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Purpose of program: The ongoing shortage of organs for transplant combined with the highest prevalence of end-stage kidney disease (ESKD) in Canada has resulted in long wait times for a deceased donor transplant in Manitoba. Therefore, the Transplant Manitoba Adult Kidney Program has ongoing quality improvement initiatives to expand the deceased donor pool. This clinical transplant protocol describes an age-targeted program intended to increase the use of transplants with a kidney donor profile index (KDPI) >85 by allocating them to suitable pre-consented recipients age ≥65 with low wait times. The goal is to improve survival and quality of life for older recipients by maximizing a previously under-utilized donor pool. Sources of information: Scoping literature review; Transplant Manitoba deceased donor audit; and key stakeholder engagement with patient partners, inter-disciplinary health care providers, and health system leaders. Methods: The alternative donor pool criteria include deceased donor kidneys with KDPI 86-100 or another concern for graft longevity but are otherwise suitable for transplantation. Patients with no living donor, age ≥65, low wait times and otherwise eligible for transplant listing will be educated, and if suitable, pre-consented for the age-targeted program. All patients remain eligible for a standard criteria donor according to the local allocation criteria. The age-targeted program waitlist follows the same provincial allocation rules using wait time, panel reactive antibody (PRA), and human leukocyte antigen (HLA) match points for determining rank order. If an age-targeted recipient experiences early graft loss from a KDPI 86-100 kidney within 12 months from transplant, their cumulative wait time, including time with the transplant, will be reinstated upon relisting. Key findings: Transplant Manitoba’s provincial allocation rules do not permit bypassing top of the list recipients for kidney offers; therefore, transplant providers were previously reluctant to utilize KDPI 86-100 donor kidneys to top of the list recipients eligible for higher quality kidneys. This age-targeted program facilitates allocation of KDPI 86-100 kidneys to suitable older pre-consented recipients with low wait times, who may obtain a survival and quality of life benefit from these transplants. This approach expands the utilized deceased donor pool to benefit all Manitobans awaiting a deceased donor kidney transplant. Limitations: This program was launched in January 2023, and there are no data reported on outcomes given the small numbers and abbreviated follow-up. Implications: The goal of this quality improvement project is to improve access to deceased donor kidney transplantation for Manitobans with ESKD. This program was developed with patient and provider feedback, including multimedia patient education materials which may be helpful for other programs. We anticipate this program is a safe and effective way to expand access to deceased donor kidney transplantation using a previously under-utilized donor pool.

Summary: Response to threatening environmental stimuli requires detection and encoding of important environmental features that dictate threat. Aversive events are highly salient, which promotes associative learning about stimuli that signal this threat. The nucleus accumbens is uniquely positioned to process this salient, aversive information and promote motivated output, through plasticity on the major projection neurons in the brain area. We describe a nucleus accumbens core local circuit whereby excitatory plasticity facilitates learning and recall of discrete aversive cues. We demonstrate that putative nucleus accumbens substance P release and long-term excitatory plasticity on dopamine 2 receptor-expressing projection neurons are required for cue-dependent fear learning. Additionally, we find that fear learning and recall is dependent on distinct projection neuron subtypes. Our work demonstrates a critical role for nucleus accumbens substance P in cue-dependent aversive learning.

Abstract High-calorie diets increase the risk of developing obesity, cardiovascular disease, type-two diabetes (T2D), and other comorbidities. These “overnutrition” diets also promote the accumulation of a variety of harmful lipids in the heart and other peripheral organs, known as lipotoxicity. However, the mechanisms underlying lipotoxicity and its influence on pathophysiology remain unknown. Our study uses genetics to identify the role of ether lipids, a class of potential lipotoxins, in a Drosophila model of overnutrition. A high-sugar diet (HSD) increases ether lipids and produces T2D-like pathophysiology phenotypes, including obesity, insulin resistance, and cardiac failure. Therefore, we targeted ether lipid biosynthesis through the enzyme dihydroxyacetonephosphate acyltransferase (encoded by the gene DHAPAT). We found that reducing DHAPAT in the fat body improved TAG and glucose homeostasis, cardiac function, respiration, and insulin signaling in flies fed a HSD. The reduction of DHAPAT may cause a switch in molecular signaling from lipogenesis to fatty acid oxidation via activation of a PPARα-like receptor, as bezafibrate produced similar improvements in HS-fed flies. Taken together, our findings suggest that ether lipids may be lipotoxins that reduce fitness during overnutrition.

Despite containing the largest extent of unfragmented landscape in the Asian elephant (Elephas maximus) range, Myanmar has high levels of human–elephant conflict. The Bago Yoma mountain region of central Myanmar has previously been identified as an elephant conflict hotspot, characterized by high levels of crop-raiding and illegal killing of elephants for the ivory and skin trades. We used non-invasive fecal sampling to evaluate the population structure and demography of wild and captive elephants in the Bago Yoma using microsatellite loci and mitochondrial DNA in combination with crop-raiding status, age, and sex. We were able to collect 252 samples from wild elephants –119 directly following conflict events– and 25 from captive elephants from which we identified 127 unique wild and 21 captive individuals. The population was biased toward subadults, which could be an important contributor to the high rates of conflict, as these individuals may lack the experience to avoid dangerous behaviors. Conflict elephants were primarily male, although both sexes and all ages engaged in crop-raiding, including females with juveniles. We found that elephants that commit solo raids were all male, while larger raiding parties often included both related and unrelated individuals of both sexes. Repeat offenders were common. These wild elephants contained high levels of genetic diversity, differentiated from local captive populations, and valuable for the species’ conservation. Overall, the elephants of Bago Yoma, Myanmar have been heavily affected by conflict, and managers could utilize the knowledge presented to aid in the preservation of this population.

