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Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.Treatment study.III.

To characterize humanitarian trauma care delivered by US military treatment facilities (MTFs) in Afghanistan and Iraq during combat operations.International Humanitarian Law, which includes the Geneva Conventions, defines protections and standards of treatment to victims of armed conflicts. In 1949, these standards expanded to include injured civilians. In 2001, the Global War on Terror began in Afghanistan and expanded to Iraq in 2003. US MTFs provided care to all military forces, civilians, and enemy prisoners. A thorough understanding of the scope, epidemiology, resource requirements, and outcomes of civilian trauma in combat zones has not been previously characterized.Retrospective cohort analysis of the Department of Defense Trauma Registry from 2005 to 2019. Inclusion criteria were civilians and Non-North Atlantic Treaty Organization (NATO) Coalition Personnel (NNCP) with traumatic injuries treated at MTFs in Afghanistan and Iraq. Patient demographics, mechanism of injury, resource requirements, procedures, and outcomes were categorized.A total of 29,963 casualties were eligible from the Registry. There were 16,749 (55.9%) civilians and 13,214 (44.1%) NNCP. The majority of patients were age above 13 years [26,853 (89.6%)] and male [28,000 (93.4%)]. Most injuries were battle-related: 12,740 (76.1%) civilians and 11,099 (84.0%) NNCP. Penetrating trauma was the most common cause of both battle and nonbattle injuries: 12,293 (73.4%) civilian and 10,029 (75.9%) NNCP. Median Injury Severity Score (ISS) was 9 in each cohort with ISS≥25 in 2236 (13.4%) civilians and 1398 (10.6%) NNCP. Blood products were transfused to 35% of each cohort: 5850 civilians received a transfusion with 2118 (12.6%) of them receiving ≥10 units; 4590 NNCPs received a transfusion with 1669 (12.6%) receiving ≥10 units. MTF mortality rates were civilians 1263 (7.5%) and NNCP 776 (5.9%). Interventions, both operative and nonoperative, were similar between both groups.In accordance with International Humanitarian Law, as well as the US military's medical rules of eligibility, civilians injured in combat zones were provided the same level of care as NNCP. Injured civilians and NNCP had similar mechanisms of injury, injury patterns, transfusion needs, and ISS. This analysis demonstrates resource equipoise in trauma care delivered to civilians and NNCP. Hospitals in combat zones must be prepared to manage large numbers of civilian casualties with significant human and material resources allocated to optimize survival. The provision of humanitarian trauma care is resource-intensive, and these data can be used to inform planning factors for current or future humanitarian care in combat zones.

The COVID-19 pandemic has underscored the need to strengthen national surveillance systems to protect a globally connected world. In low-income and middle-income countries, zoonotic disease surveillance has advanced considerably in the past two decades. However, surveillance efforts often prioritise urban and adjacent rural communities. Communities in remote rural areas have had far less support despite having routine exposure to zoonotic diseases due to frequent contact with domestic and wild animals, and restricted access to health care. Limited disease surveillance in remote rural areas is a crucial gap in global health security. Although this point has been made in the past, practical solutions on how to implement surveillance efficiently in these resource-limited and logistically challenging settings have yet to be discussed. We highlight why investing in disease surveillance in remote rural areas of low-income and middle-income countries will benefit the global community and review current approaches. Using semi-arid regions in Kenya as a case study, we provide a practical approach by which surveillance in remote rural areas can be strengthened and integrated into existing systems. This Viewpoint represents a transition from simply highlighting the need for a more holistic approach to disease surveillance to a solid plan for how this outcome might be achieved.

Body language is a powerful tool that we use to communicate how we feel, but it is unclear whether other primates also communicate in this way. Here, we use functional magnetic resonance imaging to show that the body-selective patches in macaques are activated by affective body language. Unexpectedly, we found these regions to be tolerant of naturalistic variation in posture as well as species; the bodies of macaques, humans, and domestic cats all evoked a stronger response when they conveyed fear than when they conveyed no affect. Multivariate analyses confirmed that the neural representation of fear-related body expressions was species-invariant. Collectively, these findings demonstrate that, like humans, macaques have body-selective brain regions in the ventral visual pathway for processing affective body language. These data also indicate that representations of body stimuli in these regions are built on the basis of emergent properties, such as socio-affective meaning, and not just putative image properties.

