aphasia, or behavior problems such as apathy, disinhibition, and personality changes. Among participants with final CDR score of 2-3, those with LATE-NC were more likely to have visuospatial impairment, delusions, and/or visual hallucinations. These differences were robust after sensitivity analyses excluding older (≥80 years at death), LATE-NC stage 3, or severe Alzheimer cases. Overall, FTLD-TDP was more globally severe, and affected younger participants, whereas psychoses were more common in LATE-NC., (© 2021 American Association of Neuropathologists, Inc. All rights reserved.)

Road traffic accidents claim millions of lives every year across the world. Fortunately, effective safety and preventive measures such as routine maintenance of vehicles and roads and the use of seat belts exist. Yet, authorities in some countries fail to enforce laws on these measures. One of the barriers to compliance with traffic laws is poor enforcement. Using a cross-sectional study design, we explored the barriers to the enforcement of mandatory seat belt laws in Ghana. We employed an open-ended key informant interview guide to interview 26 staff of the Motor Traffic and Transport Department of the Ghana Police Service, National Road Safety Authority and the Driver and Vehicle Licensing Authority. The interviews which lasted between 30 and 45 min per session were analysed through a thematic approach facilitated by ATLAS.ti. The findings showed that the barriers to the enforcement of seat belt laws mentioned by the participants were institutional factors (inadequate resources and logistics and inability to enforce vehicle safety standards) political factors (external interference and lack of consensus on seat belt law implementation) and human factors (poor public attitudes and non- recognition of road safety as both individual and collective responsibility). The enforcement of road safety laws could be enhanced by adequately resourcing officers, addressing external interference of police duties and empowering officers to perform their duties without fear or favour. These findings are also useful in continuous public education and enhanced enforcement of the seat belt laws., (© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Seat-belt use is effective in preventing traffic fatalities and injuries yet its use is not universal. This study sought to determine the predictors of self-reported seat-belt use among bus passengers in Ghana based on the theory of planned behaviour and health belief model., Methods: A quantitative cross-sectional study design with 633 randomly selected intercity bus passengers was conducted using a structured questionnaire in Kumasi, Ghana. The resulting data were analysed using SPSS version 23.0. Ordinal regression was employed to determine the predictors of self-reported seat-belt use., Results: Majority of the respondents were male (61.5%) with a mean age of 32.2 (SD = 11.6). A third (33.0%) reported that they always wear their seat-belt as bus passengers. The results indicated that intention (OR = 1.49, 95% CI = 1.21-1.84, p = 0.001), subjective norm (OR = 1.57, 95% CI = 1.15-2.13, p = 0.004) and perceived behavioural control (OR = 1.53; 95% CI = 1.21-1.92, p = 0.001) variables from the theory of planned behaviour were significant independent predictors of seat-belt use. Among the health belief model variables, perceived severity (OR = 1.57, 95% CI = 1.15-2.16, p = 0.005) and perceived barriers (OR = 0.52, 95% CI = 0.39-0.67, p = 0.001) were the only significant independent predictors of self-reported seat-belt use., Conclusion: The findings suggest that intention, subjective norm, perceived behavioural control, perceived severity and perceived barriers play an important role in determining bus passengers' seat-belt use behaviour. Road safety programmes to increase seat-belt use will gain from giving serious attention to these factors in the design and implementation of such programmes., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Trauma quality improvement (QI) programs improve care and outcomes for injured patients. Information about QI programs for pediatric traumatic brain injury (TBI) is sparse in Latin America., Methods: We gathered data on the status of QI programs and activities that encompass pediatric TBI at 15 Argentine hospitals. Data were gathered during 2019 and included hospital characteristics, QI practices, presence of a queryable registry, and use of protocols for TBI care. Level of QI activities was compared between hospital types using Fisher's exact test., Results: Most hospitals had guidelines for pediatric TBI care, including management and/or prevention of intracranial pressure (100%) and central-line-associated infections (87%). Morbidity and mortality meetings or other types of case discussions in which quality of pediatric TBI care was discussed were held by all hospitals, with most (53%) having weekly-monthly meetings, but 27% having rare or annual meetings. Sixty percent of hospitals had adequate data for case reviews (fewer than 25% of cases with essential information missing). Fifty-three percent documented discussions that occurred at these meetings and 53% utilized computerized trauma registries. Larger hospitals (> 200 beds) more frequently had adequate data (88%) for case reviews than smaller hospitals (29%, P = 0.046). Hospital size did not affect other QI activities., Conclusions: Most hospitals had guidelines for pediatric TBI care. Adequacy of care was discussed at reasonably frequent case conferences. Opportunities for improvement include increasing documentation of case reviews and improving adequacy of data for case reviews, especially at smaller hospitals. Greater use of computerized trauma registries could provide such data., (Copyright © 2021. Published by Elsevier Inc.)

Background: The Lancet Commission on Global Surgery (LCoGS) recommended an annual surgical rate at which low- and middle-income countries (LMICs) could achieve most of the population-wide benefits of surgery. However, condition-specific guidelines were not proposed. To inform rates of surgery for cancer, we sought to assess the current met and unmet need for oncologic surgery in Ghana., Methods: Data on all operations performed in Ghana over a one-year period (2014-15) were obtained from representative samples of 48/124 first-level and 12/16 referral hospitals and scaled-up for nationwide estimates. Procedures for cancer were identified by indication. Using modified LCoGS methodology with disease prevalence, Ghana's annual rate of cancer surgery was compared to that of New Zealand to quantify current unmet needs., Results: 232,776 surgical procedures were performed in Ghana; 2,562 procedures (95%UI 1878-3255) were for cancer. Of these, 964 (37%) were surgical biopsies. The annual rate of procedures treating cancer was 2115 surgeries/100,000 cancer cases, or 21% of the New Zealand benchmark. Cervical, breast, and prostate cancer were found to meet 2.1%, 17.2%, and 32.1% of their respective surgical need., Conclusions: There is a large unmet need for cancer surgery in Ghana. Cancer surgery constitutes under 2% of the total surgeries performed in Ghana, an important proportion of which are used for biopsies. Therapeutic operative rate is deficient across most cancer types, and may lag behind improvements in screening efforts. As cancer prevalence and diagnosis increase in LMICs, cancer-specific surgical capacity must be increased to meet these evolving needs., (© 2021. Société Internationale de Chirurgie.)

