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Results from single-region studies suggest that stay at home orders (SAHOs) had unforeseen consequences on the volume and patterns of traumatic injury during the initial months of the Coronavirus disease 2019 (COVID-19). The aim of this study was to describe, using a multi-regional approach, the effects of COVID-19 SAHOs on trauma volume and patterns of traumatic injury in the US.A retrospective cohort study was performed at four verified Level I trauma centers spanning three geographical regions across the United States (US). The study period spanned from April 1, 2020 - July 31, 2020 including a month-matched 2019 cohort. Patients were categorized into pre-COVID-19 (PCOV19) and first COVID-19 surge (FCOV19S) cohorts. Patient demographic, injury, and outcome data were collected via Trauma Registry queries. Univariate and multivariate analyses were performed.A total 5,616 patients presented to participating study centers during the PCOV19 (2,916) and FCOV19S (2,700) study periods. Blunt injury volume decreased (p = 0.006) due to a significant reduction in the number of motor vehicle collisions (MVCs) (p = 0.003). Penetrating trauma experienced a significant increase, 8% (246/2916) in 2019 to 11% (285/2,700) in 2020 (p = 0.007), which was associated with study site (p = 0.002), not SAHOs. Finally, study site was significantly associated with changes in nearly all injury mechanisms, whereas SAHOs accounted for observed decreases in calculated weekly averages of blunt injuries (p0.02) and MVCs (p = 0.003).Results of this study suggest that COVID-19 and initial SAHOs had variable consequences on patterns of traumatic injury, and that region-specific shifts in traumatic injury ensued during initial SAHOs. These results suggest that other factors, potentially socioeconomic or cultural, confound trauma volumes and types arising from SAHOs. Future analyses must consider how regional changes may be obscured with pooled cohorts, and focus on characterizing community-level changes to aid municipal preparation for future similar events.

Screening, brief intervention, and referral to treatment (SBIRT) is an intervention originally developed to prevent and deter substance abuse. Adaptation of the SBIRT model to prevent post-traumatic stress disorder (PTSD) may potentially reduce acute stress symptoms after traumatic injury. We conducted a prospective randomized control study of adult patients admitted for gunshot wounds. Patients were randomized to intervention (INT) vs. treatment as usual (TAU) groups. INT received the newly developed SBIRT Intervention for Trauma Patients (SITP)—a 15-minute session with elements of cognitive behavioral therapy techniques. SITP took place during the index hospitalization; both groups had followup at 30 and 90 days at which time a validated PTSD screening tool, PCL-5, was administered. Most of the 46 participants were young (mean age = 30.5y), male (91.3%), and black (86.9%). At three-month follow-up, SBIRT and TAU patients had similar physical healing scores but the SBIRT arm showed reductions in PTSD symptoms.

As hospital systems plan for health care utilization surges and stress, understanding the necessary resources of a trauma system is essential for planning capacity. We aimed to describe trends in high-intensity resource utilization (operating room [OR] usage and intensive care unit [ICU] admissions) for trauma care during the initial months of the COVID-19 pandemic. Trauma registry data (2019 pre-COVID-19 and 2020 COVID-19) were collected retrospectively from 4 level I trauma centers. Direct emergency department (ED) disposition to the OR or ICU was used as a proxy for high-intensity resource utilization. No change in the incidence of direct ED to ICU or ED to OR utilization was observed (2019: 24%, 2020 23%; P = .62 and 2019: 11%, 2020 10%; P = .71, respectively). These results suggest the need for continued access to ICU space and OR theaters for traumatic injury during national health emergencies, even when levels of trauma appear to be decreasing.

ObjectivesUsing rectal contrast computed tomography (CT) to identify traumatic colorectal injuries has become commonplace; however, these injuries remain relatively infrequent findings on CTs obtained for penetrating back and flank trauma. We conducted a meta-analysis to ascertain the efficacy of rectal contrast CT in identifying such injuries in victims penetrating injuries.MethodsPubMed and Embase were queried for relevant articles between 1974 and 2022. Review articles, case studies, and non-English manuscripts were excluded. Studies without descriptive CT and operative findings were excluded. Positive scans refer to rectal contrast extravasation. Sensitivity and specificity of rectal contrast CT scans were calculated with aggregated CT findings that were cross-referenced with laparotomy findings.ResultsOnly 8 manuscripts representing 506 patients quantified colorectal injuries and specified patients with rectal contrast extravasation. Seven patients with true colorectal injuries had no contrast extravasation on CT. There was one true positive scan. Another scan identified contrast extravasation, but laparotomy revealed no colorectal injury. Rectal contrast had sensitivity of 12.5%, specificity 99.8%, positive predictive value (PPV) 50%, negative predictive value (NPV) 99%, and a false negative rate of 88% in identifying colonic injuries.DiscussionThe summation of 8 manuscripts suggest that the addition of rectal contrast in identifying colonic and rectal injuries may be of limited utility given its poor sensitivity and may be unnecessary. In its absence, subtle clues such as hematomas, extraluminal air, IV-dye extravasation, and trajectory may be additional indicators of injury. Further investigations are required to demonstrate a true benefit for the addition of rectal contrast.