The 2022 war in Ukraine has highlighted the unacceptable consequences wrought on civilians and health infrastructure by conflict. Children are among the most vulnerable of those affected and constitute an increasing percentage of non-combatants injured in conflicts globally. A disproportionate number of these injuries are caused by blast mechanisms from munitions including ‘conventional’ landmines and indiscriminate explosive weapons such as barrel bombs and improvised explosive devices. In 21st century conflict, children are no longer only accidental casualties of war, but are increasingly targeted by parties through acts such as bombing of school buses and playgrounds, conscription as child soldiers, and use as human shields. In the present viewpoint article, we review the state of pediatric blast injury studies, synthesizing current understandings of injury epidemiology and identifying gaps in research to advance the field towards a concrete agenda to improve care for this vulnerable population.

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.

Arousal evoked by detecting a performance error may provide a mechanism by which error detection leads to either adaptive or maladaptive changes in attention and performance. By pairing EEG data acquisition with simultaneous measurements of pupil diameter, which is thought to reflect norepinephrinergic arousal, this study tested whether transient changes in EEG oscillations in the alpha frequency range (8-12 Hz) following performance mistakes may reflect error-evoked arousal. In the inter-trial interval following performance mistakes (approximately 8% of trials), pupil diameter increased and EEG alpha power decreased, compared to the inter-trial interval following correct responses. Moreover when trials were binned based on pupil diameter on a within-subjects basis, trials with greater pupil diameter were associated with lower EEG alpha power during the inter-trial interval. This pattern of association suggests that error-related alpha suppression, like pupil dilation, reflects arousal in response to error commission. Errors were also followed by worse next-trial performance, implying that error-evoked arousal may not always be beneficial for adaptive control.

Background Conflict-related injuries sustained by civilians and local combatants are poorly described, unlike injuries sustained by US, North Atlantic Treaty Organization, and coalition military personnel. An understanding of injury epidemiology in twenty-first century armed conflict is required to plan humanitarian trauma systems capable of responding to population needs. Methods We conducted a systematic search of databases (e.g., PubMed, Embase, Web of Science, World Health Organization Catalog, Google Scholar) and grey literature repositories to identify records that described conflict-related injuries sustained by civilians and local combatants since 2001. Results The search returned 3501 records. 49 reports representing conflicts in 18 countries were included in the analysis and described injuries of 58,578 patients. 79.3% of patients were male, and 34.7% were under age 18 years. Blast injury was the predominant mechanism (50.2%), and extremities were the most common anatomic region of injury (33.5%). The heterogeneity and lack of reporting of data elements prevented pooled analysis and limited the generalizability of the results. For example, data elements including measures of injury severity, resource utilization (ventilator support, transfusion, surgery), and outcomes other than mortality (disability, quality of life measures) were presented by fewer than 25% of reports. Conclusions Data describing the needs of civilians and local combatants injured during conflict are currently inadequate to inform the development of humanitarian trauma systems. To guide system-wide capacity building and quality improvement, we advocate for a humanitarian trauma registry with a minimum set of data elements. Electronic supplementary material The online version of this article (10.1007/s00268-020-05428-y) contains supplementary material, which is available to authorized users.

Urban environments marked by violence create fear that can have real impacts on the urban poor, particularly women and girls. Any efforts to tackle poverty and promote health must address the impacts to their access to livelihoods and education, healthcare, markets, and social support that underlie wellbeing. This study aimed to elucidate specific impacts that violence and fear have on the very poor in rapidly growing cities and the coping strategies employed. This multi-country qualitative study was conducted in Dhaka, Bangladesh, Port-au-Prince, Haiti; and Addis Ababa, Ethiopia. Participants in all three cities employed similar tactics to avoid violence. People adjusted how, when, and where they travel and how they interact with people who threaten them. These coping strategies led participants to spend more money on goods and to restrict access to livelihood opportunities, education, healthcare, and social activities. Women are impacted more than men in all spheres and city specific differences are highlighted. Residents of urban slums, particularly women, in these three cities cope with urban violence in many ways, suffering consequences in a range of categories - leading to significant impacts to their own health and well-being and their families.

Since Boko Haram captured international attention with the 2014 kidnapping of the Chibok schoolgirls, the group has catapulted to the top of the Global Terrorism Index. In 2015 the group joined for...

Child victims of conflict embody the unnecessary suffering wrought by war. In addition to morbidity and mortality sustained through direct injury, children suffer indirect effects of conflict such ...