Objective: We aimed to describe the incidence of childhood household injuries and prevalence of modifiable household risk factors in rural Ghana to inform prevention initiatives., Setting: 357 randomly selected households in rural Ghana., Participants: Caregivers of children aged <5 years., Primary and Secondary Outcome Measures: Childhood injuries that occurred within 6 months and 200 metres of the home that resulted in missed school/work, hospitalisation and/or death. Sampling weights were applied, injuries were described and multilevel regression was used to identify risk factors., Results: Caregivers from 357 households had a mean age of 35 years (SD 12.8) and often supervised ≥2 children (51%). Households typically used biomass fuels (84%) on a cookstove outside the home (79%). Cookstoves were commonly <1 metre of the ground (95%). Weighted incidence of childhood injury was 542 per 1000 child-years. Falls (37%), lacerations (24%), burns (12%) and violence (12%) were common mechanisms. There were differences in mechanism across age groups (p<0.01), but no gender differences (p=0.25). Presence of older children in the home (OR 0.15, 95% CI 0.09 to 0.24; adjusted OR (aOR) 0.26, 95% CI 0.13 to 0.54) and cooking outside the home (OR 0.28, 95% CI 0.19 to 0.42; aOR 0.25, 95% CI 0.13 to 0.49) were protective against injury, but other common modifiable risk factors (eg, stove height, fuel type, secured cabinets) were not., Conclusions: Childhood injuries occurred frequently in rural Ghana. Several common modifiable household risk factors were not associated with an increase in household injuries. Presence of older children was a protective factor, suggesting that efforts to improve supervision of younger children might be effective prevention strategies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Childhood household injuries incur a major proportion of the global disease burden, particularly in low- and middle-income countries (LMICs). However, household injury hazards are differentially distributed across developed environments. Therefore, we aimed to compare incidence of childhood household injuries and prevalence of risk factors between communities in urban and rural Ghana to inform prevention initiatives., Methods: Data from urban and a rural cluster-randomized, population-based surveys of caregivers of children <5 years in Ghana were combined. In both studies, caregivers were interviewed about childhood injuries that occurred within the past 6 months and 200 meters of the home that resulted in missed school/work, hospitalization, and/or death. Sampling weights were applied, injuries and incidence rate ratios (IRRs) were described, and multi-level regression was used to identify and compare risk factors., Results: We sampled 200 urban and 357 rural households that represented 20,575 children in Asawase and 14,032 children in Amakom, Ghana, respectively. There were 143 and 351 injuries in our urban and rural samples, which equated to 594 and 542 injuries per 1,000 child-years, respectively (IRR 1.09, 95%CI 1.05-1.14). Toddler-aged children had the highest odds of injury both urban and rural communities (OR 3.77 vs 3.17, 95%CI 1.34-10.55 vs 1.86-5.42 compared to infants, respectively). Urban children were more commonly injured by falling (IRR 1.50, 95%CI 1.41-1.60), but less commonly injured by flame/hot substances (IRR 0.51, 95%CI 0.44-0.59), violence (IRR 0.41, 95%CI 0.36-0.48), or motor vehicle (IRR 0.50, 95%CI 0.39-0.63). Rural households that cooked outside of the home (OR 0.36, 95%CI 0.22-0.60) and that also supervised older children (OR 0.33, 95%CI 0.17-0.62) had lower odds of childhood injuries than those that did not., Conclusions: Childhood injuries were similarly common in both urban and rural Ghana, but with different patterns of mechanisms and risk factors that must be taken into account when planning prevention strategies. However, the data suggest that several interventions could be effective, including: community-based, multi-strategy initiatives (e.g., home hazard reduction, provision of safety equipment, establishing community creches); traffic calming interventions in rural community clusters; and passive injury surveillance systems that collect data to inform violence and broader prevention strategies., Competing Interests: Declaration of Competing Interest The authors have no real or potential conflicts of interest to disclose., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: information on occupational injuries to health care workers (HCWs) in Africa is limited. We sought to determine the prevalence of occupational injuries among HCWs at a Ghanaian hospital, determine the most common types of injuries, and assess HCWs' knowledge regarding occupational safety., Methods: we interviewed 246 HCWs at a government hospital regarding occupational injuries during the prior year. The sample included: nurses (77.6%), physicians (9.3%), laboratory staff (5.7%), and non-clinical staff (6.9%)., Results: the 12-month prevalence of occupational injury was 29.7%. Incidence was 1.63 injuries per person-year. Leading mechanisms were needlesticks (35.4% of injuries), cuts from sharp objects (34.6%), hit by object (25.2%), and violence (24.4%). Most (62.2%) respondents had training in occupational safety. Most reported adherence to safety practices, including properly disposing sharps (86.6%) and using personal protective equipment (85.8%). However, there were gaps in knowledge. Few HCWs knew the officer in-charge for post-exposure prophylaxis (5.3%) or that there was a hospital occupational safety unit (26.4%). Many (20.8%) reported difficulty in seeking care for their injury. On multivariable analysis, correlates of injury included stress at work (aOR 2.68; 95% CI 1.26, 5.71) and being a laboratory worker (aOR 3.26; 95% CI 1.02, 10.50)., Conclusion: occupational injuries to HCWs were unacceptably frequent. There is, however, a solid foundation to build on. Most HCWs had training in occupational safety and many reported adherence to safety practices. Health care workers need to be better informed of existing resources. Care for injuries needs to be improved, such as by increasing capacity for post-exposure prophylaxis., Competing Interests: The authors declare no competing interests., (Copyright: Helena Appiagyei et al.)