Repair of penetrating retrohepatic inferior vena cava (IVC) injuries continues to challenge trauma surgeons due to difficulty in accessing the injury, hemorrhage prior to the repair, and associated high mortality rates. Complication by suprahepatic vena cava injuries portends an increased risk of an unfavorable outcome. Over time, overall survival has been relatively unchanged, and the morbidity and mortality associated with these injuries continue to be very high. First proposed by Shrock et al. in 1968, atriocaval shunt placement remains the gold standard approach for the temporary bypass of these lesions by controlling bleeding from the retrohepatic IVC to allow time for repair prior to exsanguination and death. Despite familiarity with this management strategy for decades, these injuries remain infrequent but continue to have poor survival due to their complexity. There are only rare examples of the use of this approach resulting in successful discharge from the hospital. We present a case report of survival after the successful deployment of an atriocaval shunt in a patient who sustained multiple gunshot wounds to his right thoraco-abdomen, left chest, and upper and lower extremities. He ultimately survived to discharge from the hospital. We provide a brief review of the current literature and propose future approaches to repairs of juxtahepatic IVC injuries.

Stable patients with less severe injuries are not necessarily triaged to high-level trauma centers according to current guidelines. Obese patients are prone to comorbidities and complications. We hypothesized that stable obese patients with low-energy trauma have lower mortality and fewer complications if treated at Level-I/II trauma centers.

There are limited data comparing the severity of traumatic adrenal injury (TAI) and the need for interventions, such as transfusions, hospitalization, or incidence of adrenal insufficiency (AI) and other clinical outcomes. The aim of this study was to analyze the relationship between the grade of TAI and the need for subsequent intervention and clinical outcomes following the injury.After obtaining Institutional Review Board approval, our trauma registry was queried for patients with TAI between 2009 and 2017. Contrast-enhanced computed tomography (CT) examinations of the abdomen and pelvis were evaluated by a board-certified radiologist with subspecialty expertise in abdominal and trauma imaging, and adrenal injuries were classified as either low grade (American Association for the Surgery of Trauma (AAST) grade I-III) or high grade (AAST grade IV-V). Patients without initial contrast-enhanced CT imaging and those with indeterminate imaging findings on initial CT were excluded.A total of 129 patients with 149 TAI were included. Eight-six patients demonstrated low-grade injuries and 43 high grade. Age, gender, and Injury Severity Score (ISS) were not statistically different between the groups. There was an increased number of major vascular injuries in the low-grade vs. high-grade group (23% vs. 5%, p 0.01). No patient required transfusions or laparotomy for control of adrenal hemorrhage. There was no statistical difference in hospital length of stay (LOS), ventilator days, or mortality. Low-grade adrenal injuries were, however, associated with shorter ICU LOS (10 days vs. 16 days, p = 0.03).The need for interventions and clinical outcomes between the low-grade and high-grade groups was similar. These results suggest that, regardless of the TAI grade, treatment should be based on a holistic clinical assessment and less focused on specific interventions directed at addressing the adrenal injury.

Background Despite significant attempts to educate civilians in hemorrhage control, the majority remain untrained. We sought to determine if laypersons can successfully apply one of three commercially available tourniquets; including those endorsed by the United States Military and the American College of Surgeons. Methods Preclinical graduate health science students were randomly assigned a commercially available windless tourniquet: SAM XT, Combat Application Tourniquet (CAT), or Special Operation Forces Tactical Tourniquet (SOFT-T). Each was given up to 1 minute to read package instructions and asked to apply it to the HapMed Leg Tourniquet Trainer. Estimated blood loss was measured until successful hemostatic pressure was achieved or simulated death occurred from exsanguination. Simulation survival, time to read instructions and stop bleeding, tourniquet pressure, and blood loss were analyzed. Results Of the 150 students recruited, 55, 46, and 49 were randomized to the SAM XT, CAT, SOFT-T, respectively. Mean overall simulation survival was less than 66% (65%, 72%, 61%; p = 0.55). Of survivors, all three tourniquets performed similarly in median pressure applied (319, 315, and 329 mm Hg; p = 0.54) and median time to stop bleeding (91, 70, 77 seconds; p = 0.28). There was a statistical difference in median blood loss volume favoring SOFT-T (SAM XT, 686 mL; CAT, 624 mL; SOFT-T, 433 mL; p = 0.03). All 16 participants with previous experience were able to successfully place the tourniquet compared with 81 (62%) of 131 first-time users (p = 0.008). Conclusion No one should die of extremity hemorrhage, and civilians are our first line of defense. We demonstrate that when an untrained layperson is handed a commonly accepted tourniquet, failure is unacceptably high. Current devices are not intuitive and require training beyond the enclosed instructions. Plans to further evaluate this cohort after formal "Stop the Bleed" training are underway.