Human-wildlife conflict has direct and indirect consequences for human communities. Understanding how both types of conflict affect communities is crucial to developing comprehensive and sustainable mitigation strategies. We conducted an interview survey of 381 participants in two rural areas in Myanmar where communities were exposed to human-elephant conflict (HEC). In addition to documenting and quantifying the types of direct and indirect impacts experienced by participants, we evaluated how HEC influences people's attitudes towards elephant conservation. We found that 99% of participants suffered from some type of indirect impact from HEC, including fear for personal and family safety from elephants and fear that elephants will destroy their home. Despite experiencing moderate levels of indirect impacts from HEC at the community level, participants expressed attitudes consistent with supporting future elephant conservation programs.

Promoting human-wildlife coexistence is critical to the long-term conservation of many wild animal species that come into conflict with humans. Loss of livestock to carnivore species (e.g., lions, tigers, wolves) is a well-documented occurrence and the focus of mitigation strategies around the world. One area that has received little research is the impact of noncarnivores on livestock. Both African and Asian elephant species are known to cause livestock injuries and deaths. Livestock owners within elephant ranges perceive elephants as a risk to their livestock, which may reduce their tolerance towards elephants and jeopardize conservation efforts in the area. Though feral hogs may not be of conservation concern, these animals contribute significant losses to farmers' livelihoods. We advocate for the inclusion of noncarnivore species in policies that promote livestock protection because it will allow for better communication regarding effective strategies and more application in the field.

In the southern Bago Yoma mountain range in Myanmar, Asian elephants are being killed at a disturbing rate. This emerging crisis was identified initially through a telemetry study when 7 of 19 of collared elephants were poached within a year of being fitted with a satellite-GPS collar. Subsequent follow up of ground teams confirmed the human caused death or disappearance of at least 19 elephants, including the seven collared individuals, within a 35 km2 area in less than two years. The carcasses of 40 additional elephants were found in areas located across south-central Myanmar once systematic surveys began by our team and collaborators. In addition to the extreme rate of loss, this study documents the targeting of elephants for their skin instead of the more common ivory, an increasing trend in Myanmar. Intensive research programs focused on other conservation problems identified this issue and are now encouraging local authorities to prioritize anti-poaching efforts and improve conservation policies within the country. Myanmar represents one of the last remaining countries in Asia with substantial wildlands suitable for elephants. Increasing rates of human-elephant conflict and poaching events in this country pose a dire threat to the global population.

Abstract Introduction This resource is a small-group activity aimed to facilitate discussions after a viewing of the Emmy award-winning movie “Wit.” The facilitator's guide and accompanying materials will enable faculty to lead small groups to effectively discuss breaking bad news, death and dying, do-not-resuscitate (DNR) orders, and clinical research trials after showing the movie. Methods A student handout, paper topics, and exam questions are included. It is strongly recommended that this lesson be timed to coincide with the students' advanced cardiovascular life support training, as it includes discussion of when to raise the question of DNR with patients based on realistic outcomes of CPR for patients with an underlying life-threatening illness. Results This activity has been a required 3-hour-long class for second-year medical students for the past 3 consecutive years. The movie is very effective in dramatizing the human toll that results from poor informed consent and deferring the DNR discussion. Discussion The small groups give students a chance to process their feelings and apply them to both the clinical ethics topics (DNR, palliative care) and the research ethics topics (informed consent, therapeutic misconception, right to withdraw from a study). The only limitation to this resource is that instructors must buy or rent a copy of the film.

BACKGROUND: In 2000, Ontario, Canada, initiated a universal influenza immunization program (UIIP) to provide free influenza vaccines for the entire population aged 6 mo or older. Influenza immunization increased more rapidly in younger age groups in Ontario compared to other Canadian provinces, which all maintained targeted immunization programs. We evaluated the effect of Ontario's UIIP on influenza-associated mortality, hospitalizations, emergency department (ED) use, and visits to doctors' offices. METHODS AND FINDINGS: Mortality and hospitalization data from 1997 to 2004 for all ten Canadian provinces were obtained from national datasets. Physician billing claims for visits to EDs and doctors' offices were obtained from provincial administrative datasets for four provinces with comprehensive data. Since outcomes coded as influenza are known to underestimate the true burden of influenza, we studied more broadly defined conditions. Hospitalizations, ED use, doctors' office visits for pneumonia and influenza, and all-cause mortality from 1997 to 2004 were modelled using Poisson regression, controlling for age, sex, province, influenza surveillance data, and temporal trends, and used to estimate the expected baseline outcome rates in the absence of influenza activity. The primary outcome was then defined as influenza-associated events, or the difference between the observed events and the expected baseline events. Changes in influenza-associated outcome rates before and after UIIP introduction in Ontario were compared to the corresponding changes in other provinces. After UIIP introduction, influenza-associated mortality decreased more in Ontario (relative rate [RR] = 0.26) than in other provinces (RR = 0.43) (ratio of RRs = 0.61, p = 0.002). Similar differences between Ontario and other provinces were observed for influenza-associated hospitalizations (RR = 0.25 versus 0.44, ratio of RRs = 0.58, p < 0.001), ED use (RR = 0.31 versus 0.69, ratio of RRs = 0.45, p < 0.001), and doctors' office visits (RR = 0.21 versus 0.52, ratio of RRs = 0.41, p < 0.001). Sensitivity analyses were carried out to assess consistency, specificity, and the presence of a dose-response relationship. Limitations of this study include the ecological study design, the nonspecific outcomes, difficulty in modeling baseline events, data quality and availability, and the inability to control for potentially important confounders. CONCLUSIONS: Compared to targeted programs in other provinces, introduction of universal vaccination in Ontario in 2000 was associated with relative reductions in influenza-associated mortality and health care use. The results of this large-scale natural experiment suggest that universal vaccination may be an effective public health measure for reducing the annual burden of influenza.

