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Quantification of the impact of local masking policies may help guide future policy interventions to reduce SARS-COV-2 disease transmission. This study's objective was to identify factors associated with adherence to masking and social distancing guidelines.Faculty from 16 U.S. colleges and universities trained 231 students in systematic direct observation. They assessed correct mask use and distancing in public settings in 126 US cities from September 2020 through August 2021.Of 109,999 individuals observed in 126 US cities, 48% wore masks correctly with highest adherence among females, teens and seniors and lowest among non-Hispanic whites, those in vigorous physical activity, and in larger groups (P.0001). Having a local mask mandate increased the odds of wearing a mask by nearly 3-fold (OR = 2.99, P = .0003) compared to no recommendation. People observed in non-commercial areas were least likely to wear masks. Correct mask use was greatest in December 2020 and remained high until June 2021 (P.0001). Masking policy requirements were not associated with distancing.The strong association between mask mandates and correct mask use suggests that public policy has a powerful influence on individual behavior.Mask mandates should be considered in future pandemics to increase adherence.

Objective: Emergency medical (EM) response systems require extensive coordination, particularly during mass casualty incidents (MCIs). The recognition of preparedness gaps and contextual priorities to MCI response capacity in low- and middle-income countries (LMICs) can be better understood through the components of EM reponse systems. This study aims to delineate essential components and provide a framework for effective emergency medical response to MCIs. Methods: A scoping review was conducted using 4 databases. Title and abstract screening was followed by full-text review. Thematic analysis was conducted to identify themes pertaining to the essential components and integration of EM response systems. Results: Of 20,456 screened citations, 181 articles were included in the analysis. Seven major and 40 sub-themes emerged from the content analysis as the essential components and supportive elements of MCI medical response. The essential components of MCI response were integrated into a framework demonstrating interrelated connections between essential and supportive elements. Conclusions: Definitions of essential components of EM response to MCIs vary considerably. Most literature pertaining to MCI response originates from high income countries with far fewer reports from LMICs. Integration of essential components is needed in different geopolitical and economic contexts to ensure an effective MCI emergency medical response.

The purpose of this study was to understand the predictors of masking—especially age, race/ethnicity and gender—in Hillsborough County Florida, a region without mask mandates. Masking and social distancing behaviors of individuals were observed in Hillsborough County during one-week intervals in July 2021, August 2021 and Late September—early October 2021. Demographic and behavioral observations were recorded and logistic regression was utilized to determine the odds ratio of wearing a mask amongst various groups. Overall, masking ranged from 36.80% to 48.64%, peaking during the second observation period. Masking rates were highest amongst people of color, women and seniors. Establishments posting mask-negative language, such as “masks NOT required,” saw a 46% decrease in the odds of masking compared to establishments without mask-related signage (thereby defaulting to no mandate). Understanding who engaged in masking and social distancing behaviors will provide local public health officials with a deeper understanding of the effectiveness of previously used strategies, which can be leveraged in future surges of COVID-19 and other emergencies to create maximum impact. Lessons learned regarding policy implementation and understanding patterns of uptake of health guidelines are important for the continuous improvement of public health practice.

Background Previous US-based studies have shown that a trauma center designation of level 1 is associated with improved patient outcomes. However, most studies are cross-sectional, focus on volume-related issues and are direct comparisons between levels. This study investigates the change in patient characteristics when individual trauma centers transition from level 2 to level 1 and whether the patients have similar outcomes during the initial period of the transition. Study Design We performed a retrospective cohort study that analyzed hospital and patient records included in the National Trauma Data Bank from 2007 to 2016. Patient characteristics were compared before and after their hospitals transitioned their trauma level. Mortality; complications including acute kidney injury, acute respiratory distress syndrome, cardiac arrest with CPR, deep surgical site infection, deep vein thrombosis, extremity compartment syndrome, surgical site infection, osteomyelitis, pulmonary embolism, and so on; ICU admission; ventilation use; unplanned returns to the OR; unplanned ICU transfers; unplanned intubations; and lengths of stay were obtained following propensity score matching, comparing posttransition years with the last pretransition year. Results Sixteen trauma centers transitioned from level 2 to level 1 between 2007 and 2016. One was excluded due to missing data. After transition, patient characteristics showed differences in the distribution of race, comorbidities, insurance status, injury severity scores, injury mechanisms, and injury type. After propensity score matching, patients treated in a trauma center after transition from level 2 to 1 required significantly fewer ICU admissions and had lower complication rates. However, significantly more unplanned intubations, unplanned returns to the OR, unplanned ICU transfers, ventilation use, surgical site infections, pneumonia, and urinary tract infections and higher mortality were reported after the transition. Conclusions Trauma centers that transitioned from level 2 to level 1 had lower overall complications, with fewer patients requiring ICU admission. However, higher mortality and more surgical site infections, pneumonia, urinary tract infections, unplanned intubations, and unplanned ICU transfers were reported after the transition. These findings may have significant implications in the planning of trauma systems for administrators and healthcare leaders.