What is your brain doing while your mind is wandering? This study used a within-subjects experience-sampling design to test whether episodes of mind-wandering during a demanding cognitive task are associated with increases in EEG alpha power. Alpha refers to cyclic oscillations in EEG activity at 8-12 Hz, and has been previously correlated with internally rather than externally directed cognition. Participants completed a speeded performance task with more than 800 trials while EEG was recorded. Intermittent experience-sampling probes asked participants to indicate whether their mind was wandering or on-task. Participants reported mind-wandering in response to approximately half of the probes. EEG alpha power was significantly higher preceding probes to which participants reported mind-wandering, compared with probes to which participants reported being on task. These findings imply that dynamic changes in alpha power may prove a valuable tool in studying momentary fluctuations in mind-wandering.

Nomadic pastoralists are among the world’s hardest-to-reach and least-served populations. Pastoralist communities are notoriously difficult to capture in household surveys due to factors including their high degree of mobility, the remote terrain they inhabit, fluid domestic arrangements, and cultural barriers. Most surveys utilize census-based sampling frames which do not accurately capture the demographic and health parameters of nomadic populations. As a result, pastoralists are largely “invisible” in population data such as the Demographic and Health Surveys (DHS). By combining remote sensing and geospatial analysis, we developed an alternative sampling strategy designed to capture the current distribution of nomadic populations. We then implemented this sampling frame to survey a population of mobile pastoralists in southwest Ethiopia, focusing on maternal and child health (MCH) indicators. Using standardized instruments from DHS questionnaires, we assessed the MCH status of this population in order to draw comparisons with regional and national data. We find substantial disparities between our data collected using a geospatial sampling frame and regional DHS data in core MCH indicators including vaccination coverage, skilled birth attendance, and nutritional status. Census-based measures do not adequately capture population-level characteristics, risking substantial misreporting of the health status of mobile populations. Our study is the first to employ a geospatial survey of a nomadic group at the population level, and our field validation demonstrates that this methodology is a logistically feasible alternative to conventional sampling frames. Geospatial sampling methods open up cost-affordable and logistically feasible strategies for sampling pastoralists and other mobile populations, which is a crucial first step towards reaching these underserved groups with health services.

The global trend of rapid urbanization raises concerning issues related to the living standards of the urban poor, many of whom live in dense informal settlements. Residents of informal urban settlements can face significant insecurity, with men and women experiencing different threats. While space and socioeconomic status have specific consequences on the hazard of violence that urban residents face, gender modifies the impact of that violence. In an attempt to understand the drivers of insecurity within a social ecological framework, this study investigated underdeveloped neighborhoods in Addis Ababa, Ethiopia; Dhaka, Bangladesh; and Port-au-Prince, Haiti. The qualitative approach employed focus group discussions using various probing techniques and key informant interviews followed by a thematic analysis of the data. The direct quotes and experiences of young and older women compared to those of young and older men highlight how the combination of factors - gender and poverty - drive differential risk for women compared to men among the urban poor in these cities.

Background Children represent a significant percentage of casualties in modern conflict. Yet, the epidemiology of conflict-related injury among children is poorly understood. A comprehensive analysis of injuries sustained by children in 21st-century armed conflict is necessary to inform planning of local, military, and humanitarian health responses. Methods We conducted a systematic search of databases including PubMed, Embase, Web of Science, World Health Organization Catalog, and Google Scholar to identify records that described conflict-related injuries sustained by children since 2001. Results The search returned 5,264 records. 9 eligible reports without potentially duplicative data were included in analysis, representing 5,100 pediatric patients injured in 5 conflicts. Blast injury was the most frequent mechanism (57%), compared to 24.8% in adults. Mortality was only slightly higher among children (11.0% compared to 9.8% among adults; p Conclusions Children sustain a higher proportion of blast injury than adults in conflict. Existing data do support the conclusion that child casualties have higher mortality than adults overall; however, this difference is slighter than has been previously reported. Specific subpopulations of children appear to have worse outcomes. Overall, non-uniform reporting renders currently available data insufficient to understand the needs of children injured in modern conflict.