Background: We aimed to determine the incidence of childhood burn injuries in rural Ghana and describe modifiable household risk factors to inform prevention initiatives., Methods: We performed a cluster-randomized, population-based survey of caregivers of children in a rural district in Ghana, representing 2713 households and 14,032 children. Caregivers were interviewed regarding childhood burn injuries within the past 6 months and household risk factors., Results: 357 households were sampled. Most used an open fire with biomass fuel for cooking (85.8%). Households rarely cooked in a separate kitchen (10%). Stove height was commonly within reach of children under five years (<1 m; 96.0%). The weighted annualized incidence of CBI was 63 per 1000 child-years (6.4% of children per year); reported mean age was 4.4 years (SD 4.0). The most common etiology was flame burn. Older age (OR 0.89, 95% CI 0.8-1.0) and households with an older sibling ≥12 years (OR 0.58, 95% CI 0.3-1.3) seemed to be associated with lower odds of CBI., Conclusions: Childhood burn injury is common in rural Ghana. Opportunities exist to reduce the risk of childhood burn injury childhood burns in rural settings by supporting the transition to safer cooking arrangements, child barrier apparatuses in homes without older children, and/or development of formal childcare programs., (Copyright © 2020 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Hemorrhage is an important cause of preventable injury-related death. Many low- and middle-income country (LMIC) patients do not have timely access to safe blood. We sought to determine the degree of appropriateness of blood transfusion among patients with injuries requiring surgical intervention at presentation to a tertiary hospital in Ghana., Methods: We performed a retrospective review of such patients presenting to Komfo Anokye Teaching Hospital (KATH), from January 2015 to December 2016. Patients' hemoglobin levels at presentation were determined as the first record of hemoglobin after presentation and their receipt of blood transfusion was determined by explicit documentation in the chart. We defined appropriate blood transfusion practice as patients receiving transfusion when hemoglobin was equal or below a threshold, or patients not being transfused when hemoglobin was above the threshold. We considered both restrictive (hemoglobin ≤7 g/dL) and liberal (hemoglobin ≤10 g/dL) transfusion thresholds., Results: There were 1,408 patients who presented to KATH with injuries that met inclusion criteria. Two hundred and ninety two (292) patients were excluded because of missing hemoglobin information. Four hundred and fifty eight (458;41%) patients received blood transfusion. Transfused patients had a higher mean age (38 vs 35 years) and were less likely to be male (62% vs 71%). Transfused patients underwent more external fixation procedures (28% vs 19%), trauma amputations (5% vs 1%) and trauma laparotomies (3% vs 1%). At a restrictive transfusion threshold (hemoglobin ≤7 g/dL), 20% of patients who needed a transfusion did not receive one and 39% of patients who did not need a transfusion received one. At a liberal threshold (hemoglobin ≤10 g/dL), 33% of patients who needed a transfusion did not receive one and 30% of patients who did not need a transfusion received one. Blood transfusion practice was inappropriate in 31%-39% of all patients., Conclusion: Our data suggest that clearer guidelines for blood transfusion among emergency surgery patients are needed in Ghana and similar LMICs to avoid inappropriate use of blood as a scarce resource., Competing Interests: Declaration of Competing Interest The authors of the manuscript titled “Assessing the appropriateness of blood transfusion among injured patients at a Ghanaian tertiary hospital: Time for clarity on the use of a scarce resource” declare no conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Introduction: falls contribute to almost one-fifth of injury-related deaths. The majority of these occur in low- and middle-income countries. The impact of fall injury in low- and middle-income countries is greater in younger individuals. We aimed to determine the epidemiology of falls among rural Ghanaian children., Methods: from March to May, 2018, we conducted a cluster-randomized household survey of caregivers in a rural Ghanaian sub-district, regarding household child falls and their severity. We utilized a previously validated survey tool for household child injury. Associations between household child falls and previously described predictors of household child injury were examined with multivariable logistic regression. These included age and gender of the child, household socioeconomic status, caregiver education, employment status, and their beliefs on why household child injuries occur., Results: three hundred and fifty-seven caregivers of 1,016 children were surveyed. One hundred and sixty-four children under 18 years had sustained a household fall within the past six months, giving a household child fall prevalence of 16% (95% C.I, 14%-19%). Mean age was 4.4 years; 59% were males. Ground level falls were more common (80%). Severity was mostly moderate (86%). Most caregivers believed household child injuries occurred due to lack of supervision (85%) or unsafe environment (75%); only 2% believed it occurred because of fate. Girls had reduced odds of household falls (adjusted O.R 0.6; 95% C.I 0.4-0.9). Five to nine year-old and 15-17 year-old children had reduced odds of household falls (adjusted O.R 0.4; 95% C.I 0.2-0.7 and 0.1; 95% C.I 0.02-0.3, respectively) compared to 1-4 year-olds. Caregiver engagement in non-salary paying work was associated with increased odds of household child falls (adjusted O.R 2.2; 95% C.I 1.0-4.7) compared to unemployed caregivers. There was no association between household child falls and caregiver education, socioeconomic status and beliefs about why household child injuries occurred., Conclusion: the prevalence of household child falls in rural Ghana was 16%. This study confirms the need to improve supervision of all children to reduce household falls, especially younger children and particularly boys. Majority of caregivers also acknowledge the role of improper child supervision and unsafe environments in household child falls. These beliefs should be reinforced and emphasized in campaigns to prevent household child falls in rural communities., Competing Interests: The authors declare no competing interests., (Copyright: Adam Gyedu et al.)

Introduction:  Currently, there are no existing benchmarks for evaluating a nation's pediatric surgical capacity in terms of met and unmet needs., Materials and Methods:  Data on pediatric operations performed from 2014 to 2015 were obtained from a representative sample of hospitals in Ghana, then scaled up for national estimates. Operations were categorized as "essential" (most cost-effective, highest population impact) as designated by the World Bank's Disease Control Priorities versus "other." Estimates were then compared with pediatric operation rates in New Zealand to determine unmet pediatric surgery need in Ghana., Results:  A total of 29,884 operations were performed for children <15 years, representing an annual operation rate of 284/100,000 (95% uncertainty interval: 205-364). Essential procedures constituted 66% of all pediatric operations; 12,397 (63%) were performed at district hospitals. General surgery (8,808; 29%) and trauma (6,302; 21%) operations were most common. Operations for congenital conditions were few (826; 2.8%). Tertiary hospitals performed majority (55%) of operations outside of the essential category. Compared with the New Zealand benchmark (3,806 operations/100,000 children <15 years), Ghana is meeting only 7% of its pediatric surgical needs., Conclusion:  Ghana has a large unmet need for pediatric surgical care. Pediatric-specific benchmarking is needed to guide surgical capacity efforts in low- and middle-income country healthcare systems., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: This study aimed to track development assistance for trauma care (DAH-TC), uncover funding trends and gaps, and compare DAH-TC to development assistance for other health conditions., Methods: A systematic search of the OECD Creditor Reporting System (CRS) and Development Assistance Committee (DAC) databases was performed to capture projects related to trauma care. Reports from large foundations and public-private partnerships were also searched. DAH-TC was described, and comparisons were made between DAH-TC and other health conditions., Results: The search yielded 1754 records; after applying exclusion criteria, 301 records were included for analysis. During the 25-year period, US$93.7M of DAH-TC was disbursed to low- and middle-income countries (LMICs) (0.02% of total DAH). Contributions were dominated by a few donors and fluctuated dramatically over time. A sizable portion of DAH-TC came in the form of investments to build infrastructure (38% of DAH-TC); information and research activities (17%); and training (16%). Nearly US$58M (62% of DAH-TC) was funneled to projects that targeted victims of war. Trauma care received US$0.04 per DALY incurred, while malaria, TB, HIV and MCH received US$9.62 per DALY, US$25.09 per DALY, US$4.05 per DALY and US$45.75 per DALY, respectively., Conclusions: DAH-TC is critically underfunded, particularly compared to other health foci. To improve the DAH-TC landscape, stakeholders can better mobilize domestic resources; use advocacy more effectively by catalyzing network convergence, grafting trauma care onto related high-priority issues, and seeking broader coalitions; and develop partners within the donor and channel communities to promote strategic DAH-TC disbursements., Competing Interests: Competing interests: The authors completed the ICMJE Unified Competing Interest form (available upon request from the corresponding author), and declare no conflicts of interest., (Copyright © 2021 by the Journal of Global Health. All rights reserved.)