Background: Cancer is known to be the second significant cause of death worldwide. Chemotherapeutic agents such as platinum-based compounds are frequently used single-handedly or accompanied by additional chemotherapies to treat cancer patients. Chemotherapy-induced peripheral painful neuropathy is seen in around 40% of patients who are treated with platinum-based compounds, including cisplatin. This not only decreases the quality of life of patients but also patients’ compliance with cisplatin. Objectives: Nalbuphine, an opioid, is frequently used to treat acute and chronic pain, coupled with cisplatin in cancer patients. However, long term use of nalbuphine induces tolerance to its analgesic effects. We employed the same strategy to induce tolerance in mice. Methods: Here, we investigated analgesic effects of 2-[(pyrrolidin-1-yl) methyl]-1H-benzimidazole (BNZ), a benzimidazole derivative, on nalbuphine-induced tolerance during cisplatin-induced neuropathic pain using hot plate test, tail-flick tests and von Frey filament in mouse models. Furthermore, we investigated the effects of BNZ on the expression of Tumor Necrosis Factor-alpha (TNF-α) in the spinal cord. Results: The results showed that BNZ reduced tolerance to analgesic effects of nalbuphine and TNF-α expression in mice. Conclusion: BNZ could be a potential drug candidate for the management of nalbuphine-induced tolerance in cisplatin-induced neuropathic pain.

The purpose of this article is to discuss the important role for physicians in advocating for the prevention of road traffic and firearm injuries. Physicians have shown to be effective advocates for a variety of injuries, and this needs to continue and be enhanced for these injury categories. Road traffic and firearm injuries are among the leading causes of death across the lifespan. The influence and credibility of physicians enhance the messages they provide in advocacy efforts. It is important that physicians educate and counsel patients in a variety of healthcare settings along with joining advocacy efforts of professional associations. Recommendations are provided for advocacy components related to these injuries. Also, it is very important that physicians receive training in medical school and/or residency about injuries and how to successfully advocate for evidence-based injury prevention strategies.

The purpose of this study was to assess the effect of yoga therapy (YT) on health outcomes of women suffering from polycystic ovary syndrome (PCOS). Interventional studies, with postmenarchal and premenopausal females with PCOS who received YT, with any health outcome reported, were included. Scopus, Cochrane, PubMed, Embase, and Medline databases were electronically searched. Systematic review included 11 experimental studies, representing 515 participants with PCOS, out of which 2 randomized controlled trials (RCTs) were included for meta-analysis. Random effects model was applied using Review Manager Software version 5.4.1 and strength of evidence was assessed using GRADEpro Guideline Development Tool, 2020. Meta-analysis showed that YT may significantly decrease menstrual irregularity (MD −.41, 95% CI −.74 to −.08), clinical hyperandrogenism (MD −.70, 95% CI −1.15 to −.26), fasting blood glucose (MD −.22 mmol/L, 95% CI −.44 to −.01), fasting insulin (MD −28.21 pmol/L, 95% CI −43.79 to −12.63), and homeostatic model assessment-insulin resistance value (MD −.86, 95% CI −1.29 to −.43). Strength of evidence was “low.” In conclusion, YT may have beneficial effects on health outcomes in women suffering from PCOS. However, low strength of evidence suggests need of conducting well-designed RCTs to assess the efficacy of YT for PCOS.

Background Injury is a great contributor to the Vietnamese disease burden. Road traffic injuries were the leading cause of injury mortality from 2005 to 2013. Our objective was to understand the intricacies of the trauma care system in Hanoi, Vietnam. Methods We aimed to elucidate the trauma care continuum (pre-hospital, hospital and post hospital care) and identify perceptions of system functioning. This was done via in-depth interviews and focus group discussions. Results Ten interviews and two focus groups were conducted. Participants were: community stakeholders, hospital leadership, the Ministry of Health, National Traffic Safety Committee and Hanoi Emergency Response Centre. 59% of respondents were male and there was variation in education level and employment status. Thematic analysis was conducted using the NVivo 12 software. The major theme identified was prehospital care with the relevant issues being communication, transportation and human resources deficits. The minor themes were around hospital care, community education and governance. A common barrier to effective care across multiple themes was the lack of coordination and integration between various institutions. Conclusion The trauma care landscape is multifaceted but there are areas which could potentially benefit with the major one being prehospital care. Specific policies that can arise as a result of this work include improving the logistical coordination of prehospital transportation, a legal framework to protect bystanders providing first aid, and bolstering a non-physician prehospital care workforce. Learning Outcomes The results provide a direction to guide governmental (both local and national) and organizational efforts toward prehospital trauma care.

BackgroundIn Sub-Saharan African countries, the incidence of traumatic brain injury (TBI) is estimated to be many folds higher than the global average and outcome is hugely impacted by access to healthcare services and quality of care. We conducted an analysis of the TBI registry data to determine the disparities and delays in treatment for patients presenting at a tertiary care hospital in Uganda and to identify factors predictive of delayed treatment initiation.MethodsThe study was conducted at the Mulago National Referral Hospital, Kampala. The study included all patients presenting to the emergency department (ED) with suspected or documented TBI. Early treatment was defined as first intervention within 4 hours of ED presentation—a cut-off determined using sensitivity analysis to injury severity. Descriptive statistics were generated and Pearson’s χ2 test was used to assess the sample distribution between treatment time categories. Univariable and multivariable logistic regression models with ResultsOf 3944 patients, only 4.6% (n=182) received an intervention for TBI management within 1 hour of ED presentation, whereas 17.4% of patients (n=708) received some treatment within 4 hours of presentation. 19% of those with one or more serious injuries and 18% of those with moderate to severe head injury received care within 4 hours of arrival. Factors independently associated with early treatment included young age, severe head injury, and no known pre-existing conditions, whereas older or female patients had significantly less odds of receiving early treatment.DiscussionWith the increasing number of patients with TBI, ensuring early and appropriate management must be a priority for Ugandan hospitals. Delay in initiation of treatment may impact survival and functional outcome. Gender-related and age-related disparities in care should receive attention and targeted interventions.Level of evidencePrognostic and epidemiological study; level II evidence.