Introduction: Africa is the least motorized populated continent, yet it experiences the highest traffic fatality rate. Despite laws mandating helmet and seatbelt use, data on protective gear use among Cameroonian road traffic injury (RTI) patients remains sparse., Methods: We extracted Cameroon Trauma Registry data prospectively collected from 10 hospitals during July 2022 to December 2023. Protective gear users wore helmets in motorcycle and seatbelts/car seats in vehicle crashes. We categorized patients into five economic clusters based on ownership of durable goods using parallel distance matrix computation. We analyzed associations between continuous variables with Wilcoxon rank-sum and categorical variables with χ2 and multivariate logistic regression. Our primary outcome was in-hospital death or major disability at discharge., Results: Among 3,554 RTI patients, 303 (9%) used protective gear. A larger proportion of patients who did not use protective gear were designated as majorly disabled or dead (20% vs. 16%, p < 0.001). The greatest percentage of protective gear users belonged to the richest cluster, while the poorest cluster patients comprised the smallest proportion of protective gear users (13% vs. 3%, p < 0.001). The richest cluster demonstrated the smallest percentage of major disability or death (13%), while the poorest cluster had the greatest percentage (28%, p < 0.001). When controlling for age, protective gear use, and injury severity, the three poorest clusters showed the greatest odds of major disability or death (cluster 3: adjusted odds ratio [AOR], 2.34; 95% confidence interval [CI], 1.58-3.46; cluster 4: AOR, 2.09; 95% CI, 1.59-2.74; cluster 5: AOR, 2.38; 95% CI, 1.24-4.58)., Conclusion: Greater economic status is associated with increased protective gear use during RTIs in Cameroon. Despite suffering the most severe outcomes, the poorest patients remain less likely to use protective gear. Enforcement of protective gear laws and economic incentives such as price subsidies for helmets and seatbelts would particularly benefit the most vulnerable population., Level of Evidence: Retrospective Comparative Study; Level IV., (Copyright © 2025 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Surgery of Trauma.)

Background: Thoracic trauma is the third most common cause of death after abdominal injury and head trauma in polytrauma patients. The identification of a patient at risk of thoracic trauma mortality is necessary to avoid delays that may lead to morbidity and mortality. Therefore, the objective was to assess the factors associated with mortality among thoracic trauma patients in Cameroon., Materials and Methods: This is a retrospective analysis of the Cameroon Trauma Registry currently running in 10 pilot hospital sites across seven of the ten regions. We retrieved data for all patients with thoracic trauma between the period June 2022 to May 2023 and analyzed factors associated to mortality using multivariate logistic regression. Statistical significance was set at p-value <0.05., Results: Out of 4851 trauma patients, 642 (13.2 %) presented with thoracic trauma. Over 80 % were males and the majority [168 (26.2 %)] were within the age group of 25-34 years. The most common injury mechanism was Road Traffic Injury (RTI). Overall thoracic trauma mortality rate was 9 % with road traffic Injury being the commonest mechanism. Factors associated to thoracic trauma mortality were abnormal chest movement and respiration [(AOR = 5.18, 95 % CI = 1.89-14.19, P = 0.001) and (AOR = 4.72, 95 % CI = 1.44-15.42, P = 0.01) respectively]. Tracheal deviation, breath sounds and respiration were other factors associated with mortality., Conclusion: This analysis highlights thoracic trauma in Cameroon and its contribution to the overall injury death toll. Abnormal chest movement and respiration were factors associated with mortality among thoracic trauma patients. To improve the health outcomes, it is important to understand the treatment logic, involve thoracic surgeons and a multidisciplinary team to improve diagnosis and management., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence this research., (© 2024 Published by Elsevier Ltd.)

Background: In low- and middle-income countries, trauma is the leading cause of death among youth and it is also a major cause of disability. Globally, more than 1,600 children and adolescents below the age of 19-years die every day from preventable injuries. Traffic-related injuries, falls, sports-related injuries, assaults, burns, and drownings are the most commonly reported causes of traumatic mortality among children. The mechanism of injury is always diverse in different contexts due to the differences in social determinants of health., Objectives: To determine the epidemiological pattern of trauma among children 0-9 years in Cameroon., Methods: This is a retrospective analysis of prospectively collected data from the Cameroon Trauma Registry currently running in 10 pilot sites across seven of the ten regions of Cameroon. We retrieved data for all children aged 0-9 years from June 2022 to August 2023. Data was analyzed with respect to the demographics, injury characteristics and outcomes., Results: Of the 5,439 patients captured in the trauma registry, 267 (4.9%) were children aged 0-9 years. Over 50% (152/267) of the patients were males with 35% (93/267) from rural settings. The top injury mechanism was road traffic injuries (RTI) [137(52.1%)]. These injuries occurred on the streets [142(53.4%)] during leisure activities [205(78.5%)]. Majority of children [104(39%)] involved in RTI injuries were pedestrians and no prehospital care offered to 216(82.8%) of injured children. A total of 39 (16.9%) were discharged with major disability, 111 (48.1%) had limited ability to move and 5 (2.2%) demised or succumbed to their injuries. There was a significant association between injury activity and gender (P = 0.006). Unlike the females, majority of the males were discharged with major disability [21 (53.8%)]., Conclusion: This preliminary analysis highlights the burden of trauma among children aged 0-9 years and its contribution to the proportion of disabled persons in Cameroon. Leisure activities on the streets increased the number of pediatric injuries especially among males. It is therefore imperative to put in place or reinforce environmental interventions to reduce the burden of pediatric injuries., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Background: Adverse