Mobile pastoralists are one of the last populations to be reached by health services and are frequently missed by health campaigns. Since health interventions among pastoralists have been staged across a range of disciplines but have not yet been systematically characterised, we set out to fill this gap.We conducted a systematic search in PubMed/MEDLINE, Scopus, Embase, CINAL, Web of Science, WHO Catalog, AGRICOLA, CABI, ScIELO, Google Scholar and grey literature repositories to identify records that described health interventions, facilitators and barriers to intervention success, and factors influencing healthcare utilisation among mobile pastoralists. No date restrictions were applied. Due to the heterogeneity of reports captured in this review, data were primarily synthesised through narrative analysis. Descriptive statistical analysis was performed for data elements presented by a majority of records.Our search yielded 4884 non-duplicate records, of which 140 eligible reports were included in analysis. 89.3% of reports presented data from sub-Saharan Africa, predominantly in East Africa (e.g. Ethiopia, 30.0%; Kenya, 17.1%). Only 24.3% of reports described an interventional study, while the remaining 75.7% described secondary data of interest on healthcare utilisation. Only two randomised controlled trials were present in our analysis, and only five reports presented data on cost. The most common facilitators of intervention success were cultural sensitivity (n = 16), community engagement (n = 12) and service mobility (n = 11).Without adaptations to account for mobile pastoralists' unique subsistence patterns and cultural context, formal health services leave pastoralists behind. Research gaps, including neglect of certain geographic regions, lack of both interventional studies and diversity of study design, and limited data on economic feasibility of interventions must be addressed to inform the design of health services capable of reaching mobile pastoralists. Pastoralist-specific delivery strategies, such as combinations of mobile and 'temporary fixed' services informed by transhumance patterns, culturally acceptable waiting homes, community-directed interventions and combined joint human-animal One Health design as well as the bundling of other health services, have shown initial promise upon which future work should build.Les éleveurs nomades sont l'une des dernières populations à être touchées par les services de santé et sont souvent ratés par les campagnes de santé. Etant donné que les interventions de santé parmi ces éleveurs ont été programmées dans une gamme de disciplines mais n'ont pas encore été systématiquement caractérisées, nous avons entrepris de combler cette lacune. MÉTHODES: Nous avons effectué une recherche systématique dans les répertoires PubMed/MEDLINE, Scopus, EMBASE, CINAL, Web of Science, WHO Catalog, AGRICOLA, CABI, ScIELO, Google Scholar et de la littérature grise pour identifier les reports décrivant les interventions de santé, les facilitateurs et les obstacles au succès de l'intervention ainsi que les facteurs influençant l'utilisation des soins de santé chez les éleveurs nomades. Aucune restriction de date n'a été appliquée. En raison de l'hétérogénéité des rapports capturés dans cette revue, les données ont été principalement synthétisées au moyen d'une analyse narrative. Une analyse statistique descriptive a été effectuée pour les éléments de données présentés par une majorité des reports. RÉSULTATS: Notre recherche a révélé 4.884 rapports non dupliqués, dont 140 éligibles ont été inclus dans l'analyse. 89,3% des rapports présentaient des données d'Afrique subsaharienne, principalement en Afrique de l'Est (ex: Ethiopie, 30,0%; Kenya, 17,1%). Seuls 24,3% des rapports décrivaient une étude interventionnelle, tandis que les 75,7% restants décrivaient des données d'intérêt secondaires sur l'utilisation des soins de santé. Seuls deux essais contrôlés randomisés étaient présents dans notre analyse, et seuls cinq rapports présentaient des données sur le coût. Les facilitateurs les plus courants du succès des interventions étaient la sensibilité culturelle (n=16), l'engagement communautaire (n=12) et la mobilité des services (n=11).Sans adaptations pour tenir compte des modèles de subsistance et du contexte culturel uniques des éleveurs nomades, les services de santé formels les laissent de côté. Les lacunes de la recherche, y compris la négligence de certaines régions géographiques, le manque d'études interventionnelles et la diversité de la conception des études, et les données limitées sur la faisabilité économique des interventions doivent être comblées pour éclairer la conception de services de santé capables d'atteindre les éleveurs nomades. Des stratégies de prestation spécifiques aux éleveurs nomades, telles que des combinaisons de services mobiles et «fixes temporaires» éclairés par des schémas de transhumance, des maisons d'attente culturellement acceptables, des interventions dirigées par la communauté et une conception conjointe d'une seule santé homme-animal ainsi que le regroupement d'autres services de santé, ont montré une promesse initiale sur laquelle les travaux futurs devraient s'appuyer.

Mobile pastoralists subsist primarily on herds of livestock such as camels, cattle, and goats, migrating seasonally to access water and grazing areas. Speculative estimates of their global population have ranged from 50-200 million, while others have suggested that the number of pastoralists in Africa alone may equal these figures.