Work-related injury (WRI) control is an integral part of occupational safety. In rapidly developing Gulf countries such as Qatar with a predominantly expatriate workforce, WRI control is a complex issue often seen in conjunction with the implementation of labour laws and labour rights. We aimed to implement a public health approach to facilitate efforts to achieve long-term WRI control in Qatar. A range of initiatives helped to gain visibility and momentum for this important public health problem, including identifying and engaging with key stakeholders, workers&rsquo, surveys, steps to establish a unified injury database, and the implementation of a WRI identification tool in the electronic medical records. A contemporaneous improved enforcement of existent occupational safety regulations through heightened worksite inspections and efforts to improve living conditions for migrant workers also took place. WRIs are not only a Qatar-specific problem, the same issues are faced by neighbouring Gulf countries and other rapidly developing economies with large expatriate worker populations. These strategies are also useful starting points for similar countries interested in nurturing a safe, healthy and productive workforce.

Background Roadside observational studies play a fundamental role in designing evidence-informed strategies to address the pressing global health problem of road traffic injuries. Paper-based data collection has been the standard method for such studies, although digital methods are gaining popularity in all types of primary data collection. Objective This study aims to understand the reliability, productivity, and efficiency of paper vs digital data collection based on three different road user behaviors: helmet use, seatbelt use, and speeding. It also aims to understand the cost and time efficiency of each method and to evaluate potential trade-offs among reliability, productivity, and efficiency. Methods A total of 150 observational sessions were conducted simultaneously for each risk factor in Mumbai, India, across two rounds of data collection. We matched the simultaneous digital and paper observation periods by date, time, and location, and compared the reliability by subgroups and the productivity using Pearson correlations (r). We also conducted logistic regressions separately by method to understand how similar results of inferential analyses would be. The time to complete an observation and the time to obtain a complete dataset were also compared, as were the total costs in US dollars for fieldwork, data entry, management, and cleaning. Results Productivity was higher in paper than digital methods in each round for each risk factor. However, the sample sizes across both methods provided a precision of 0.7 percentage points or smaller. The gap between digital and paper data collection productivity narrowed across rounds, with correlations improving from r=0.27-0.49 to 0.89-0.96. Reliability in risk factor proportions was between 0.61 and 0.99, improving between the two rounds for each risk factor. The results of the logistic regressions were also largely comparable between the two methods. Differences in regression results were largely attributable to small sample sizes in some variable levels or random error in variables where the prevalence of the outcome was similar among variable levels. Although data collectors were able to complete an observation using paper more quickly, the digital dataset was available approximately 9 days sooner. Although fixed costs were higher for digital data collection, variable costs were much lower, resulting in a 7.73% (US $3011/38,947) lower overall cost. Conclusions Our study did not face trade-offs among time efficiency, cost efficiency, statistical reliability, and descriptive comparability when deciding between digital and paper, as digital data collection proved equivalent or superior on these domains in the context of our project. As trade-offs among cost, timeliness, and comparability—and the relative importance of each—could be unique to every data collection project, researchers should carefully consider the questionnaire complexity, target sample size, implementation plan, cost and logistical constraints, and geographical contexts when making the decision between digital and paper.

Work-related injuries (WRIs) are recognized as a leading cause of admission to the national trauma center of Qatar. A retrospective analysis of trauma registry data and electronic medical records was conducted on a cohort of all WRI patients who were admitted to the Hamad Trauma Center (HTC), in Doha, Qatar, between 2011 and 2017. A total of 3757 WRI patients were treated at the HTC over the 7-year study period. The overall cost for treatment was 124,671,431 USD (18 million USD per year), with a median cost of 19,071 USD. There was a strong positive correlation between the overall cost and hospital-stay cost (r2 = 0.949, p = 0.00001) and between the overall cost and procedure cost (r2 = 0.852, p = 0.00001). Motor vehicle crash (MVC) victims who wore seatbelts had significantly lower injury severity, hospital stay and median total costs. A comparison of patients by quartiles of the costs incurred showed that the proportions of MVC victims, pedestrian injuries and mortality were significantly higher in the fourth quartile when compared to other quartiles (p < 0.05). These findings suggest that investments in the primary prevention of work-related injuries from falls and MVCs, through proven interventions, should be priorities for occupational safety and health in Qatar.

BACKGROUND Roadside observational studies play a fundamental role in designing evidence-informed strategies to address the pressing global health problem of road traffic injuries. Paper-based data collection has been the standard method for such studies, although digital methods are gaining popularity in all types of primary data collection. OBJECTIVE This study aims to understand the reliability, productivity, and efficiency of paper vs digital data collection based on three different road user behaviors: helmet use, seatbelt use, and speeding. It also aims to understand the cost and time efficiency of each method and to evaluate potential trade-offs among reliability, productivity, and efficiency. METHODS A total of 150 observational sessions were conducted simultaneously for each risk factor in Mumbai, India, across two rounds of data collection. We matched the simultaneous digital and paper observation periods by date, time, and location, and compared the reliability by subgroups and the productivity using Pearson correlations (r). We also conducted logistic regressions separately by method to understand how similar results of inferential analyses would be. The time to complete an observation and the time to obtain a complete dataset were also compared, as were the total costs in US dollars for fieldwork, data entry, management, and cleaning. RESULTS Productivity was higher in paper than digital methods in each round for each risk factor. However, the sample sizes across both methods provided a precision of 0.7 percentage points or smaller. The gap between digital and paper data collection productivity narrowed across rounds, with correlations improving from r=0.27-0.49 to 0.89-0.96. Reliability in risk factor proportions was between 0.61 and 0.99, improving between the two rounds for each risk factor. The results of the logistic regressions were also largely comparable between the two methods. Differences in regression results were largely attributable to small sample sizes in some variable levels or random error in variables where the prevalence of the outcome was similar among variable levels. Although data collectors were able to complete an observation using paper more quickly, the digital dataset was available approximately 9 days sooner. Although fixed costs were higher for digital data collection, variable costs were much lower, resulting in a 7.73% (US $3011/38,947) lower overall cost. CONCLUSIONS Our study did not face trade-offs among time efficiency, cost efficiency, statistical reliability, and descriptive comparability when deciding between digital and paper, as digital data collection proved equivalent or superior on these domains in the context of our project. As trade-offs among cost, timeliness, and comparability—and the relative importance of each—could be unique to every data collection project, researchers should carefully consider the questionnaire complexity, target sample size, implementation plan, cost and logistical constraints, and geographical contexts when making the decision between digital and paper.