events reviews are a fundamental component of trauma quality improvement (QI) that facilitate the correction of systemic issues in care. Although injury-related mortality in Cameroon is substantial, to our knowledge, opportunities for QI have not been formally assessed. Thus, a formal review of adverse events in Cameroonian trauma patients was implemented as a first step toward identifying targets for systems modification., Methods: A QI committee composed of multidisciplinary experts at four hospitals in Cameroon was formed to review adverse events including deaths among trauma patients from 2019 to 2021. Events were discussed at newly established morbidity and mortality conferences and committee meetings to identify contributing factors and overall preventability., Results: During 50 meetings, 95 adverse events were reviewed, including 58 deaths (61%). Other adverse events were delays in diagnosis/treatment (22%) and surgical site infections (17%). Overall, 34 deaths (59%) were classified as preventable, 21% potentially preventable, and 21% not preventable. Over half (52%) of the 46 preventable or potentially preventable deaths occurred in the emergency department (ED); while brain injury (57%), respiratory failure (41%), and hemorrhage (39%) were the most frequent physiologic factors associated with mortality. Contributory factors identified include lack of a structured approach to patient management, absence of continuous training for personnel, and locally adapted protocols., Conclusions: Basic improvements in evaluation and management of life-threatening issues in the ED can significantly reduce the high rate of preventable trauma-related deaths across Cameroon. Formal trauma QI methods can be utilized in low-resource environments to determine mortality root causes and identify intervention targets., (© 2024 The Author(s). World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Cameroon is amongst the worst affected countries by road traffic injuries with an estimated 1443 disability-adjusted life years per 100,000 population. There have been very limited reports on the crucial prehospital response to road traffic injuries in Cameroon. This study aimed to identify prehospital factors associated with RTI mortality in Cameroon., Methods: We included patients enrolled between June 2022 and March 2023 in the Cameroon Trauma Registry. Information about prehospital factors and demographic data was obtained from patients or their proxies. We examined the association of prehospital care factors like care at the crash scene and type of transportation during crash with final patient outcome. We used Chi-squared test to investigate the association between selected independent variables and mortality. A multivariable logistic regression model was built to identify independent predictors of dying from an RTI., Results: RTIs constituted 69.5% (n = 3203) of all injuries in the Cameroon Trauma Registry. Only 20.7% (n = 102) of 4 + wheel vehicle occupants had seatbelts on and just 2.7% (n = 53) of motorcycle riders were wearing helmets during the collision. Only 4.9% (n = 156) of patients received any form of scene care. In-hospital mortality was 4.3% (n = 139) and was associated with male sex (AOR = 1.7, 95%CI = 1.08-2.80), crashing on a motorcycle (AOR = 2.08, 95%CI = 1.1-3.67) and scene care (AOR = 0.25, 95%CI = 0.04-0.80)., Conclusions: Receiving any type of care at the scene such as bleeding control or being placed in the recovery position by bystanders is associated with improved survival. Improving on existing informal prehospital care responses should be a priority in Cameroon., (© 2024. The Author(s).)

Background: Global surgery research efforts have been criticized for failure to transition from problem identification to intervention implementation. We developed a context-appropriate trauma quality improvement (TQI) bundle to ameliorate care gaps at a regional referral hospital in Cameroon. We determined associations between bundle implementation and improvement in trauma resuscitation practices., Methods: We implemented a TQI bundle consisting of a hospital-specific trauma protocol, staff training, a trauma checklist, provision of essential emergency trauma supplies in the resuscitation area, and monthly quality improvement meetings. We compared trends in target process measures (e.g., frequency and timing of vital sign collection and primary survey interventions) in the six-month period pre- and post-bundle implementation using Wilcoxon rank-sum and Fisher's exact tests., Results: We compared 246 pre-bundle patients with 203 post-bundle patients. Post-bundle patients experienced a greater proportion of all vital signs collected compared to the pre-intervention cohort (0 % pre-bundle vs. 69 % post-bundle, p < 0.001); specifically, the proportion of respiratory rate (0.8 % pre-bundle vs. 76 % post-bundle, p < 0.001) and temperature (7 % pre-bundle vs. 91 % post-bundle, p < 0.001) vital sign collection significantly increased. The post-bundle cohort had vital signs measured sooner (74 % vital signs measured within 15 min of arrival pre-bundle vs. 90 % post-bundle, p < 0.001) and more frequently per patient (7 % repeated vitals pre-bundle vs 52 % post-bundle, p < 0.001). Key primary survey interventions such as respiratory interventions (1 % pre-bundle vs. 8 % post-bundle, p < 0.001) and cervical collar placement (0 % pre-bundle vs. 7 % post-bundle, p < 0.001) also increased in the post-bundle cohort., Conclusions: The implementation of a context-appropriate TQI bundle was associated with significant improvements in previously identified trauma care deficits at a single regional hospital. Data-derived interventions targeting frontline capacity at the local level can bridge the gap between identifying care limitations and improvement in resource-limited settings., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Mark T. Yost and Dennis J. Zheng report financial support was provided by National Institutes of Health Fogarty International Center (award number D43TW009343) and the University of California Global Health Institute. Mark T. Yost reports financial support was provided by the H & H Lee Research Program and LB Research and Education Foundation. Catherine Juillard, Alain Chichom-Mefire, and S. Ariane Christie report financial support was provided by National Institutes of Health (award number U54TW012087). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH., (Copyright © 2024. Published by Elsevier Ltd.)

