Journal Article > CommentaryFull Text
PLOS Med. 2014 April 22; Volume 11 (Issue 4); DOI:10.1371/journal.pmed.1001632
Gerdin M, Clarke M, Allen C, Kayabu B, Summerskill W, et al.
PLOS Med. 2014 April 22; Volume 11 (Issue 4); DOI:10.1371/journal.pmed.1001632
Conference Material > Poster
Amat Camacho N, von Schreeb J, della Corte F, Kolokotroni O
MSF Paediatric Days 2022. 2022 November 30; DOI:10.57740/pf49-p583
Journal Article > ResearchFull Text
Malar J. 2011 April 17; Volume 10 (Issue 1); 94.; DOI:10.1186/1475-2875-10-94
Thomson A, Knogali M, de Smet M, Reid AJ, Mukhtar A, et al.
Malar J. 2011 April 17; Volume 10 (Issue 1); 94.; DOI:10.1186/1475-2875-10-94
BACKGROUND
Malaria is hyper-endemic and a major public health problem in Sierra Leone. To provide malaria treatment closer to the community, Médecins Sans Frontières (MSF) launched a community-based project where Community Malaria Volunteers (CMVs) tested and treated febrile children and pregnant women for malaria using rapid diagnostic tests (RDTs). RDT-negative patients and severely ill patients were referred to health facilities. This study sought to determine the referral rate and compliance of patients referred by the CMVs.
METHODS
In MSF's operational area in Bo and Pujehun districts, Sierra Leone, a retrospective analysis of referral records was carried out for a period of three months. All referral records from CMVs and referral health structures were reviewed, compared and matched for personal data. The eligible study population included febrile children between three and 59 months and pregnant women in their second or third trimester with fever who were noted as having received a referral advice in the CMV recording form.
RESULTS
The study results showed a total referral rate of almost 15%. During the study period 36 out of 2,459 (1.5%) referred patients completed their referral. There was a significant difference in referral compliance between patients with fever but a negative RDT and patients with signs of severe malaria. Less than 1% (21/2,442) of the RDT-negative patients with fever completed their referral compared to 88.2% (15/17) of the patients with severe malaria (RR = 0.010 95% CI 0.006 - 0.015).
CONCLUSIONS
In this community-based malaria programme, RDT-negative patients with fever were referred to a health structure for further diagnosis and care with a disappointingly low rate of referral completion. This raises concerns whether use of CMVs, with referral as backup in RDT-negative cases, provides adequate care for febrile children and pregnant women. To improve the referral completion in MSF's community-based malaria programme in Sierra Leone, and in similar community-based programmes, a suitable strategy needs to be defined.
Malaria is hyper-endemic and a major public health problem in Sierra Leone. To provide malaria treatment closer to the community, Médecins Sans Frontières (MSF) launched a community-based project where Community Malaria Volunteers (CMVs) tested and treated febrile children and pregnant women for malaria using rapid diagnostic tests (RDTs). RDT-negative patients and severely ill patients were referred to health facilities. This study sought to determine the referral rate and compliance of patients referred by the CMVs.
METHODS
In MSF's operational area in Bo and Pujehun districts, Sierra Leone, a retrospective analysis of referral records was carried out for a period of three months. All referral records from CMVs and referral health structures were reviewed, compared and matched for personal data. The eligible study population included febrile children between three and 59 months and pregnant women in their second or third trimester with fever who were noted as having received a referral advice in the CMV recording form.
RESULTS
The study results showed a total referral rate of almost 15%. During the study period 36 out of 2,459 (1.5%) referred patients completed their referral. There was a significant difference in referral compliance between patients with fever but a negative RDT and patients with signs of severe malaria. Less than 1% (21/2,442) of the RDT-negative patients with fever completed their referral compared to 88.2% (15/17) of the patients with severe malaria (RR = 0.010 95% CI 0.006 - 0.015).
CONCLUSIONS
In this community-based malaria programme, RDT-negative patients with fever were referred to a health structure for further diagnosis and care with a disappointingly low rate of referral completion. This raises concerns whether use of CMVs, with referral as backup in RDT-negative cases, provides adequate care for febrile children and pregnant women. To improve the referral completion in MSF's community-based malaria programme in Sierra Leone, and in similar community-based programmes, a suitable strategy needs to be defined.