Objective Lack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the TBI burden. This paper describes a scientific approach for hospital based systematic data collection in a low-income country. The registry is based on the evaluation framework for injury surveillance systems which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) review of the identified variables based on adopted specific, measurable, assignable, realistic, and time-related criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system. Results The electronic hospital-based TBI registry is designed through a collaborative approach to capture comprehensive, yet context specific, information on each TBI case, from the time of injury until death or discharge from the hospital. It includes patients’ demographics, pre-hospital and hospital assessment and care, TBI causes, injury severity, and patient outcomes. The registry in Uganda will open the opportunity to replicate the process in other similar context and contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries. Electronic supplementary material The online version of this article (10.1186/s13104-018-3419-1) contains supplementary material, which is available to authorized users.

Many Arab countries have undergone the epidemiologic transition of diseases with increasing economic development and a proportionately decreasing prevalence of communicable diseases. With this transition, injuries have emerged as a major cause of mortality and morbidity in the Gulf Cooperation Council countries in addition to diseases of affluence. Injuries are the number one cause of years of life lost and disability-adjusted life-years in the Sultanate of Oman. The burden of injuries, which affects mostly young Omani males, has a unique geographic distribution that is in contrast to the trauma care capabilities of the country. The concentration of health care resources in the northern part of the country makes it difficult for the majority of Omanis who live elsewhere to access high-quality and time-sensitive care. A broader multisectorial national injury prevention strategy should be evidence based and must strengthen human resources, service delivery, and information systems to improve care of the injured and loss of life. This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies.

Background Emergency care services in low-and middle-income countries (LMICs) have traditionally received less attention in the dominant culture favouring vertical health programs. The unmet needs of pre-hospital and hospital-based emergency services are high but the barriers to accessing safe and quality emergency medical services (EMS) remain largely unaddressed. Few studies in Sub-Saharan Africa have qualitatively investigated barriers to EMS use, and quality of pre-hospital services from the providers and community perspective. We conducted a qualitative study to describe the patient-centred approach to emergency care in Kampala, Uganda, with specific attention to access to EMS.Methods The data collection was comprised of Key Informant Interviews (KII) and Focus Group Discussions (FGDs) with the community members. KII participants were selected using maximum purposive sampling based on expert knowledge of emergency care systems, and service delivery. FGDs were conducted to understand perceptions and experiences towards access to pre-hospital care, and to explore barriers to utilization of EMS. The respondents of ten KII and seven FGDs included pre-hospital EMS (PEMS) administrators, policy makers, police, health workers and community members. We conducted a directed content analysis to identify key themes and triangulate findings across different informant groups.Results Key themes emerged across interviews and discussions concerning: (1) lack of funds, (2) lack of standards, (3) need for upfront payments for emergency transport and care, 4) corruption, 5) poor quality pre-hospital emergency service, 6) poor quality hospital emergency care, and 7) delay in seeking treatment.Conclusions Patient-centred emergency care should be an integral part of comprehensive health care services. As Uganda and other LMICs continue to strive for universal health coverage, it is critical to prioritize and integrate emergency care within health systems owing to its cross-cutting nature. Community perceptions around access and quality of PEMS should be addressed in national policies covering affordable and safe EMS.

Introduction: Despite the high income level in Arabian Gulf countries, people in the region need to improve their use of child restraint systems (CRSs) to reduce the incidence of preventable injuries to child automobile passengers. Anecdotal reports have attributed the resistance to using CRSs to the expense and unavailability of the systems, prompting car seat giveaway programs. Previous studies have not assessed the adoption of CRS. This study reports the results of a rapid market survey (RMS) to understand the availability, characteristics, and affordability of CRSs in Qatar and recommend future child restraint policies and legislation. Methods: The RMS identified all retail outlets that sell CRSs in Qatar and collected standard data on each restraint system: brand, model number, age/weight limits, compliance with standards, availability, and language of the owner's manual. A previously utilized metric for child safety devices was used to measure affordability. Results: The RMS showed a sufficient number (83) and variety (five types) of car seat models at 15 retail outlets, selling at a wide price range of $14–$1,399. All the car seats complied with the European standard. Only 2% showed a manufacturing or expiry date. A user manual was available for 71% of the seats and in different languages, but only 28% appeared in Arabic. The median CRS price was equivalent to the wages for less than one day of work. Conclusion: The RMS demonstrates the availability, variety, and affordability of CRSs in Qatar. Unavailability and expense cannot be cited as barriers to use CRS, and the market is prepared for legislation requiring car seats for children in Qatar. Areas for improvement include requiring user manuals for all seats, especially in Arabic; requiring that all car seats comply with globally accepted safety standards, especially for expiry/manufacturing dates, given the harsh local climate; and encouraging further varieties of CRSs in the local market.