There is a strong need to critically consider the neocolonial context when discussing the impact evaluation of Eemergency Medical Services (EMS) systems in many low to middle-income countries. Many of these countries have faced exploitation and settler colonialism, and in today's world the aftermath of these political-economic unequal power dynamics persists through neocolonialism. "Solutions" to prehospital care and related donor-driven development sector aid programs are typically orchestrated by high-income countries in the Global North, many of whom directly benefited from centuries of colonizing the Global South. This perpetuates the financial and technocratic dependency of many low to middle-income countries. Traditional Global North-led impact assessment typically revolves around mortality outcomes. This is problematic because singularly tracking mortality can obscure the influence of important factors at play beyond the emergency response incident itself, such as morbidity and socioeconomic privilege. This is why process indicators such as response times and economic impacts on first responders and communities are crucial. Hence, instead of trying to develop a one-size-fits-all impact assessment criteria for all the diverse prehospital care system contexts across the world, it is important to focus on enabling bottom-up, community-led, and participatory approaches to finding context-tailored solutions. A key element of this should be the co-creation of the measures of success themselves with the community stakeholders. Such a decolonial holistic approach may then help put the spotlight on often neglected important measures, such as the inclusion of underprivileged minorities in emergency response and the level of protection against catastrophic health care expenditure built into EMS systems. In doing so, it can encourage a monitoring and evaluation shift from short-term mortality to long-term wellbeing, taking into account cultural contexts about what "wellbeing" entails. Furthermore, it is important to challenge the taken-for-granted notion that in low to middle-income countries, EMS systems are solely for trauma and medical emergencies. It is also important to consider (with the dialogue led by the local stakeholders) what sustainability would look like, and how resources accordingly should be allocated, in those regions in low to middle-income countries where there is political and economic volatility as a consequence of continuing neocolonial hegemony., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Despite high injury mortality rates, Cameroon currently lacks a formal prehospital care system. In other sub-Saharan African low and middle-income countries, Lay First Responder (LFR) programs have trained non-medical professionals with high work-related exposure to injury in principles of basic trauma care. To develop a context-appropriate LFR program in Cameroon, we used trauma registry data to understand current layperson bystander involvement in prehospital care and explore associations between current non-formally trained bystander-provided prehospital care and clinical outcomes. The Cameroon Trauma Registry (CTR) is a longitudinal, prospective, multisite trauma registry cohort capturing data on injured patients presenting to four hospitals in Cameroon. We assessed prevalence and patterns of prehospital scene care among all patients enrolled the CTR in 2020. Associations between scene care, clinical status at presentation, and outcomes were tested using univariate and multivariate logistic regression. Injury severity was measured using the abbreviated injury score. Data were analyzed using Stata17. Of 2212 injured patients, 455 (21%) received prehospital care (PC) and 1699 (77%) did not receive care (NPC). Over 90% (424) of prehospital care was provided by persons without formal medical training. PC patients were more severely injured (p<0.001), had markers of increased socioeconomic status (p = 0.01), and longer transport distances (p<0.001) compared to NPC patients. Despite increased severity of injury, patients who received PC were more likely to present with a palpable pulse (OR = 6.2, p = 0.02). Multivariate logistic regression adjusted for injury severity, socioeconomic status and travel distance found PC to be associated with reduced emergency department mortality (OR = 0.14, p<0.0001). Although prehospital injury care in Cameroon is rarely performed and is provided almost entirely by persons without formal medical training, prehospital intervention is associated with increased early survival after injury. Implementation of LFR training to strengthen the frequency and quality of prehospital care has considerable potential to improve trauma survival., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 O’Connor et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: We analyzed resuscitation practices in Cameroonian patients with trauma as a first step toward developing a context-appropriate resuscitation protocol. We hypothesized that more patients would receive crystalloid-based (CB) resuscitation with a faster time to administration than blood product (BL) resuscitation., Methods: We included patients enrolled between 2017 and 2019 in the Cameroon Trauma Registry (CTR). Patients presenting with hemorrhagic shock (systolic blood pressure (SBP) <100 mm Hg and active bleeding) were categorized as receiving CB, BL, or no resuscitation (NR). We evaluated differences between cohorts with the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. We compared time to treatment with the Wilcoxon rank sum test., Results: Of 9635 patients, 403 (4%) presented with hemorrhagic shock. Of these, 278 (69%) patients received CB, 39 (10%) received BL, and 86 (21%) received NR. BL patients presented with greater injury severity (Highest Estimated Abbreviated Injury Scale (HEAIS) 4 BL vs 3 CB vs 1 NR, p<0.001), and lower median hemoglobin (8.0 g/dL BL, 11.4 g/dL CB, 10.6 g/dL NR, p<0.001). CB showed greater initial improvement in SBP (12 mm Hg CB vs 9 mm Hg BL vs 0 NR mm Hg, p=0.04) compared with BL or no resuscitation, respectively. Median time to treatment was lower for CB than BL (12 vs 131 min, p<0.01). Multivariate logistic regression adjusted for injury severity found no association between resuscitation type and mortality (CB adjusted OR (aOR) 1.28, p=0.82; BL aOR 1.05, p=0.97)., Conclusions: CB was associated with faster treatment, greater SBP elevation, and similar survival compared with BL in Cameroonian patients with trauma with hemorrhagic shock. In blood-constrained settings, treatment delays associated with blood product transfusion may offset the physiologic benefits of an early BL strategy. CB prior to definitive hemorrhage control in this resource-limited setting may be a necessary strategy to optimize perfusion pressure., Level of Evidence and Study Type: III, retrospective study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Lack of routine follow-up for trauma patients after hospital discharge likely contributes to high rates of injury-related complications in Cameroon. Mobile phone contact may facilitate timely follow-up and reduce disability for high-risk patients. A previous single-center study showed promising feasibility of mobile health (mHealth) triage, but