BackgroundEstrogen increases dramatically during pregnancy, but quickly drops below pre-pregnancy levels at birth and remains suppressed during the postpartum period. Clinical and rodent work suggests that this postpartum drop in estrogen results in an “estrogen withdrawal” state that is related to changes in affect, mood, and behavior. Most studies examining the effect of estrogen withdrawal on the brain have focused solely on the hippocampus.MethodsWe used a hormone-simulated pseudopregnancy model in Syrian hamsters, a first for this species. Ovariectomized females were given daily injections to approximate hormone levels during gestation and then withdrawn from estrogen to simulate postpartum estrogen withdrawal. Subjects were tested for behavioral assays of anxiety and anhedonia during estrogen withdrawal. Following sacrifice, neuroplasticity in oxytocin-producing neurons in the paraventricular nucleus of the hypothalamus (PVH) and its efferent targets was measured.ResultsEstrogen-withdrawn females had increased anxiety-like behaviors in the elevated plus and open field, but did not differ from controls in sucrose preference. Furthermore, estrogen-withdrawn females had more oxytocin-immunoreactive cells and oxytocin mRNA in the PVH, as well as an increase in oxytocin receptor density in the dorsal raphe nucleus (DRN). Finally, blocking oxytocin receptors in the DRN during estrogen withdrawal prevented the high-anxiety behavioral phenotype in estrogen-withdrawn females.ConclusionsEstrogen withdrawal alters oxytocin signaling in the PVH and DRN to increase anxiety-like behavior during the postpartum period. More broadly, these experiments suggest Syrian hamsters as a novel organism in which to model the effects of postpartum estrogen withdrawal on the brain and anxiety-like behavior.

Background Estrogen increases dramatically during pregnancy but quickly drops below prepregnancy levels at birth and remains suppressed during the postpartum period. Clinical and rodent work suggests that this postpartum drop in estrogen results in an estrogen withdrawal state that is related to changes in affect, mood, and behavior. How estrogen withdrawal affects oxytocin (OT) neurocircuitry has not been examined. Methods We used a hormone-simulated pseudopregnancy followed by estrogen withdrawal in Syrian hamsters, a first for this species. Ovariectomized females were given daily injections to approximate hormone levels during gestation and then withdrawn from estrogen to simulate postpartum estrogen withdrawal. These hamsters were tested for behavioral assays of anxiety and anhedonia during estrogen withdrawal. Neuroplasticity in OT-producing neurons in the paraventricular nucleus of the hypothalamus and its efferent targets was measured. Results Estrogen-withdrawn females had increased anxiety-like behaviors in the elevated plus maze and open field tests but did not differ from control females in sucrose preference. Furthermore, estrogen-withdrawn females had more OT-immunoreactive cells and OT messenger RNA in the paraventricular nucleus of the hypothalamus and an increase in OT receptor density in the dorsal raphe nucleus. Finally, blocking OT receptors in the dorsal raphe nucleus during estrogen withdrawal prevented the high-anxiety behavioral phenotype in estrogen-withdrawn females. Conclusions Estrogen withdrawal induces OT neuroplasticity in the paraventricular nucleus of the hypothalamus and dorsal raphe nucleus to increase anxiety-like behavior during the postpartum period. More broadly, these experiments suggest Syrian hamsters as a novel organism in which to model the effects of postpartum estrogen withdrawal on the brain and anxiety-like behavior.

Background Decades of war left the Republic of South Sudan with a fragile health system that has remained deprived of resources since the country’s independence. We describe the coverage of interventions for women’s and children’s health in Upper Nile and Unity states, and explore factors that affected service provision during a protracted conflict. Methods We conducted a case study using a desk review of publicly available literature since 2013 and a secondary analysis of intervention coverage and conflict-related events from 2010 to 2017. During June through September 2018, we conducted 26 qualitative interviews with technical leads and 9 focus groups among health workers working in women and children’s health in Juba, Malakal, and Bentiu. Results Coverage for antenatal care, institutional delivery, and childhood vaccines were low prior to the escalation of conflict in 2013, and the limited data indicate that coverage remained low through 2017. Key factors that determined the delivery of services for women and children in our study sites were government leadership, coordination of development and humanitarian efforts, and human resource capacity. Participants felt that national and local health officials had a limited role in the delivery of services, and financial tracking data showed that funding stagnated or declined for humanitarian health and development programming during 2013–2014. Although health services were concentrated in camp settings, the availability of healthcare providers was negatively impacted by the protracted nature of the conflict and insecurity in the region. Conclusions Health care for women and children should be prioritized during acute and protracted periods of conflict by strengthening surveillance systems, coordinating short and long term activities among humanitarian and development organizations, and building the capacity of national and local government officials to ensure sustainability.