Background: Rapid advances in mobile technologies and applications and the continued growth in digital network coverage have the potential to transform data collection in low- and middle-income countries. A common perception is that digital data collection (DDC) is faster and quickly adaptable. Objective: The objective of this study was to test whether DDC is faster and more adaptable in a roadside environment. We conducted a reliability study comparing digital versus paper data collection in 3 cities in Ghana, Vietnam, and Indonesia observing road safety risk factors in real time. Methods: Roadside observation of helmet use among motorcycle passengers, seat belt use among 4-wheeler passengers, and speeding was conducted in Accra, Ghana; Ho Chi Minh City (HCMC), Vietnam; and Bandung, Indonesia. Two independent data collection teams were deployed to the same sites on the same dates and times, one using a paper-based data collection tool and the other using a digital tool. All research assistants were trained on paper-based data collection and DDC. A head-to-head analysis was conducted to compare the volume of observations, as well as the prevalence of each risk factor. Correlations (r) for continuous variables and kappa for categorical variables are reported with their level of statistical significance. Results: In Accra, there were 119 observation periods (90-min each) identical by date, time, and location during the helmet and seat belt use risk factor data collection and 118 identical periods observing speeding prevalence. In Bandung, there were 150 observation periods common to digital and paper data collection methods, whereas in HCMC, there were 77 matching observation periods for helmet use, 82 for seat belt use, and 84 for speeding. Data collectors using paper tools were more productive than their DDC counterparts during the study. The highest mean volume per session was recorded for speeding, with Bandung recording over 1000 vehicles on paper (paper: mean 1092 [SD 435]; digital: mean 807 [SD 261]); whereas the lowest volume per session was from HCMC for seat belts (paper: mean 52 [SD 28]; digital: mean 62 [SD 30]). Accra and Bandung showed good-to-high correlation for all 3 risk factors (r=0.52 to 0.96), with higher reliability in speeding and helmet use over seat belt use; HCMC showed high reliability for speeding (r=0.99) but lower reliability for helmet and seat belt use (r=0.08 to 0.32). The reported prevalence of risk factors was comparable in all cities regardless of the data collection method. Conclusions: DDC was convenient and reliable during roadside observational data collection. There was some site-related variability in implementing DDC methods, and generally the productivity was higher using the more familiar paper-based method. Even with low correlations between digital and paper data collection methods, the overall reported population prevalence was similar for all risk factors.

BackgroundTraumatic brain injury (TBI) is an important cause of morbidity and mortality in low/middle-income countries. The objective was to assess causes and outcomes of unintentional and intentional TBI among patients presenting to a tertiary care hospital in Uganda.MethodsThis study was conducted at Mulago National Referral Hospital, Kampala, Uganda, for 15 months in 2016–2017. Patients of all ages, males and females, presenting to the emergency department with suspected or documented TBI were enrolled. Patient demographics, TBI causes and outcomes were recorded. The outcome of interest was unintentional and intentional TBI.ResultsIntent was known for 3749 patients, of these 69.7% were unintentional TBI and 30.3% were intentional TBI. The average age of patients in both groups was similar (28±14 years) with over 70% of patients between 19 and 45 years age group. About 80% were males in both groups. The main causes of unintentional TBI were road traffic injuries (RTI) (88.9%) and falls (11.1%). Pedestrians (42.1%) and motorcycle drivers (28.1%) were the most common road users. Among patients with unintentional TBI, about 43.6% were admitted, 34.0% were sent home. There were 73 deaths: 63 were patients with RTI and 10 had a fall. Although assault (97.1%) was the main cause of intentional TBI, those patients with self-harm were likely to be in severe Glasgow Coma Scale range (39.4%) compared with victims of assault (14.2%). Among patients with intentional TBI, 42.6% were admitted and 37.1% were sent home. There were 30 deaths: 29 were assault victims and 1 of self-harm.DiscussionUnintentional TBI caused by RTI and intentional TBI caused by assault are common among young males attending Mulago Hospital in Kampala.Level of evidenceProspective observational study, level III.

Surgery and anaesthesia care is progressively making its way into the Global Public Health arena, which was d omi na ted by ma ter nal an d c hild h e al th an d communicable diseases in low-and middle-income countries (LMICs). Global Surgery (GS) could potentially make an impact on survival and quality of life in all age groups for a variety of disease conditions. After success in highlighting knowledge, policy and advocacy gaps, Global Surgery is transitioning from problem identification to designing and implementing solutions. A shared vision will lay out priorities to achieve the common goal of providing safe and affordable surgical and anaesthesia care in under-developed and developing countries. A systematic thinking approach could amplify the impact of such efforts by highlighting the bigger picture, enabling Global Surgery leaders in such countries to build multidisciplinary coalitions and utilise crosslevel interactions between Global Surgery and other initiatives.