generalizability remains unknown. We evaluated the feasibility and acceptability of implementing a postdischarge mHealth triage tool at four hospitals in Cameroon., Methods: Trauma patients from four Cameroonian hospitals were contacted at 2 weeks, 1, 3, and 6 months postdischarge. Program feasibility was assessed by calculating the proportion of successful contacts and overall cost. Odds of successful contact were compared using generalized estimating equations across patient socioeconomic status. Acceptability was assessed using a structured patient survey at 2 weeks and 6 months postdischarge., Results: Of 3896 trauma patients, 59% were successfully contacted at 2 weeks postdischarge. Of these, 87% (1370/1587), 86% (1139/1330), and 90% (967/1069) were successfully reached at the 1-month, 3-month, and 6-month timepoints, respectively. The median cost per patient contact was US$3.17 (IQR 2.29-4.29). Higher socioeconomic status was independently associated with successful contact; rural poor patients were the least likely to be reached (adjusted OR 0.11; 95% CI 0.04 to 0.35). Almost all surveyed patients reported phone-based triage to be an acceptable follow-up method., Conclusion: Telephone contact is a feasible and acceptable means to triage postdischarge trauma patients in Cameroon. While scaling an mHealth follow-up program has considerable potential to decrease injury morbidity in this setting, further research is needed to optimize inclusion of socioeconomically marginalized groups., Level of Evidence: Level III, prospective observational study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Routine in-person follow-up for injured patients after hospital discharge is unfeasible in low- and middle-income countries where trauma morbidity and mortality are the highest. Mobile technology screening may facilitate early detection of complications and timely treatment. In this prospective, multisite implementation study, we cross-validate the performance of a cellphone screening tool developed to risk stratify trauma patients in need of further care after discharge in Cameroon., Methods: Between June 2019 and August 2022, research assistants contacted trauma patients by cellphone 2 weeks after discharge to administer a 14-question follow-up survey. All surveyed patients were asked to return for a physical examination. Physicians blinded to survey results categorized patients as low or moderate or high risk (HR) for poor outcomes without further care. Logistic regression tested associations between each survey question and physician examination. Predictive survey questions generated a preliminary model with high sensitivity for identifying patients in need of further care., Results: Of 1,712 successfully contacted patient households, 96% (1643) participated in telephone triage compared with 33% (560) who returned for physician examination. Physicians designated 39% (220) as being HR. On multiple logistic regression, 8 of 13 candidate triage questions were independently associated with HR. Positive survey response on the resultant eight question screen yielded 89.2% sensitivity for HR with a 10.8% false negative rate. Weighted for variable importance based on triage risk scores, 39% of triaged patients screened as low risk, 39% as moderate risk, and 22% as high risk for HR. Likelihood of HR was significantly greater for patients screening as high (odds ratio, 5.9) or moderate risk (odds ratio, 1.9; both p < 0.01)., Conclusion: Cellphone triage provides sensitive risk stratification of patients in need of further care after hospital discharge in Cameroon. Given low in-person return rates, limited resources should highly prioritize efforts to repatriate patients screening as high risk for poor outcomes., Level of Evidence: Therapeutic/Care Management; Level III., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Despite having the highest rates of injury-related mortality in the world, trauma system capacity in sub-Saharan Africa remains underdeveloped. One barrier to prompt diagnosis of injury is limited access to diagnostic imaging. As part of a larger quality improvement initiative and to assist priority setting for policy makers, we evaluated trauma outcomes among patients who did and did not receive indicated imaging in the Emergency Department (ED). We hypothesize that receiving imaging is associated with increased early injury survival. We evaluated patterns of imaging performance in a prospective multi-site trauma registry cohort in Cameroon. All trauma patients enrolled in the Cameroon Trauma Registry (CTR) between 2017 and 2019 were included, regardless of injury severity. Patients prescribed diagnostic imaging were grouped into cohorts who did and did not receive their prescribed study. Patient demographics, clinical course, and outcomes were compared using chi-squared and Kruskal-Wallis tests. Multivariate logistic regression was used to explore associations between radiologic testing and survival after injury. Of 9,635 injured patients, 47.5% (4,574) were prescribed at least one imaging study. Of these, 77.8% (3,556) completed the study (COMPLETED) and 22.2% (1,018) did not receive the prescribed study (NC). Compared to COMPLETED patients, NC patients were younger (p = 0.02), male (p<0.01), and had markers of lower socioeconomic status (SES) (p<0.01). Multivariate regression adjusted for age, sex, SES, and injury severity demonstrated that receiving a prescribed study was strongly associated with ED survival (OR 5.00, 95% CI 3.32-7.55). Completing prescribed imaging was associated with increased early survival in injured Cameroonian patients. In a resource-limited setting, subsidizing access to diagnostic imaging may be a feasible target for improving trauma outcomes., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Driban et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Injury-related deaths overwhelmingly occur in low and middle-income countries (LMICs). Community-based injury surveillance is essential to accurately capture trauma epidemiology in LMICs, where one-third of injured individuals never present to formal care. However, community-based studies are constrained by the lack of a validated surrogate injury severity metric. The primary objective of this bipartite study was to cross-validate a novel community-based injury severity (CBS) scoring system with previously-validated injury severity metrics using multi-center trauma registry data. A set of targeted questions to ascertain injury severity in non-medical settings-the CBS test-was iteratively developed with Cameroonian physicians and laypeople. The CBS test was first evaluated in the community-setting in a large household-based injury surveillance survey in southwest Cameroon. The CBS test was subsequently incorporated into the Cameroon Trauma Registry, a prospective multi-site national hospital-based trauma registry, and cross-validated in the hospital setting using objective injury metrics in patients presenting to four trauma hospitals. Among 8065 surveyed household members with 503 injury events, individuals with CBS indicators (CBS+) were more likely to report ongoing disability after injury compared to CBS- individuals (OR 1.9, p = 0.004), suggesting the CBS test is a promising injury severity proxy. In 9575 