Background: Traditional bonesetters (TBS) are still highly patronized by people with fractures in Africa. We sought to investigate factors affecting the utilization of TBS services in the Northern Region of Ghana., Methods: A mixed-methods study that combined both qualitative and quantitative approaches was conducted among 64 TBS clients in the Northern Region of Ghana. Participants were purposively selected and should have utilized the services of TBSs at the time of the study. In addition, three focus group discussions (FGDs) were conducted to complement the quantitative results. Quantitative analysis was performed by calculating means and proportions. For the qualitative data, content analysis was done manually based on emerging themes in line with the study objectives., Results: Sixty-four (64) clients were recruited. Twenty-four (37.5%) were female. The modal age group was 19-39 years. The educational status of the clients was dominated by primary/junior secondary education (39.1%), but included the full spectrum from no formal education / illiterate (26.6%) to tertiary (12.5%). Cheaper fees (26.3%), cultural beliefs (17.9%), and quick service (15.9%) were the main reason of patronizing TBSs. Twenty-two (34.3%) would have preferred orthodox care and the reasons cited included availability of X-rays (27.3%) and pain management (25.3%). These themes were reiterated by FGDs with an additional 30 clients. Additional themes identified by the FGDs included a belief that TBSs address both physical and spiritual aspects of the injury and the major role that families (not the injured person alone) make in deciding on type of treatment. Clients were supportive of orthodox providers linking with TBSs for activities such as training to improve pain control., Conclusion: TBSs have patronage from the full spectrum of society. The decision to opt for TBS treatment was influenced by cheaper fees, cultural belief, and quick service. TBS clients wanted greater linkages between TBSs and orthodox providers., Competing Interests: The authors declared no conflicts of interest., (© 2020 African Federation for Emergency Medicine. Publishing services provided by Elsevier.)

Introduction: Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana., Methods: We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE., Results: Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p  > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p  < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08-0.55)., Conclusions: NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children., Competing Interests: The authors declared no conflict of interest., (© 2020 African Federation for Emergency Medicine. Publishing services provided by Elsevier.)

Introduction: The majority of injury deaths occur outside health facilities. However, many low- and middle-income countries (LMICs) continue to lack efficient Emergency Medical Services (EMS). Understanding current first aid practices and perceptions among members of the community is vital to strengthening non-EMS, community-based prehospital care., Study Objective: This study sought to determine caregiver first aid practices and care-seeking behavior for common household child injuries in rural communities in Ghana to inform context-specific interventions to improve prehospital care in LMICs., Methods: A cluster-randomized, population-based household survey of caregivers of children under five years in a rural sub-district (Amakom) in Ghana was conducted. Caregivers were asked about their practices and care-seeking behaviors should children sustain injuries at home. Common injuries of interest were burns, laceration, choking, and fractures. Multiple responses were permitted and reported practices were categorized as: recommended, low-risk, or potentially harmful to the child. Logistic regression was used to examine the association between caregiver characteristics and first aid practices., Results: Three hundred and fifty-seven individuals were sampled, representing 5,634 caregivers in Amakom. Mean age was 33 years. Most (79%) were mothers to the children; 68% had only completed basic education. Most caregivers (64%-99%) would employ recommended first aid practices to manage common injuries, such as running cool water over a burn injury or tying a bleeding laceration with a piece of cloth. Nonetheless, seven percent to 56% would also employ practices which were potentially harmful to the child, such as attempting manual removal of a choking object or treating fractures at home without taking the child to a health facility. Reporting only recommended practices ranged from zero percent (burns) to 93% (choking). Reporting only potentially harmful practices ranged from zero percent (burns) to 20% (fractures). Univariate regression analysis did not reveal consistent associations between various caregiver characteristics and the employment of recommended only or potentially harmful only first aid practices., Conclusions: Caregivers in rural Ghanaian communities reported using some recommended first aid practices for common household injuries in children. However, they also employed many potentially harmful practices. This study highlights the need to increase context-appropriate, community-targeted first aid training programs for rural community populations of LMICs. This is important as the home-based care provided for injured children in these communities might be the only care they receive.

Background: Injuries are a major public health problem globally. With sound planning and organization, essential trauma care can be reliably provided with relatively low-cost equipment and supplies. However, availability of these resources requires an effective and efficient supply chain and good stock management practices. Therefore, this study aimed to assess trauma care resource-related supply management structures and processes at health facilities in Ghana. By doing so, the findings may allow us to identify specific structures and processes that could be improved to facilitate higher quality and more timely care., Methods: Ten hospitals were purposively selected using results from a previously performed national trauma care capacity assessment of hospitals of all levels in Ghana. Five hospitals with low resource availability and 5 hospitals with high resource availability were assessed using the United States Agency for International Development (USAID) Logistics Indicators Assessment Tool and stock ledger review. Data were described and stock management practices were correlated with resource availability., Results: There were differences in stock management practices between low and high resource availability hospitals, including frequency of reporting and audit, number of stock-outs on day of assessment (median 9 vs 2 stock-outs, range 3-57 vs 0-9 stock-outs, respectively; p = 0.05), duration of stock-outs (median 171 vs 8 days, range 51-1268 vs 0-182 days, respectively; p = 0.02), and fewer of up-to-date stock cards (24 vs 31 up-to-date stock cards, respectively; p = 0.07). Stock-outs were common even among low-cost, essential resources (e.g., nasal cannulas and oxygen masks, endotracheal tubes, syringes, sutures, sterile gloves). Increased adherence to stock management guidelines and higher percentage of up-to-date stock cards were correlated with higher trauma resource availability scores. However, the variance in trauma resource availability scores was poorly explained by these individual factors or when analyzed in a multivariate regression model (r 2  = 0.72; p value for each covariate between 0.17-0.34)., Conclusions: Good supply chain and stock management practices are correlated with high trauma care resource availability. The findings from this study demonstrate several opportunities to improve stock management practices, particularly at low resource availability hospitals.

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., ((c) 2020 The authors; licensee World Health Organization.)

Introduction: we sought to explore the knowledge and practices among traditional bonesetters (TBSs) in the Northern Region of Ghana and to assess opportunities for their engagement with the formal health sector., Methods: we identified 28 TBSs widely distributed in the Northern Region. They were interviewed using qualitative and quantitative methods, regarding their background, training, current practices, opinions regarding orthodox care, and interests in future linkages with the formal health sector., Results: most TBSs (67.9%) had no formal education and most (85.7%) learned their skills from older family members. Their treatments included reasonable versions of closed reduction and immobilization, but also use of locally-derived concoctions and spiritual aspects, such as incantations. Only 21.4% regularly referred complications to hospital. Nonetheless, all endorsed advantages to orthodox care, such as X-rays (100%), record keeping (100%), and pain management (85.7%). Almost all (96.4%) expressed an interest in training courses or other engagement with the formal health sector. Topics in which they were interested for training included record keeping (100%), pain management (85.7%), and management of open fractures and complications (82.1%)., Conclusion: factors making linkage between TBSs and the formal health sector difficult included low levels of formal education, training through secretive in-family methods, and spiritual and mystical aspects of their practice that might make communications about modern medicine difficult. Nonetheless, most indicated interest in linking with modern care, especially through training courses. Topics they suggested for such courses provide a foundation to build on in future efforts to engage TBSs with the formal health sector., Competing Interests: The authors declare no competing interests., (Copyright: Tolgou Yempabe et al.)