IntroductionCharacterisation of injury severity is an important pillar of scientific research to measure and compare the outcomes. Although majority of injury severity measures were developed in high-income countries, many have been studied in low-income and middle-income countries (LMICs). We conducted this study to identify and characterise all injury severity measures, describe how widely and frequently they are used in trauma research from LMICs, and summarise the evidence on their performance based on empirical and theoretical validation​ analysis.MethodsFirst, a list of injury measures was identified through PubMed search. Subsequently, a systematic search of PubMed, Global Health and EMBASE was undertaken on LMIC trauma literature published from January 2006 to June 2016, in order to assess the application and performance of injury severity measures to predict in-hospital mortality. Studies that applied one or more global injury severity measure(s) on all types of injuries were included, with the exception of war injuries and isolated organ injuries.ResultsOver a span of 40 years, more than 55 injury severity measures were developed. Out of 3862 non-duplicate citations, 597 studies from 54 LMICs were listed as eligible studies. Full-text review revealed 37 studies describing performance of injury severity measures for outcome prediction. Twenty-five articles from 13 LMICs assessed the validity of at least one injury severity measure for in-hospital mortality. Injury severity score was the most commonly validated measure in LMICs, with a wide range of performance (area under the receiver operating characteristic curve (AUROC) between 0.9 and 0.65). Trauma and Injury Severity Score validation studies reported AUROC between 0.80 and 0.98.ConclusionEmpirical studies from LMICs frequently use injury severity measures, however, no single injury severity measure has shown a consistent result in all settings or populations and thus warrants validation studies for the diversity of LMIC population.

BACKGROUND Rapid advances in mobile technologies and applications and the continued growth in digital network coverage have the potential to transform data collection in low- and middle-income countries. A common perception is that digital data collection (DDC) is faster and quickly adaptable. OBJECTIVE The objective of this study was to test whether DDC is faster and more adaptable in a roadside environment. We conducted a reliability study comparing digital versus paper data collection in 3 cities in Ghana, Vietnam, and Indonesia observing road safety risk factors in real time. METHODS Roadside observation of helmet use among motorcycle passengers, seat belt use among 4-wheeler passengers, and speeding was conducted in Accra, Ghana; Ho Chi Minh City (HCMC), Vietnam; and Bandung, Indonesia. Two independent data collection teams were deployed to the same sites on the same dates and times, one using a paper-based data collection tool and the other using a digital tool. All research assistants were trained on paper-based data collection and DDC. A head-to-head analysis was conducted to compare the volume of observations, as well as the prevalence of each risk factor. Correlations (r) for continuous variables and kappa for categorical variables are reported with their level of statistical significance. RESULTS In Accra, there were 119 observation periods (90-min each) identical by date, time, and location during the helmet and seat belt use risk factor data collection and 118 identical periods observing speeding prevalence. In Bandung, there were 150 observation periods common to digital and paper data collection methods, whereas in HCMC, there were 77 matching observation periods for helmet use, 82 for seat belt use, and 84 for speeding. Data collectors using paper tools were more productive than their DDC counterparts during the study. The highest mean volume per session was recorded for speeding, with Bandung recording over 1000 vehicles on paper (paper: mean 1092 [SD 435]; digital: mean 807 [SD 261]); whereas the lowest volume per session was from HCMC for seat belts (paper: mean 52 [SD 28]; digital: mean 62 [SD 30]). Accra and Bandung showed good-to-high correlation for all 3 risk factors (r=0.52 to 0.96), with higher reliability in speeding and helmet use over seat belt use; HCMC showed high reliability for speeding (r=0.99) but lower reliability for helmet and seat belt use (r=0.08 to 0.32). The reported prevalence of risk factors was comparable in all cities regardless of the data collection method. CONCLUSIONS DDC was convenient and reliable during roadside observational data collection. There was some site-related variability in implementing DDC methods, and generally the productivity was higher using the more familiar paper-based method. Even with low correlations between digital and paper data collection methods, the overall reported population prevalence was similar for all risk factors.

Emergency medical services (EMS) is defined as the system that organizes all aspects of care provided to patients in the pre-hospital or out-of-hospital environment. Hence, EMS is a critical component of the health systems and is necessary to improve outcomes of injuries and other time-sensitive illnesses. Still there exists a substantial need for evidence to improve our understanding of the capacity of such systems as well as their strengths, weaknesses, and priority areas for improvement in low-resource environments. The aim was to develop a tool for assessment of the pre-hospital EMS system using the World Health Organization (WHO) health system framework. Relevant literature search and expert consultation helped identify variables describing system capacity, outputs, and goals of pre-hospital EMS. Those were organized according to the health systems framework, and a multipronged approach is proposed for data collection including use of qualitative and quantitative methods with triangulation of information from important stakeholders, direct observation, and policy document review. The resultant information is expected to provide a holistic picture of the pre-hospital emergency medical services and develop key recommendations for PEMS systems strengthening.

ObjectivesInjuries are among the top causes of hospital-based mortality for adults in Oman. However, little is known about the distribution and risk of injuries among children. This paper describes the epidemiology and risk factors for childhood injuries (0–15 years of age), in two hospitals of Oman.MethodsData were collected between November 2014 and April 2015 at Khoula and Nizwa Hospitals. All patients between 0 and 15 years with a diagnosis of injury/trauma admitted to the hospital, and those who had trauma team activation in the emergency department were included in the analysis. Descriptive and multivariable Poisson regression analyses were conducted to generate sociodemographic risk factor profiles associated with the need for surgical management of injuries.ResultsOut of 795 cases, 59% were under 5 years of age; 67% were males. Around 50% injuries were fall related, followed by exposure to inanimate mechanical forces and transport injuries. Burn injuries were more prevalent in females than males. Three-fourths of all injuries occurred in private residences. Almost 92% injuries were minor (Injury Severity Score ConclusionIn this study, >30% of injury admissions were children 0–15 years of age. The high incidence of falls, home injuries and burns highlight the need for age-targeted interventions and injury control programmes. Although infrequent, transport injuries and head injuries put children in need of surgical management and prolonged hospital care.