Journal Article > ResearchFull Text
Journal of Emergency Medicine. 2021 September 16; Volume S0736-4679 (Issue 21); 00636-3.; DOI:10.1016/j.jemermed.2021.07.054
Nerlander M, Pini A, Trelles M, Majanen H, Al-Abbasi O, et al.
Journal of Emergency Medicine. 2021 September 16; Volume S0736-4679 (Issue 21); 00636-3.; DOI:10.1016/j.jemermed.2021.07.054
BACKGROUND
Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts.
OBJECTIVE
This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict.
METHODS
During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant.
RESULTS
The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately one-third of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED.
CONCLUSION
The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflict-related injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.
Armed conflicts constitute a significant public health problem, and the advent of asymmetric warfare tactics creates unique and new challenges to health care organizations providing trauma care in conflicts.
OBJECTIVE
This study aimed to analyze the epidemiology of presentations to a civilian field hospital deployed close to an ongoing conflict.
METHODS
During the 2016-2017 Mosul offensive, the humanitarian organization Médecins Sans Frontières deployed a field hospital 30 km south of Mosul. This study is a retrospective analysis of routinely collected patient data of all presentations to the emergency department (ED) during its period of operation between February 23 and July 18, 2017. Data were collected in Microsoft Excel by health care workers and analyzed in JMP, version 13. Chi-square test was used to compare proportions. A p value < 0.05 was considered significant.
RESULTS
The analysis included 3946 presentations. Most were due to conflict-related injuries, including explosives (40.4%) and firearms (12.9%), which presented in consecutive waves over time. Approximately one-third of presentations (32.3%) were due to medical issues, which outweighed conflict-related presentations toward the latter half of the operational period. Explosives caused most of the mass casualty events. A total of 20 patients (0.5%) died in the ED.
CONCLUSION
The study demonstrated a cyclical burden of conflict-related injuries and extensive medical needs, which increased over time. Among conflict-related injuries, explosive etiology predominated and was likely to result in mass casualty incidents. The low mortality might be due to critical but potentially salvageable patients not reaching the hospital in time, owing to the adverse context.
Protocol > Research Study
JMIR Res Protoc. 2018 November 26; Volume 7 (Issue 11); e12334.; DOI:10.2196/12334
Alga A, Wong S, Haweizy R, Conneryd Lundgren K, von Schreeb J, et al.
JMIR Res Protoc. 2018 November 26; Volume 7 (Issue 11); e12334.; DOI:10.2196/12334
BACKGROUND
In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.
OBJECTIVE
The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.
METHODS
This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.
RESULTS
The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.
CONCLUSIONS
To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.
In armed conflict, injuries commonly affect the extremities and contamination with foreign material often increases the risk of infection. The use of negative-pressure wound therapy has been described in the treatment of acute conflict-related wounds, but reports are retrospective and with limited follow-up.
OBJECTIVE
The objective of this study is to investigate the effectiveness and safety of negative-pressure wound therapy use in the treatment of patients with conflict-related extremity wounds.
METHODS
This is a multisite, superiority, pragmatic randomized controlled trial. We are considering for inclusion patients 18 years of age and older who are presenting with a conflict-related extremity wound within 72 hours after injury. Patients are block randomly assigned to either negative-pressure wound therapy or standard treatment in a 1:1 ratio. The primary end point is wound closure by day 5. Secondary end points include length of stay, wound infection, sepsis, wound complications, death, and health-related quality of life. We will explore economic outcomes, including direct health care costs and cost effectiveness, in a substudy. Data are collected at baseline and at each dressing change, and participants are followed for up to 3 months. We will base the primary statistical analysis on intention-to-treat.
RESULTS
The trial is ongoing. Patient enrollment started in June 2015. We expect to publish findings from the trial by the end of 2019.
CONCLUSIONS
To the best of our knowledge, there has been no randomized trial of negative-pressure wound therapy in this context. We expect that our findings will increase the knowledge to establish best-treatment strategies.
Journal Article > ResearchFull Text
World J Surg. 2019 May 7; Volume 43 (Issue 9); 2123-2130.; DOI:10.1007/s00268-019-05015-w
Tounsi LL, Daebes HL, Warnberg MG, Nerlander M, Jaweed M, et al.