Background: The World Health Organization (WHO) Trauma Care Checklist (TCC) has been documented to improve care of the injured. Factors that promote TCC use have not been well evaluated. We sought to identify barriers and facilitators affecting TCC use., Methods: A qualitative study was conducted by interviewing regional leaders and health care providers at hospitals where the initial WHO TCC pilot study had been conducted in 2010-2012. Study participants included trauma system directors, surgeons, emergency medicine physicians, nurses, and house staff in nine countries. Interview transcripts were thematically analyzed in Dedoose software using deductive and inductive coding strategies incorporating elements of grounded theory., Results: Eighteen participants representing nine of the 11 original pilot sites were interviewed, including 14 doctors and four nurses. Participants represented departments of trauma/trauma surgery (n = 13) and emergency medicine (n = 5). Three sites continued to use the TCC in a nearly original form; three sites used a significantly modified version; and the remaining three sites no longer used it. The most commonly identified facilitator of TCC use was endorsement at both the front-line provider and institutional/leadership level (n = 7). Personnel-related issues and resistance from individual providers were the most commonly identified barriers (n = 10)., Conclusion: Presence of an institutional champion, context-specific adaptation, and integration of the TCC with existing care and documentation practices contribute to successful utilization. Personnel constraints such as revolving trainees and resistance from individual providers hinder utilization. To improve TCC uptake, participants also recommended that TCC be more closely integrated with courses such as Advanced Trauma Life Support., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)

Objective: To determine the rate of preventable trauma deaths in an African hospital, identify the potential effect of improvements in trauma care over the past decade and identify deficiencies in care that still need to be addressed., Methods: A multidisciplinary panel assessed pre-hospital, hospital, and postmortem data on 89 consecutive in-hospital trauma deaths over 5 months in 2017 at the Komfo Anokye Teaching Hospital. The panel judged the preventability of each death. For definitely and potentially preventable deaths, the panel identified deficiencies in care., Results: Thirteen percent (13%) of trauma deaths were definitely preventable, 47% potentially preventable, and 39% non-preventable. In comparison with a panel review in 2007, there was no change in total preventable deaths, but there had been a modest decrease in definitely preventable deaths (25% in 2007 to 13% in 2017, p = 0.07) There was a notable change in the pattern of deficiency (p = 0.001) with decreases in pre-hospital delay (19% of all trauma deaths in 2007 to 3% in 2017) and inadequate resuscitation (17 to 8%), but an increase in delay in treatment at the hospital (23 to 40%)., Conclusions: Over the past decade, there have been improvements in pre-hospital transport and in-hospital resuscitation. However, the preventable death rate remains unacceptably high and there are still deficiencies to address. This study also demonstrates that preventable death panel reviews are a feasible method of trauma quality improvement in the low- and middle-income country setting.

Injury is a major cause of death and disability in Ghana. Strengthening care of the injured is essential to reduce this burden. Trauma continuing professional development (CPD) courses are an important component of strengthening trauma care. In many countries, including Ghana, their use needs to be more uniformly promoted. We propose lowcost strategies to increase the utilization of trauma CPD in Ghana, especially in district hospitals and higher need areas. These strategies include developing plans by regional health directorates and teaching hospitals for the regions for which they are responsible. Lists could be kept and monitored of which hospitals have doctors with which type of training. Those hospitals that need to have at least one doctor trained could be flagged for notice of upcoming courses in the area and especially encouraged to have the needed doctors attend. The targets should include at least one surgeon or one emergency physician at all regional or large district hospitals who have taken the Advanced Trauma Life Support (ATLS) (or locally-developed alternative) in the past 4 years, and each district hospital should have at least one doctor who has taken the Primary Trauma Care (PTC) or Trauma Evaluation and Management (TEAM) (or locally-developed alternatives) in the past 4 years. Parallel measures would increase enrollment in the courses during training, such as promoting TEAM for all medical students and ATLS for all surgery residents. It is important to develop and utilize more "home grown" alternatives to increase the long-term sustainability of these efforts., Funding: None., Competing Interests: Conflict of interest: None declared, (Copyright © The Author(s).)

Purpose: To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need., Methods: Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120-275/100,000)., Results: Estimated 17,418 [95% uncertainty interval (UI) 8154-26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2-99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully trained surgeons, but nonetheless performed 38% of district-level hernia operations., Conclusions: The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.

It remains unclear what clinical features inform the accuracy of a clinical diagnosis of Alzheimer disease (AD). Data were obtained from the National Alzheimer's Coordinating Center to compare clinical and neuropathologic features among participants who did or did not have Alzheimer disease neuropathologic changes (ADNC) at autopsy. Participants (1854) had a clinical Alzheimer dementia diagnosis and ADNC at autopsy (Confirmed-AD), 204 participants had an AD diagnosis and no ADNC (AD-Mimics), and 253 participants had no AD diagnosis and ADNC (Unidentified-AD). Compared to Confirmed-AD participants, AD-Mimics had less severe cognitive impairment, while Unidentified-AD participants displayed more parkinsonian signs, depression, and behavioral problems. This study highlights the importance of developing a complete panel of biomarkers as a tool to inform clinical diagnoses, as clinical phenotypes that are typically associated with diseases other than AD may result in inaccurate diagnoses., (© 2020 American Association of Neuropathologists, Inc. All rights reserved.)

The field of dementia research is rapidly evolving, especially with regards to our understanding of the diversity of neuropathologic changes that underlie cognitive decline. Definitions and criteria for known conditions are being periodically revised and refined, and new findings are being made about neuropathologic features associated with dementia status. The database maintained by the National Alzheimer's Coordinating Center (NACC) offer researchers a robust, rapid, and statistically well-powered method to evaluate the implications of newly identified neuropathologic conditions with regards to comorbidities, demographic associations, cognitive status, neuropsychologic tests, radiographic findings, and genetics. NACC data derive from dozens of excellent US Alzheimer disease research centers, which collectively follow thousands of research volunteers longitudinally. Many of the research participants are autopsied using state-of-the-art methods. In this article, we describe the NACC database and give examples of its use in evaluating recently revised neuropathologic diagnoses, including primary age-related tauopathy (PART), limbic predominant age-related TDP-43 encephalopathy (LATE), and the preclinical stage of Alzheimer disease neuropathologic change, based on the National Institute on Aging-Alzheimer's Association consensus guidelines. The dementia research community is encouraged to make use of this readily available database as new neuropathologic changes are recognized and defined in this rapidly evolving field.

The proprietary neuropsychological tests (Form C1) of the National Alzheimer's Coordinating Center (NACC) Uniform Data Set were replaced with nonproprietary versions (Form C2) chosen to closely model their proprietary counterparts. Correlations between analogous test pairs as measured in previous work were good (0.68-0.78), but it is unclear whether the paired tests represent the same set of common factors of cognition or if important factors specific to C1 or C2 only exist. The authors performed multiple factor analysis to analyze correlated C1 and C2 data. They included participants who completed both neuropsychological batteries within 1 year with no change in cognitive status. They found that the C1 and C2 neuropsychological test pairs are strongly related and are represented by the same principal factors. These findings support the use of the C2 test results in conjunction with C1 in longitudinal analyses of NACC data.

Background: The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark., Methods: Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery., Results: About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare., Conclusions: Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels., (Copyright © 2019 Elsevier Inc. All rights reserved.)