The effects of COVID-19 have gone undocumented in nomadic pastoralist communities across Africa, which are largely invisible to health surveillance systems despite the fact that they are of key significance in the setting of emerging infectious disease. We expose these landscapes as a “blind spot” in global health surveillance, elaborate on the ways in which current health surveillance infrastructure is ill-equipped to capture pastoralist populations and the animals with which they coexist, and highlight the consequential risks of inadequate surveillance among pastoralists and their livestock to global health. As a platform for further dialogue, we present concrete solutions to address this gap.

Cattle raiding, a longstanding practice among pastoralists in South Sudan, was historically governed by cultural authorities and ritual prohibitions. However, after decades of on-and-off integration into armed forces, raiders are now heavily armed, and military-style attacks claim dozens if not hundreds of lives at a time. Beginning with the emergence of the infamous Lou Nuer “White Army” in the Bor Massacre of the early 1990s, in which Riek Machar mobilized local herders to mount a devastating attack against the heartland of Sudan People’s Liberation Army Leader John Garang, political leaders have strategically manipulated these local conflicts in order to mobilize armed herders for their political movements. Political leaders’ systematic exploitation of customary raiding practices gravely inflames the current conflict, but the role of intercommunity violence has not been part of the mainstream dialogue around political solutions. Moreover, as allegiances between pastoralist militias and political factions decay, the proliferation of informal armed groups whose motivations are often distinct from the agenda of the state or opposition forces on whose behalf they once fought poses increasing challenges to peacebuilding efforts. Neglecting local realities poses serious implications for the prospects of peace. In this article, we synthesize perspectives from anthropology, regional history, and conflict studies to offer an analysis of the interplay between local conflict and state violence in South Sudan. We highlight opportunities for conflict de-escalation, concluding with policy recommendations focused on justice and enforcement in the rural areas of South Sudan.

Importance Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures The working group’s method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

What began in 2013 as the eruption of a political struggle between forces loyal to President Salva Kiir, a member of the Dinka ethnic group, and then–vice president Riek Machar, a Nuer, has splintered into a multifaction conflict. A dizzying array of armed groups have entered the fray, many unmotivated by political leverage that conventionally brings parties to a conflict to the negotiating table. Two years and tens of thousands of deaths after the 2015 signing of the Agreement on the Resolution of the Conflict in South Sudan, with no substantive progress toward meetings its terms, it is unrealistic to think that Intergovernmental Authority on Development’s recently announced High-Level Revitalization Forum will be sufficient to address the drivers of this conflict. Current policy proposals are poorly designed to address escalating intercommunal conflict and cattle raiding, both devastating forms of violence. As measures at the international level continue to be pursued, the conflict resolution strategy should also include a more comprehensive approach incorporating local actors in order to build momentum toward long-term stability. In this article, we highlight gaps in the current dialogue around a political solution in South Sudan, as well as domains that must be part of the next push for peace. (Disaster Med Public Health Preparedness. 2019;13:663–671)

Adrenocortical carcinoma (ACC) is a rare malignancy that is frequently asymptomatic at presentation, yet has a high rate of metastatic disease at the time of diagnosis. Prognosis is overall poor, particularly with cortisol-producing tumors. While the treatment of ACC is guided by stage of disease, complete surgical resection is the most important step in the management of patients with primary, recurrent, or metastatic ACC. Triphasic chest, abdomen, and pelvis computer tomography (CT) scans and 18F flourodeoxyglucose positron emission tomography CT scanning are essential for accurate staging; moreover, MRI may be helpful to identify liver metastasis and evaluate the involvement of adjacent organs for operative planning. Surgical resection with negative margins is the single most important prognostic factor for survival in patients with ACC. To achieve the highest rate of R0 resection, open adrenalectomy is the gold standard surgical approach for confirmed or highly suspected ACC. It is extremely important that the tumor capsule is not ruptured, regardless of the surgical approach used. The best post-operative outcomes (complications and oncologic) are achieved by high-volume surgeons practicing at high-volume centers.

Humanitarian aid in settings of conflict has always been fraught with challenges. In the absence of political engagement, however, manipulation by state authorities, however, have the potential to pervert aid intervention to inflict harm. South Sudan exemplifies how states may abuse the humanitarian response to retreat from public responsibility, divert funds to further violence and conflict and dictate the distribution of aid. Recent trends toward nationalist policies in the West that favor disengagement and limited military strikes have the very effect of allowing this abuse to transform humanitarian aid into a tool for harm. (Disaster Med Public Health Preparedness. 2018;12:567–568)