World J Surg. 2019 May 7; Volume 43 (Issue 9); 2123-2130.; DOI:10.1007/s00268-019-05015-w
INTRODUCTION
There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males.
MATERIALS AND METHODS
This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression.
RESULTS
Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453).
CONCLUSION
Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
There is paucity of literature describing type of injury and care for females in conflicts. This study aimed to describe the injury pattern and outcome in terms of surgery and mortality for female patients presenting to Médecins Sans Frontières Trauma Centre in Kunduz, Afghanistan, and compare them with males.
MATERIALS AND METHODS
This study retrospectively analysed patient data from 17,916 patients treated at the emergency department in Kunduz between January and September 2015, before its destruction by aerial bombing in October the same year. Routinely collected data on patient characteristics, injury patterns, triage category, time to arrival and outcome were retrieved and analysed. Comparative analyses were conducted using logistic regression.
RESULTS
Females constituted 23.6% of patients. Burns and back injuries were more common among females (1.4% and 3.3%) than among males (0.6% and 2.0%). In contrast, open wounds and thoracic injuries were more common among males (10.1% and 0.6%) than among females (5.2% and 0.2%). Females were less likely to undergo surgery (OR 0.60, CI 0.528-0.688), and this remained significant after adjustment for age, nature of injury, triage category, multiple injuries and delay to arrival (OR 0.80, CI 0.690-0.926). Females also had lower unadjusted odds of mortality (OR 0.49, CI 0.277-0.874), but this was not significant in the adjusted analysis (OR 0.81, CI 0.446-1.453).
CONCLUSION
Our main findings suggest that females seeking care at Kunduz Trauma Centre arrived later, had different injury patterns and were less likely to undergo surgery as compared to males.
Journal Article > ResearchFull Text
BMC Infect Dis. 2018 May 22; Volume 18 (Issue 1); DOI:10.1186/s12879-018-3149-y
Alga A, Wong S, Shoaib M, Lundgren KC, Giske CG, et al.
BMC Infect Dis. 2018 May 22; Volume 18 (Issue 1); DOI:10.1186/s12879-018-3149-y
Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared.
Journal Article > ResearchFull Text
PLOS Glob Public Health. 2023 September 11; Volume 3 (Issue 9); e0001723.; DOI:10.1371/journal.pgph.0001723
Gohy B, Opava CH, von Schreeb J, Van den Bergh R, Brus A, et al.
PLOS Glob Public Health. 2023 September 11; Volume 3 (Issue 9); e0001723.; DOI:10.1371/journal.pgph.0001723
The importance of measuring outcomes after injury beyond mortality and morbidity is increasingly recognized, though underreported in humanitarian settings. To address shortcomings of existing outcome measures in humanitarian settings, the Activity Independence Measure-Trauma (AIM-T) was developed, and is structured in three subscales (i.e., core, lower limb, and upper limb). This study aimed to assess the AIM-T construct validity (structural validity and hypothesis testing) and reliability (internal consistency, inter-rater reliability and measurement error) in four humanitarian settings (Burundi, Iraq, Cameroon and Central African Republic). Patients with acute injury (n = 195) were assessed using the AIM-T, the Barthel Index (BI), and two pain scores. Structural validity was assessed through confirmatory factor analysis. Hypotheses were tested regarding correlations with BI and pain scores using Pearson correlation coefficient (PCC) and differences in AIM-T scores between patients’ subgroups, using standardized effect size Cohen’s d (d). Internal consistency was assessed with Cronbach’s alpha (a). AIM-T was reassessed by a second rater in 77 participants to test inter-rater reliability using intraclass correlation coefficient (ICC). The results showed that the AIM-T structure in three subscales had an acceptable fit. The AIM-T showed an inverse weak to moderate correlation with both pain scores (PCC<0.7, p=0.05), positive strong correlation with BI (PCC=0.7, p=0.05), and differed between all subgroups (d=0.5, p=0.05). The inter-rater reliability in the (sub)scales was good to excellent (ICC 0.86–0.91) and the three subscales’ internal consistency was adequate (a=0.7). In conclusion, this study supports the AIM-T validity in measuring independence in mobility activities and its reliability in humanitarian settings, as well as it informs on its interpretability. Thus, the AIM-T could be a valuable measure to assess outcomes after injury in humanitarian settings.