Marine protected areas are advocated as a key strategy for simultaneously protecting marine biodiversity and supporting coastal livelihoods, but their implementation can be challenging for numerous reasons, including perceived negative effects on human well-being. We synthesized research from 118 peer-reviewed articles that analyse outcomes related to marine protected areas on people, and found that half of documented well-being outcomes were positive and about one-third were negative. No-take, well-enforced and old marine protected areas had positive human well-being outcomes, which aligns with most findings from ecological studies. Marine protected areas with single zones had more positive effects on human well-being than areas with multiple zones. Most studies focused on economic and governance aspects of well-being, leaving social, health and cultural domains understudied. Well-being outcomes arose from direct effects of marine protected area governance processes or management actions and from indirect effects mediated by changes in the ecosystem. Our findings illustrate that both human well-being and biodiversity conservation can be improved through marine protected areas, yet negative impacts commonly co-occur with benefits. While marine protected areas are key for supporting biodiversity and coastal communities, the outcomes can be, and can be perceived, as a mixed bag. Synthesizing research from 118 articles, this Analysis draws broad insights about both the effects of marine protected areas as well as which aspects remain understudied.

Objective: The number and type of patients treated by trauma centers can vary widely because of a number of factors. There might be trauma centers with a high volume of torso GSWs that are not desi...

As the reach of mobile technology grows, it is becoming an increasingly powerful tool for access to welfare enhancing information and services in low- and middle-income countries (LMICs). However, digital inclusion remains far from universal. Across LMICs, 14 per cent of adults still do not own a mobile phone, 39 per cent do not use mobile internet, and 38 per cent do not own a smartphone. Among other characteristics, these digitally excluded individuals are predominantly female. This study seeks to better understand the key drivers of mobile ownership, mobile internet, and smartphone use, with a particular focus on gender. Discrete-choice models, including logit, probit and linear models, are used to estimate the probability of adoption of these three types of technology. By including a suite of control variables for observable drivers of mobile adoption (e.g. education levels, age, employment, rural-urban location), the coefficient for gender represents non-observable effects which could be a product of discrimination and cultural norms. Furthermore, importance is placed on the inclusion of interaction terms in the regressions (for example, gender interacted with rural location), in order to isolate different degrees of marginalisation across the female population. In addition to the focus on gender, the marginal effects of the dependent variables for other factors (such as geography, education, employment, and age) will aid understanding of the key predictors of mobile use more generally. This research also shows how these predictors might vary by country and region, how they relate to each other, and which are the most important. This will provide relevant and important information for policymakers. The research makes use of multiple years (2017, 2018, and 2019) of data from face-to-face consumer surveys sourced from the GSMA, which includes nationally representative samples of at least 1,000 respondents for 31 low- and middle-income countries. The wide geographic scope, and multi-year nature of the survey data results in a unique contribution to the literature, and the substantial number of observations allows for novel analysis of intersections of the female population. In summary, the initial results find that: women are 5 percentage points (pp) less likely to own a mobile phone then men, 6pp less likely to use mobile internet, and 4pp less likely to own a smartphone, even when other relevant socioeconomic and demographic factors are controlled for. This unobservable gender effect is more pronounced in certain regions, especially South Asia, but with no significant link in Latin America and Caribbean. The marginal effects of the interaction variables indicate that the negative impact is enhanced for women that live in rural areas, have low levels of literacy, and are not working. In addition, this study finds that the probability of mobile technology adoption increases (with varying magnitudes by technology type and region) with income, education, urban location, literacy, and employment. Adoption of mobile technology largely declines with age, but the impact generally does not appear to start until age 45 and above for mobile ownership.

Marine spatial planning (MSP) is occurring throughout the world, as communities and nation-states seek to resolve spatial conflicts and competition in coastal areas and reduce the impacts of human uses on marine biodiversity. The Marine Plan Partnership (MaPP) in British Columbia, Canada, is a successful example of collaborative marine planning between First Nations governments and the British Columbia provincial government, achieving the protection of ecological and cultural values, while supporting sustainable economic activities. The collaborative planning process was pre-dated by territorial marine planning by each participating First Nation, which allowed for the protection of First Nations governance and economy, cultural values and activities, and resource management priorities.