injured patients presenting for formal evaluation, the CBS test strongly predicted death in patients after controlling for age, sex, socioeconomic status, and injury type (OR 30.26, p<0.0001). Compared to established injury severity scoring systems, the CBS test comparably predicts mortality (AUC: 0.8029), but is more feasible to calculate in both the community and clinical contexts. The CBS test is a simple, valid surrogate metric of injury severity that can be deployed widely in community-based surveys to improve estimates of injury severity in under-resourced settings., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Tupper et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Mortality prediction aids clinical decision-making and is necessary for trauma quality improvement initiatives. Conventional injury severity scores are often not feasible in low-resource settings. We hypothesize that clinician assessment will be more feasible and have comparable discrimination of mortality compared to conventional scores in low and middle-income countries (LMICs)., Methods: Between 2017 and 2019, injury data were collected from all injured patients as part of a prospective, four-hospital trauma registry in Cameroon. Clinicians used physical exam at presentation to assign a highest estimated abbreviated injury scale (HEAIS) for each patient. Discrimination of hospital mortality was evaluated using receiver operating characteristic curves. Discrimination of HEAIS was compared with conventional scores. Data missingness for each score was reported., Results: Of 9,635 presenting with injuries, there were 206 in-hospital deaths (2.2%). Compared to 97.5% of patients with HEAIS scores, only 33.2% had sufficient data to calculate a Revised Trauma Score (RTS) and 24.8% had data to calculate a Kampala Trauma Score (KTS). Data from 2,328 patients with all scores was used to compare models. Although statistically inferior to the prediction generated by RTS (AUC 0.92-0.98) and KTS (AUC 0.93-0.99), HEAIS provided excellent overall discrimination of mortality (AUC 0.84-0.92). Among 9,269 patients with HEAIS scores was strongly predictive of mortality (AUC 0.93-0.96)., Conclusion: Clinical assessment of injury severity using HEAIS strongly predicts hospital mortality and far exceeds conventional scores in feasibility. In contexts where traditional scoring systems are not feasible, utilization of HEAIS could facilitate improved data quality and expand access to quality improvement programming., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Yost et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction: Extremity injuries are a leading cause of morbidity in low- and middle-income countries (LMICs), often resulting in marked short-term and long-term disabilities. Most of the existing knowledge on these injuries originates from hospital-based studies; however, poor access to health care in LMICs limits these data because of inherent selection bias. This subanalysis of a larger population-level cross-sectional study in the Southwest Region of Cameroon aims to determine patterns of limb injury, treatment-seeking behaviors, and predictors of disability., Methods: Households were surveyed in 2017 on injuries and subsequent disability sustained over the previous 12 months using a three-stage cluster sampling framework. Subgroups were compared using the chi square, Fisher exact, analysis of variance, Wald, and Wilcoxon rank-sum tests. Logarithmic models were used to identify predictors of disability., Results: Of 8,065 subjects, 335 persons (4.2%) sustained 363 isolated limb injuries. Over half of the isolated limb injuries (55.7%) were open wounds while 9.6% were fractures. Isolated limb injuries most commonly occurred in younger men and resulted from falls (24.3%) and road traffic injuries (23.5%). High rates of disability were reported, with 39% reporting difficulty with activities of daily living. Compared with individuals with other types of limb injuries, those with fractures were six times more likely to seek a traditional healer first for care (40% versus 6.7%), 5.3 times (95% CI, 1.21 to 23.42) more likely to have any level of disability after adjustment for injury mechanism, and 2.3 times more likely to have difficulty paying for food or rent (54.8% versus 23.7%)., Discussion: Most traumatic injuries sustained in LMICs involve limb injuries and often result in high levels of disability that affect individuals during their most productive years. Improved access to care and injury control measures, such as road safety training and improvements to transportation and trauma response infrastructure, are needed to reduce these injuries., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Background: Injury deaths in sub-Saharan Africa are among the world's highest, but hospital data rarely have sufficient granularity to direct quality improvement. We analyzed clinical care patterns among trauma patients who died in a prospective, multicenter sub-Saharan cohort to pinpoint trauma quality improvement intervention targets., Methods: In-hospital trauma deaths in four Cameroonian hospitals between 2017 and 2019 were included. Trauma registry data on patient demographics, injury characteristics, and clinical care were analyzed to identify opportunities for systems improvements., Results: Among 9,423 trauma patients, there were 236 deaths. Overall, 83% of patients who died in the emergency department were living on arrival (LOA). Among 183 LOA patients, 30% presented with normal vital signs, but 11% had no vital signs taken, often because of lack of equipment (43%). Of LOA patients presenting with a Glasgow Coma Scale score of <9 (56%), few received neurosurgery consults (15%), C-collar placement (9%), or intubation (1%). The most common reason for lack of c-collar placement was failure to recognize that it was indicated (66%). Tracheal deviation, unequal breath sounds, or paradoxical chest movement were present in 63% of LOA patients, but only two patients had chest tubes placed. Hypotension or active bleeding was present in 80% of LOA patients; while crystalloid bolus was given to 96% of these patients, few received transfusion (8%), tourniquet placement for extremity injury (6%), or an operation (4%)., Conclusion: Primary survey interventions are underperformed in trauma nonsurvivors in Cameroon. Protocolizing early treatment for head injury, hemorrhagic shock, and chest wall trauma could reduce trauma mortality., Level of Evidence: Prognostic and Epidemiologic; Level III., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Chronic diseases are increasing but underdiagnosed in low-income and middle-income countries (LMICs), where injury mortality is already disproportionately high. We estimated prevalence of known chronic disease comorbidities and their association with outcomes among injured patients in Cameroon., Materials and Methods: Injured patients aged ≥15 y presenting to four Cameroonian hospitals between October 2017 and January 2020 were included. Our explanatory variable was known chronic disease; prevalence was age-standardized. Outcomes were overall in-hospital mortality and admission or transfer from the emergency department (ED). Associations between known chronic disease and outcomes were evaluated