Lack of data on traumatic brain injuries (TBI) hinders the appreciation of the true magnitude of the burden, and poses a barrier to defining risks, vulnerable groups, and the impact of potential interventions. This work describes a scientific approach for hospital based systematic data collection in a low-income country (LIC), and details the steps of developing an internet-based TBI registry in Uganda. The registry is developed and implemented based on the evaluation framework for injury surveillance systems (EFISS) which comprises a four-step approach: (1) identifying characteristics that assess a surveillance system, (2) a thorough review of the identified characteristics(variables) based on adopted Specific, Measurable, Achievable, Realistic, Time-bound (SMART) criteria, (3) assessment of the proposed variables and system characteristics by an expert panel, and (4) development and application of a rating system. After extensive literature review on TBI surveillance and management, variables and implementation strategy were finalized by a peer review panel and an mHealth platform was developed for data collection in Mulago Hospital, Kampala. The TBI registry is designed to capture comprehensive, yet context-specific, information on each case, from the time of injury until death or discharge from the hospital, with a cut off at 30 days if the patient was still admitted. It included patients’ demographic information, pre-hospital and hospital assessment and care, causes of TBI, injury severity, and patient outcomes in terms of survival and disability. This was the first mHealth based TBI registry to be pilot tested in a tertiary care hospital of Uganda. An mHealth-based TBI registry in Uganda will open the opportunity to replicate the process in similar context and thus contribute to a better understanding of TBI in these settings, and feed into the global agenda of reducing deaths and disabilities from TBI in low-and middle-income countries.

The rapid proliferation of mobile technologies in low- and middle-income countries (LMICs) has generated considerable eagerness among researchers, donors, and implementers to employ these advances for improving the effectiveness and efficiency of public health programs. While mHealth innovations present promise for the field of injury prevention and control, their use in LMICs has largely been as part of pilot programs. In order to scale up the use of these innovations to improve reach, efficiency and effectiveness of injury prevention, control, and surveillance programs, we ought to examine the empirical evidence supporting their value in terms of diversity, performance. This 90-minute session will aim to highlight the use of mHealth approaches for different purposes in LMICs, such as data collection to understand risk factors for road safety, interventions for home-based child injuries, and hospital-based surveillance/registries. The presenters will share their experience with respect to the development, implementation, user satisfaction, strengths and challenges in resource-limited environments. The presentations will be followed by a moderated interactive discussion to highlight key lessons for the field and further opportunities to harness the potential of digital technology for injury prevention and control in LMICs. Program: Welcome and Overview of Nexus of Injury Research and mHealth Innovations: Dr. Adnan Hyder (10 min); Talks include ‘Establishing mHealth based trauma registries in LMICs: Implementation challenges’ by Dr. Amber Mehmood; (2) Roadside observational study of road safety risk factors using tablet-based data collection in Accra, Ghana’ by Francis Afukaar; (3) ‘mCHILD: A cell-phone based tool for the prevention of child injuries in the home environment’ by Dr. Abdulgafoor M. Bachani. Moderated panel discussion on ‘What are the future opportunities for large-scale mHealth based injury research?’

Injuries are among the top causes of hospital-based mortality in individuals 1 to 44 years of age in Oman. However, little is known about the distribution and risk of injuries among children under 15 years of age. This paper uses data collected from a trauma registry established in two hospitals in Oman to describe the epidemiology and risk factors for injuries among children 0–15 years of age. The data from pilot trauma registry of two regional hospitals (Nizwa and Khoula) of Oman, was included. All patients between 0–15 years with a diagnosis of injury/trauma admitted to the hospital, and those who had trauma team activation in the Emergency Department (ED) were included in the analysis. Descriptive and multivariate regression analyses were conducted to generate socio-demographic profiles and to study risk factors for need of surgical management of injuries. Out of 795, 59.5% children were under-5 years of age; 67% were males. Around 50% of the injuries were due to falls, followed by exposure to inanimate mechanical forces and transport injuries. Burn injuries were seen more commonly in females. Three-fourth of all injuries occurred in private residences. Almost 92% of the injuries were minor in severity (Injury severity score More than 30% of all injury admissions to EDs in Oman were children under 15 years of age. High Incidence of falls, home injuries and burns highlight the need for age-targeted interventions, programs and policies changes to reduce injury events in this population. Although infrequent, transport injuries and head injuries put the children in need of surgical management and prolong hospital care.

Injury remains a major public health problem globally, but 90% of all trauma deaths occur in Low-and-Middle-Income-Countries (LMICs), where resources to deal with this crisis are inadequate. Characterization of injury severity is an important pillar of scientific research to measure and compare the outcomes, in order to improve the quality of care. Although no single injury measure is considered the best or the most comprehensive, many have been formulated over time with a wide range of methodologies and are being used in both high-income-countries and LMICs. We conducted the following study to summarize the evidence on performance of injury severity measures based on empirical validation analysis and their applicability in LMIC settings. A systematic search of PubMed, Global Health, and EMBASE on literature published in LMICs from January 2006 through June 2016 was undertaken. We conducted a detailed literature review to assess the application and performance of injury severity measures to predict in-hospital mortality. Studies that applied one or more global injury severity measure(s) on all types of injuries were included, except for those that focused only on war injuries, poisoning, drowning, and ocular trauma. Out of 3862 non-duplicate citations, 597 studies from fifty-four LMICs were listed as eligible studies. Full text review revealed 37 studies describing performance of injury severity measures for outcome prediction. Twenty-five articles from thirteen LMICs assessed the validity of at least one injury severity measure for in-hospital mortality. ISS was the most commonly validated measure in LMICs, with a wide range of performance (AUROC between 0.9–0.65). TRISS validation studies reported AUROC between 0.80 and 0.98. Empirical studies from LMICs frequently utilize injury severity measures, however, no single injury severity measure has shown a consistent result in all settings or populations and thus warrants further validation studies.