: Most surgeons from high-income countries who work in global surgery will do so through partnerships between their institutions and institutions in low- and middle-income countries (LMICs). In this article, the American Surgical Association Working Group for Global Surgery lays out recommendations for criteria that contribute to equitable, sustainable, and effective partnerships. These include ethically engaging with the LMIC partner institution by putting its interests first and by proactively seeking to be aware of cultural issues. Formally structuring the partnership with a memorandum of understanding and clearly designating leaders at both institutions are important criteria for assuring long-term sustainability. Needs assessments can be done using existing methods, such as those established for development of national surgical, obstetric, and anesthesia plans. Such assessments help to identify opportunities for partnerships to be most effective in addressing the biggest surgical needs in the LMIC. Examples of successful high-income countries-LMIC partnerships are provided.

Exposure to dust particles during dust storms can lead to respiratory problems, diseases, and even death. The effect of dust particles at the cellular level is poorly understood. In this study, we investigated the impact that dust storm particles (Montmorillonite) have on human lung epithelial cells (A549) at the single cell level. Using live-cell imaging, we continuously followed individual cells after exposure to a wide range of concentrations of dust particles. We monitored the growth trajectory of each cell including number and timing of divisions, interaction with the dust particles, as well as time and mechanism of cell death. We found that individual cells show different cellular fates (survival or death) even in response to the same dust concentration. Cells that died interacted with dust particles for longer times, and engulfed more dust particles, compared with surviving cells. While higher dust concentrations reduced viability in a dose-dependent manner, the effect on cell death was non-monotonic, with intermediate dust concentration leading to a larger fraction of dying cells compared to lower and higher concentrations. This non-monotonic relationship was explained by our findings that high dust concentrations inhibit cell proliferation. Using cellular morphological features, supported by immunoblots and proinflammatory cytokines, we determined that apoptosis is the dominant death mechanism at low dust concentrations, while higher dust concentrations activate necrosis. Similar single cell approaches can serve as a baseline for evaluating other aerosol types that will improve our understanding of the health-related consequences of exposure to dust storms., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Primary age-related tauopathy is increasingly recognized as a separate neuropathological entity different from Alzheimer's disease. Both share the neuropathological features of tau aggregates and neuronal loss in the temporal lobe, but primary age-related tauopathy lacks the requisite amyloid plaques central to Alzheimer's disease. While both have similar clinical presentations, individuals with symptomatic primary age-related tauopathy are commonly of more advanced ages with milder cognitive dysfunction. Direct comparison of the neuropsychological trajectories of primary age-related tauopathy and Alzheimer's disease has not been thoroughly evaluated and thus, our objective was to determine how cognitive decline differs longitudinally between these two conditions after the onset of clinical symptoms. Data were obtained from the National Alzheimer's Coordinating Center on participants with mild cognitive impairment at baseline and either no neuritic plaques (i.e. primary age-related tauopathy) or moderate to frequent neuritic plaques (i.e. Alzheimer neuropathological change) at subsequent autopsy. For patients with Alzheimer's disease and primary age-related tauopathy, we compared rates of decline in the sum of boxes score from the CDR® Dementia Staging Instrument and in five cognitive domains (episodic memory, attention/working memory, executive function, language/semantic memory, and global composite) using z-scores for neuropsychological tests that were calculated based on scores for participants with normal cognition. The differences in rates of change were tested using linear mixed-effects models accounting for clinical centre clustering and repeated measures by individual. Models were adjusted for sex, age, education, baseline test score, Braak stage, apolipoprotein ε4 (APOE ε4) carrier status, family history of cognitive impairment, and history of stroke, hypertension, or diabetes. We identified 578 participants with a global CDR of 0.5 (i.e. mild cognitive impairment) at baseline, 126 with primary age-related tauopathy and 452 with Alzheimer's disease. Examining the difference in rates of change in CDR sum of boxes and in all domain scores, participants with Alzheimer's disease had a significantly steeper decline after becoming clinically symptomatic than those with primary age-related tauopathy. This remained true after adjusting for covariates. The results of this analysis corroborate previous studies showing that primary age-related tauopathy has slower cognitive decline than Alzheimer's disease across multiple neuropsychological domains, thus adding to the understanding of the neuropsychological burden in primary age-related tauopathy. The study provides further evidence to support the hypothesis that primary age-related tauopathy has distinct neuropathological and clinical features compared to Alzheimer's disease., (© The Author(s) (2020). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: SafeBoda is a motorcycle taxi company that provides road safety training and helmets to its drivers in Kampala, Uganda. We sought to determine whether SafeBoda drivers are more likely to engage in safe riding behaviours than regular drivers (motorcycle taxi drivers not part of SafeBoda ). METHODS : We measured riding behaviours in SafeBoda and regular drivers through: (1) computer-assisted personal interview (CAPI), where 400 drivers were asked about their riding behaviours (eg, helmet and mobile phone use) and (2) roadside observation, where riding behaviours were observed in 3000 boda-boda drivers and their passengers along major roads in Kampala., Results: Across the two cross-sectional studies, a higher proportion of SafeBoda drivers than regular drivers engaged in safe riding behaviours. For instance, helmet use among SafeBoda compared with regular drivers was 21% points higher (95% CI 0.15 to 0.27; p<0.001) based on the CAPI and 45% points higher (95% CI 0.43 to 0.47; p<0.001) based on roadside observation. Furthermore, compared with regular drivers, SafeBoda drivers were more likely to report having a driver's license (66.3% vs 33.5 %; p<0.001) and a reflective jacket (99.5% vs 50.5 %; p<0.001) and were less likely to report driving towards oncoming traffic (4% vs 45.7 %; p<0.001) in the past 30 days., Conclusion: The SafeBoda programme is associated with increased safe riding behaviours among motorcycle taxi drivers in Kampala. Therefore, the promotion and expansion of such programmes may lead to a reduction in morbidity and mortality due to road injuries., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

: There is growing interest in global surgery among US academic surgical departments. As academic global surgery is a relatively new field, departments may have minimal experience in evaluation of faculty contributions and how they integrate into the existing academic paradigm for promotion and tenure. The American Surgical Association Working Group on Global Surgery has developed recommendations for promotion and tenure in global surgery, highlighting criteria that: (1) would be similar to usual promotion and tenure criteria (eg, publications); (2) would likely be undervalued in current criteria (eg, training, administrative roles, or other activities that are conducted at low- and middle-income partner institutions and promote the partnerships upon which other global surgery activities depend); and (3) should not be considered (eg, mission trips or other clinical work, if not otherwise linked to funding, training, research, or building partnerships).

Objective: To estimate the annual rate of obstetric and gynecologic (ObGyn) operations performed in Ghana and establish a baseline for tracking the expansion of Ghana's surgical capacity., Methods: Data were obtained for ObGyn operations performed in Ghana between 2014 and 2015 from a nationally representative sample of hospitals and scaled up for national estimates. Operations were classified as "essential" or "other" according to The World Bank's Disease Control Priorities Project. Data were used to calculate cesarean-to-total-operation ratio (CTR) and estimate the rate of cesarean deliveries based on the number of live births in 2014., Results: A total of 90 044 (95% uncertainty interval [UI] 69 461-110 628) ObGyn operations were performed nationally over the 1-year period, yielding an annual national ObGyn operation rate of 881/100 000 females aged 12 years and over (95% UI 679-1082). Eighty-seven percent were essential procedures, 80% of which were cesarean deliveries. District hospitals performed 71% of ObGyn operations. The national rate of cesarean deliveries was 7.2% and the CTR was 0.27., Conclusion: The cesarean delivery rate of 7.2% suggests inadequate access to obstetric care. The CTR of 0.27 suggests inadequate overall surgical capacity. These measures, along with estimates of distribution of procedures by hospital level, provide useful baseline data to support surgical capacity building efforts in Ghana and similar countries., (© 2019 International Federation of Gynecology and Obstetrics.)