Journal Article > ResearchFull Text
Emerg Med J. 2021 November 10; Volume 39 (Issue 8); 628-633.; DOI:10.1136/emermed-2020-209470
Daebes HL, Tounsi LL, Nerlander M, Gerdin M, Jaweed M, et al.
Emerg Med J. 2021 November 10; Volume 39 (Issue 8); 628-633.; DOI:10.1136/emermed-2020-209470
BACKGROUND
Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF's standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings.
AIM
This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC.
METHOD AND MATERIALS
This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes.
RESULTS
Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red.
CONCLUSION
The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.
Five million people die annually due to injuries; an increasing part is due to armed conflict in low-income and middle-income countries, demanding resolute emergency trauma care. In Afghanistan, a low-income country that has experienced conflict for over 35 years, conflict related trauma is a significant public health problem. To address this, the non-governmental organisation Médecins Sans Frontières (MSF) set up a trauma centre in Kunduz (Kunduz Trauma Centre (KTC)). MSF's standardised emergency operating procedures include the South African Triage Scale (SATS). To date, there are few studies that assess how triage levels correspond with outcome in low-resource conflict settings.
AIM
This study aims to assess to what extent SATS triage levels correlated to outcomes in terms of hospital admission, intensive care unit (ICU) admission and mortality for patients treated at KTC.
METHOD AND MATERIALS
This retrospective study used routinely collected data from KTC registries. A total of 17 970 patients were included. The outcomes were hospital admission, ICU admission and mortality. The explanatory variable was triage level. Covariates including age, gender and delay to arrival were used. Logistic regression was used to study the correlation between triage level and outcomes.
RESULTS
Out of all patients seeking care, 28.7% were triaged as red or orange. The overall mortality was 0.6%. In total, 90% of those that died and 79% of ICU-admitted patients were triaged as red.
CONCLUSION
The risk of positive and negative outcomes correlated with triage level. None of the patients triaged as green died or were admitted to the ICU whereas 90% of patients who died were triaged as red.
Journal Article > ResearchFull Text
PLOS Glob Public Health. 2022 December 14; Volume 2 (Issue 12); e0001334.; DOI:10.1371/journal.pgph.0001334
Gohy B, Opava CH, von Schreeb J, Van den Bergh R, Brus A, et al.
PLOS Glob Public Health. 2022 December 14; Volume 2 (Issue 12); e0001334.; DOI:10.1371/journal.pgph.0001334
A standardized set of measures to assess functioning after trauma in humanitarian settings has been called for. The Activity Independence Measure for Trauma (AIM-T) is a clinician-rated measure of independence in 20 daily activities among patients after trauma. Designed in Afghanistan, it has since been used in other contexts. Before recommending the AIM-T for wider use, its measurement properties required confirmation. This study aims at item reduction followed by content validity assessment of the AIM-T. Using a two-step revision process, first, routinely collected data from 635 patients at five facilities managing patients after trauma in Haiti, Burundi, Yemen, and Iraq were used for item reduction. This was performed by analyzing inter-item redundancy and distribution of the first version of the AIM-T (AIM-T1) item scores, resulting in a shortened version (AIM-T2). Second, content validity of the AIM-T2 was assessed by item content validity indices (I-CVI, 0–1) based on structured interviews with 23 health care professionals and 60 patients in Haiti, Burundi, and Iraq. Through the analyses, nine pairs of redundant items (r≥0.90) were identified in the AIM-T1, leading to the removal of nine items, and resulting in AIM-T2. All remaining items were judged highly relevant, appropriate, clear, feasible and representative by most of participants (I-CVI>0.5). Ten items with I-CVI 0.5–0.85 were revised to improve their cultural relevance or appropriateness and one item was added, resulting in the AIM-T3. In conclusion, the proposed 12-item AIM-T3 is overall relevant, clear, and representative of independence in daily activity after trauma and it includes items appropriate and feasible to be observed by clinicians across different humanitarian settings. While some additional measurement properties remain to be evaluated, the present version already has the potential to serve as a routine measure to assess patients after trauma in humanitarian settings.