Background The burden of injuries is substantial and growing in Uganda. Although Emergency Medical Services (EMS) has been proven to prevent morbidity and mortality for time-sensitive illnesses and injuries, Uganda lacks a formal EMS system. We assessed existing EMS system in Kampala using a rapid assessment tool. Methods The development of the rapid assessment tool was guided by the WHO’s Health Systems Framework and its six building blocks. We used qualitative methods: document review (16 documents including government and organization level policy documents), observation of ambulance services (7 stations and 11 vehicles), key informant interviews (KIIs) (6 government and 16 EMS organization administrators and 12 EMS personnel). We analyzed interview and observation notes and categorized relevant information by the appropriate building blocks. We used document review for triangulation where appropriate. Results Service delivery: we identified 11 different EMS providers in Kampala with no coordination among them; majority was government run/funded (6); three were charities and 2 private agencies. Health workforce: staffing of ambulance vehicles varied greatly from only driver and patient attendant to driver and nurse or volunteer and driver, nurse and doctor. Information systems: only half of the providers had some type of database and data were collected in logbooks, run sheets or registers. Medical products: Most providers had triage system (2/9); most vehicles had medication cabinet (9/11), oxygen cylinders (8/11), medical supplies (9/11), life saving medications (IV fluids, pain medications and epinephrine) (8/11) and only 2 had advanced equipment. Financing: a fixed salary was the most widely used compensation structure. Governance: There was no formal EMS system and no lead agency for EMS. Conclusion and policy implications The EMS system is fragmented with gaps in all components of the system in Kampala. Focusing on EMS system improvement could improve the outcome of injuries and other time-sensitive conditions.

Traumatic brain injury (TBI) is an important cause of morbidity and mortality especially in low-and-middle income countries (LMICs). The study objective was to assess causes and outcomes of intentional TBI among patients presenting to a tertiary-care hospital in Uganda. The study site was Mulago National Referral Hospital, Kampala, Uganda. Data was collected from May 2016-July 2017. Patients of all age groups presenting to emergency department of the hospital with suspected or documented TBI were enrolled. Patient demographics, TBI causes and outcomes were recorded. TBI was grouped into mild (13–15), moderate (9–12) and severe (≤8) categories based on Glasgow Coma Scale (GCS). Ethical approval was taken from Johns Hopkins School of Public Health and Makerere University. Out of 3749 patients with known intent, 30.3% (n=1135) had intentional TBI. Majority were males (84.5%); mean age was 28.5±14.5 years. Assault (97.1%) was the main cause, however, there were 33 (2.9%) cases of self-harm. Common assault methods were use of bodily force (33.7%), iron bar (24.2%) and hammer (12%). Gun was used in 3 cases. About 60.9% of these victims were breadwinners. 62.8% were in mild GCS category, 22.4% in moderate and 14.9% were in severe category. About 42.6% of the patients were admitted to ward, 37.1% were sent home. There were 30 deaths; 29 were assault victims and 1 of self-harm. Intentional TBI is common among young males in Kampala with assault being the main cause of TBI. TBI resulting from assault among young males in Kampala is an important cause of mortality and morbidity. This has consequences for LMICs like Uganda which has a young population contributing to a broad population pyramid. There is need for further exploration of intentional injuries among youth in the country and to develop programs to engage youth in productive activities for contribution towards country’s economic development.

Measuring performance of Emergency Medical Services (EMS) is vital to improving the quality of prehospital emergency care yet is challenging due to lack of consensus over valid evidence-based performance indicators in EMS research. We aimed to determine the state of the field by conducting a review of literature to identify, describe, and map existing EMS performance indicators. Articles were identified using search strategies for ‘EMS,’ ‘performance indicators,’ and related terms in PubMed, EMBase, and Web of Science. Inclusion was limited to peer-reviewed literature published in or before December 2017 whose main purpose was to discuss, analyze, or promote measures of quality, safety, efficiency, or appropriateness of care in EMS. Most articles (n=25) originated from North America, Western Europe, or Scandinavia (80.0%), and nearly all were published after 2000 (92.0%), with a large proportion appearing in the past 5 years (40.0% from 2012 to 2017). The articles included a cumulative total of 450 performance indicators, of which 255 (56.6%) were linked to specific clinical conditions. Cardiac arrest accounted for the highest number of clinical indicators (25.1%), followed by traumatic injury (19.2%) and acute coronary syndrome (18.0%). Among non-clinical indicators, intervals of time (22.6%) or deployment resource-related indicators (21.5%) were dominant. Across all indicators, clinical and non-clinical, 69 were grounded in time interval measurement (15.3%). When organized according to the Donabedian model, the distribution of indicators was as follows: 71 structural (15.8%); 332 process (73.8%); and 48 outcome (10.7%). Of non-outcome indicators, only 34 were accompanied by citations with evidence of impact on health outcomes (8.5%). Administration of aspirin for acute coronary syndrome was the most often included clinical indicator across articles (24.0%). This review demonstrates the need to move beyond binary response-time process metrics for life-threatening conditions toward more holistic, relevant indicators for the diverse aspects of modern EMS.