The mining environment is particularly dangerous in low- and middle-income countries. We sought to better understand the burden, characteristics and risk factors associated with gold mining, through a household survey of 1,029 miners in four districts, in Ghana. We found a high burden of injuries, with 25.5% of workers injured in the past year, giving an incidence of 19.67 injuries per 200,000 hours worked. Notably, an increase in injury risk was associated with work in the informal mining sector ( galamsey ), with an adjusted injury incidence ratio of 1.57 (95%CI: 1.12, 2.19) compared with miners in the formal sector. Half of gold miners in Ghana work in galamasey , and this sector is a high priority for safety promotion. Improving the safety of the equipment, which accounted for nearly half (46.2%) of galamsey -related injuries, could be a prime target for improving safety.

Background: To determine the potential risk factors for injury, estimate the annual injury rate and examine the safety perceptions, and use of personal protective equipment among small-scale gold miners in Ghana., Methods: A cross-sectional survey was carried out with 494 small-scale gold miners from four major mining districts in Ghana. A household-based approach was used to obtain a representative sample of miners. The study was conducted from June 2015 to August 2016. A systematic sampling technique was used to select households and recruit respondents to interview. Miners were asked about any mining related injury that they had sustained in the past year. A logistics regression model was employed to examine the association between risk factors and injury. Data were analyzed with STATA version 14.0., Results: The annual incidence rate of mining-related injury was 289 per 1000 workers. Injuries were mainly caused by machinery/tools 66(46.1%), followed by slip/falls 46(32.2%). The major risk factor for injury was underground work (adjusted odds ratio for injury 3.19; 95% CI = 1.42-7.20) compared with surface work. Higher education levels were protective, with adjusted odds ratios of 0.48 (95% CI = 0.24-0.99) for middle school education and 0.38 (95% CI 0.17-0.83) for secondary school compared with no schooling. Only 15(3.0%) of miners reported to have had safety training in the past year and 105(21.3%) indicated that there were safety regulations at their work place. A moderate number of workers reported using work boots 178(36.0%) and hand gloves 134(27.1%), but less than 10% of workers used other personal protective equipment., Conclusion: The annual injury incidence rate among small-scale gold miners is high. Potential targets for improving safety include increasing safety training, increasing use of personal protective equipment, and better understanding potential changes that can be made in the machinery and tools used in small-scale mining, which were associated with almost half of all injuries.

SafeBoda is a transportation company that provides road safety training and helmets to its motorcycle taxi drivers in Kampala. We sought to determine whether risk of road traffic crash (RTC) was lower in SafeBoda compared to regular (non-SafeBoda) motorcycle taxi drivers during a 6-month follow-up period. We collected participant demographic and behavioural data at baseline using computer-assisted personal interview, and occurrence of RTC every 2 months using text messaging and telephone interview from a cohort of 342 drivers. There were 85 crashes (31 in SafeBoda and 54 in regular drivers) during follow-up. Over the 6-month follow-up period, SafeBoda drivers were 39% less likely to be involved in a RTC than regular drivers after adjusting for age, possession of a driver's license, and education (RR: 0.61, 95% CI: 0.39-0.97, p  = .04). These findings suggest that the SafeBoda programme results in safer driving and fewer RTCs among motorcycle taxi drivers in Kampala.

Background: India has a high traumatic brain injury (TBI) burden and intracranial pressure monitoring (ICP) remains controversial but some patients may benefit., Objective: To examine the association between ICP monitor placement and outcomes, and identify Indian patients with severe TBI who benefit from ICP monitoring., Methods: We conducted a secondary analysis of a prospective cohort study at a level 1 Indian trauma center. Patients over 18 yr with severe TBI (admission Glasgow coma scale score < 8) who received tracheal intubation for at-least 48 h were examined. Propensity-based analysis using inverse probability weighting approach was used to examine ICP monitor placement within 72 h of admission and outcomes. Outcomes were in-hospital mortality and Glasgow Outcome Scale (GOS) score at discharge, 3, 6, and 12 mo. Death, vegetative, or major impairment defined unfavorable outcome., Results: The 200 patients averaged 36 [18 to 85] yr of age and average injury severity score of 31.4 [2 to 73]. ICP monitors were placed in 126 (63%) patients. Patients with ICP monitor placement experienced lower in-hospital mortality (adjusted relative risk [aRR]; 0.50 [0.29, 0.87]) than patients without ICP monitoring. However, there was no benefit at 3, 6, and 12 mo. With ICP monitor placement, absence of cerebral edema (aRR 0.54, 95% confidence interval 0.35-0.84), and absence of intraventricular hemorrhage (aRR 0.52, 95% confidence interval 0.33-0.82) were associated with reduced unfavorable outcomes., Conclusion: ICP monitor placement without cerebrospinal fluid drainage within 72 h of admission was associated with reduced in-patient mortality. Patients with severe TBI but without cerebral edema and without intraventricular hemorrhage may benefit from ICP monitoring., (Copyright © 2018 by the Congress of Neurological Surgeons.)

Introduction: The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark., Methods: Data on operations performed for elderly patients over a 1-year period in 2014-5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) versus other according to The World Bank's Disease Control Priority project (DCP-3). Data from New Zealand's National Minimum Dataset were used to derive a benchmark operation rate for the elderly., Results: 16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95% UI 1440-2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category., Conclusion: The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana's elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.

Primary age-related tauopathy (PART) is increasingly recognized as a pathologic entity distinct from Alzheimer's disease (AD). Given that the diagnosis of PART is an autopsy diagnosis, it is unclear how PART is perceived in clinical practice. Thus, we investigated the presumptive primary and contributing diagnoses in individuals who had cognitive impairment while alive and who met neuropathologic criteria for PART at autopsy. We also compared these clinical diagnoses for people with PART to those with AD neuropathology (ADNP). We used data on 1354 participants from the National Alzheimer's Coordinating Center, restricting to those with no neuritic plaques (PART) or moderate/frequent neuritic plaques (ADNP); clinical visit within two years of autopsy; and mild cognitive impairment (MCI) or dementia at last visit. To assess if PART participants were less likely to receive a clinical diagnosis of AD at their last visit prior to autopsy, we used logistic regression, controlling for age, sex, education, and APOE ε4 status. There were 161 PART individuals (n = 49 MCI; n = 112 dementia) and 1193 individuals with ADNP (n = 75 MCI; n = 1118 dementia). Primary clinical diagnosis of AD was more common in those with ADNP (MCI: 69%; demented: 86%) than PART (MCI: 57%; demented: 52%). In the adjusted analysis, primary and contributing clinical diagnoses of AD remained less likely in PART vs. ADNP participants with dementia (OR: 0.22, 95% CI: 0.13-0.38). This study suggests that clinicians recognize a distinction in the clinical presentation between PART and ADNP, diagnosing AD less frequently in those with PART. Nonetheless, clinical AD was diagnosed greater than 50% of the time in PART participants with MCI or dementia. Ante-mortem criteria for diagnosis of PART need to be established, as PART is a neuropathological entity that is distinct from AD and has its own clinical and cognitive outcomes.

Backgroud: Groin hernia repairs (GHR), though classified as clean surgeries, are associated with varying rates of surgical site infections. We assessed the practices of surgeons in Ghana regarding antibiotic use for GHR in comparison to evidence-based international guidelines (EBIG)., Methods: We interviewed surgeons trained by the Ghana College of Physicians and Surgeons (GCPS), from inception (2003) through 2016, about their use of antibiotics for GHR. We defined the outcome variable of consistently following EBIG in antibiotics use for GHR. Logistic regression was used to examine how a priori selected covariates contributed to the outcome., Results: Eighty-two of 117 surgeons reported performing/supervising at least one GHR per week. They performed/supervised a mean of five GHR per week. Thirty-two (40%) reported using mesh for at least 50% of GHR. For primary GHR, 75% of surgeons administered antibiotics according to EBIG, whereas for GHR with mesh only, 45% did so. Predictors of consistently following EBIG were increasing number of GHR performed per week (adjusted odds ratio 1.44, 95% CI 1.07-1.96) and increasing time spent for clinical work (adjusted odds ratio 0.95, 95% CI 0.91-0.99). Years of practice since GCPS graduation, total operations performed per week, and hospital level of practice were not predictive of the outcome variable., Conclusions: Two-thirds of Ghanaian surgeons interviewed do not consistently administer antibiotics for GHR per EBIG, raising the need to improve access to evidence-based medical information overall to guide practice. Determining local surgical site infections rates to guide antibiotic use in GHR will be useful in Ghana and other LMICs., (Copyright © 2019 Elsevier Inc. All rights reserved.)

This study examined differences in neuropsychological test scores between individuals with primary age-related tauopathy (PART) and Alzheimer disease (AD) using cross-sectional data from the National Alzheimer's Coordinating Center. Linear regression tested for differences in 4 cognitive domains stratified by cognitive status (global Clinical Dementia Rating [CDR]). The sample included 240 participants with no neuritic plaques (NP) (definite PART), 186 with sparse NP (possible PART), and 510 with moderate/frequent NP (AD). Four cognitive domain z-score outcome variables (memory, attention, executive function, and semantic memory/language) were calculated using 12 neuropsychological tests. Definite PART participants had a sparing of semantic memory/language compared to those with AD, with a mean adjusted z-score difference of 0.37 (95% confidence interval [CI]: 0.16-0.58) for those with CDR = 0.5 or 1 and of 0.92 (CI: 0.22-1.63) for those with CDR = 2 or 3. Compared to participants with AD, definite PART participants with CDR = 0.5 or 1 had sparing of memory (adjusted z-score difference: 0.61; CI: 0.39-0.84) and definite PART participants with CDR = 2 or 3 had sparing of attention (adjusted z-score difference: 0.76: CI: 0.09-1.43). Patterns of cognitive impairment differed between definite PART and AD, suggesting significant differences in clinical presentation between individuals from these 2 groups., (© 2019 American Association of Neuropathologists, Inc. All rights reserved.)

Background: Prior to 2003, production of new surgeons in Ghana was limited. In 2003, the Ghana College of Physicians and Surgeons (GCPS) initiated the first wholly in-country training and credentialing of surgeons. The purpose of this study was to assess the impact of in-country training of surgeons in Ghana., Methods: We interviewed 117 (80%) of the 146 surgeons trained through the GCPS from inception through 2016. We gathered data on type of training, practice location, clinical workload, and administrative and teaching roles. Operations were categorized into those deemed essential (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities project versus other., Results: In-country retention was 87-97%. A little more than half (56%) were working in the two largest cities and 44% were working in higher need areas. Twenty-two (19%) were the first surgeon to have worked at their current hospital. The surgeons performed a mean of 13 operations per week (seven electives, six emergencies). 35% of elective and 77% of emergency operations were in the essential category. Most (79%) surgeons were engaged in training/teaching; 46% were engaged in research; and 33% held an administrative office., Conclusions: In-country surgical training has led to high retention and wide geographic distribution, including high need areas. The in-country trained surgeons are playing key roles in clinical practice, training, and administration. These data provide support for investments in similar efforts in other low- and middle-income countries.

Background: Traumatic brain injuries in Uganda are on the increase, however little is known about the neuropsychological outcomes in survivors. This study characterized patients with traumatic brain injury (TBI) and the associated six-month neuropsychological outcomes in a Ugandan tertiary hospital., Methods: Patients admitted at Mulago Hospital with head injury from November 2015 to April 2016 were prospectively enrolled during admission and followed up at six months after discharge to assess cognition, posttraumatic stress symptoms (PTSS), depression symptoms and physical disability. The outcomes were compared to a non-head-injury group recruited from among the caretakers, siblings and neighbours of the patients with age and sex entered as covariates., Results: One hundred and seventy-one patients and 145 non-head injury participants were enrolled. The age range for the whole sample was 1 to 69 years with the non-head injury group being older (mean age (SD) 33.34 (13.35) vs 29.34 (14.13) years of age, p = 0.01). Overall, motorcycle crashes (36/171, 38.6%) and being hit by an object (58/171, 33.9%) were the leading causes of TBI. Head injury from falls occurred more frequently in children < 18 years (13.8% vs 2.8%, p = 0.03). In adults 18 years and older, patients had higher rates of neurocognitive impairment (28.4% vs 6.6%, p < 0.0001), PTSS (43.9% vs 7.9%, p < 0.0001), depression symptoms (55.4% vs 10%, p < 0.0001) and physical disability (7.2% vs 0%, p = 0.002). Lower Glasgow Coma Score (GCS) on admission was associated with neurocognitive impairment (11.6 vs 13.1, p = 0.04) and physical disability (10 vs 12.9, p = 0.01) six months later., Conclusion: This first such study in the East-African region shows that depth of coma on admission in TBI is associated with neurocognitive impairment and physical disability.

There is a large and unacceptable burden of death and disability from conditions that are treatable by surgery. Several global efforts to address this burden have included the World Health Assembly resolution (WHA68.15) on emergency and essential surgical care, the Lancet Commission on Global Surgery, and the Disease Control Priorities project. On a country level, progress can be made in almost any location by taking a logical approach that includes defining the most costeffective surgical interventions that can and should be made available to anyone in a given country, identifying and addressing the barriers to such care that often include finding ways to address financial barriers, and developing monitoring mechanisms to ensure that access to quality care is indeed being achieved. To accomplish these goals, there is a need for collaborative work by the fields of surgery and public health.