using logistic regression adjusted for age, gender, estimated injury severity score (eISS), hospital, and household socioeconomic status. Unadjusted eISS-stratified and age-stratified outcomes were also compared via chi-squared tests., Results: Of 7509 injured patients, 370 (4.9%) reported at least one known chronic disease; age-standardized prevalence was 8.4% (95% confidence interval [CI] 7.5%-9.2%). Patients with known chronic disease had higher mortality (4.6% versus 1.5%, adjusted odds ratio [aOR]: 2.61 [95% CI: 1.25-5.47], P = 0.011) and were more likely to be admitted or transferred from the ED (38.7% versus 19.8%, aOR: 1.40 [95% CI: 1.02-1.92], P = 0.038) compared to those without known comorbidities. Crude differences in mortality (11.3% versus 3.3%, P = 0.002) and hospital admission or transfer (63.8% versus 46.6%, P = 0.011) were most notable for patients with eISS 16-24., Conclusions: Despite underdiagnosis among Cameroonians, we demonstrated worse injury outcomes among those with known chronic diseases. Integrating chronic disease screening with injury care may help address underdiagnosis in Cameroon. Future work should assess whether chronic disease prevention in LMICs could improve injury outcomes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Home injuries are an important cause of morbidity and mortality in high-income countries. In Sub-Saharan Africa, including Cameroon, many people live in unplanned settlements with poorly constructed houses, predisposing them to home injuries. However, little is known about the epidemiology and care-seeking behaviors of the domestically injured. In this study, our objective was to determine the epidemiology and care-seeking behaviors of home injuries in the Southwest Region of Cameroon., Methods: A sub-analyses of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months was conducted. Sampling was done using three-stage cluster sampling technique. Differences between groups were evaluated using Chi-squared and Adjusted Wald tests., Results: Of 8065 participants, 157 suffered home injuries giving an incidence of 19.6 (16.8-23.0 95% CI) cases per 1000-person years. Home injuries comprised 31.2% of all 503 injuries and affected more females (60.8%) and younger individuals (mean age (SE) 25.1 years (2.0)) than non-home injuries. The most common activity and mechanism of home injury was leisure/play (51%) and falls (37.9%) respectively. Amongst those with home injuries, 37.6% did not seek care from any care provider (versus 25.0% of non-home injuries, p = 0.004) and were more likely to seek treatment within the family or at home (p = 0.008) or at church (p = 0.010). Those with home injuries experienced a median of 14 disability days and 22.9% of families faced difficulties affording basic expenses (p = 0.001)., Conclusion: Home injuries comprise about a third of the Southwest Region of Cameroon's burden of injury and likely have a profound socioeconomic impact. Though these injuries cause severe disabilities, a large proportion of victims do not seek care from providers. Prevention efforts should address the design of homes and victims of home injury should be encouraged to utilize formal care services., Competing Interests: The authors have declared that no competing interests exist.

Objectives: In Cameroon, long-term outcomes after discharge from trauma are largely unknown, limiting our ability to identify opportunities to reduce the burden of injury. In this study, we evaluated injury-related death and disability in Cameroonian trauma patients over a 6-month period after hospital discharge., Design: Prospective cohort study., Setting: Four hospitals in the Littoral and Southwest regions of Cameroon., Participants: A total of 1914 patients entered the study, 1304 were successfully contacted. Inclusion criteria were patients discharged after being treated for traumatic injury at each of four participating hospitals during a 20-month period. Those who did not possess a cellular phone or were unable to provide a phone number were excluded., Primary and Secondary Outcome Measures: The Glasgow Outcome Scale-Extended (GOSE) was administered to trauma patients at 2 weeks, 1 month, 3 months and 6 months post discharge. Median GOSE scores for each timepoint were compared and regression analyses were performed to determine associations with death and disability., Results: Of 71 deaths recorded, 90% occurred by 2 weeks post discharge. At 6 months, 22% of patients still experienced severe disability. Median (IQR) GOSE scores at the four timepoints were 4 (3-7), 5 (4-8), 7 (4-8) and 7 (5-8), respectively, (p<0.01). Older age was associated with greater odds of postdischarge disability (OR: 1.23, 95% CI: 1.07 to 1.41) and mortality (OR: 2.15, 95% CI: 1.52 to 3.04), while higher education was associated with decreased odds of disability (OR: 0.65, 95% CI: 0.58 to 0.73) and mortality (OR: 0.38, 95% CI: 0.31 to 0.47). Open fractures (OR: 1.73, 95% CI: 1.38 to 2.18) and closed fractures (OR: 1.83, 95% CI: 1.42 to 2.36) were associated with greater postdischarge disability, while higher Injury Severity Score (OR: 2.44, 95% CI: 2.13 to 2.79) and neurological injuries (OR: 4.40, 95% CI: 3.25 to 5.96) were associated with greater odds of postdischarge mortality., Conclusion: Mobile follow-up data show significant morbidity and mortality, particularly for orthopaedic and neurologic injuries, up to 6 months following trauma discharge. These results highlight the need for reliable follow-up systems in Cameroon., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Risk factors for interpersonal violence-related injury (IPVRI) in low-income and middle-income countries (LMICs) remain poorly defined. We describe associations between IPVRI and select social determinants of health (SDH) in Cameroon., Methods: We conducted a cross-sectional analysis of prospective trauma registry data collected from injured patients > 15 years old between October 2017 and January 2020 at four Cameroonian hospitals. Our primary outcome was IPVRI, compared with unintentional injury. Explanatory SDH variables included education level, employment status, household socioeconomic status (SES) and alcohol use. The EconomicClusters model grouped patients into household SES clusters: rural, urban poor, urban middle-class (MC) homeowners, urban MC tenants and urban wealthy. Results were stratified by sex. Categorical variables were compared via Pearson's χ 2 statistic. Associations with IPVRI were estimated using adjusted odds ratios (aOR) with 95% confidence intervals (95%CI)., Results: Among 7605 patients, 5488 (72.2%) were men. Unemployment was associated with increased odds of IPVRI for men (aOR 2.44 (95% CI 1.95 to 3.06), p<0.001) and women (aOR 2.53 (95% CI 1.35 to 4.72), p=0.004), as was alcohol use (men: aOR 2.33 (95% CI 1.91 to 2.83), p<0.001; women: aOR 3.71 (95% CI 2.41 to 5.72), p<0.001). Male patients from rural (aOR 1.45 (95% CI 1.04 to 2.03), p=0.028) or urban poor (aOR 2.08 (95% CI 1.27 to 3.41), p=0.004) compared with urban wealthy households had increased odds of IPVRI, as did female patients with primary-level/no formal (aOR 1.78 (95% CI 1.10 to 2.87), p=0.019) or secondary-level (aOR 1.54 (95% CI 1.03 to 2.32), p=0.037) compared with tertiary-level education., Conclusion: Lower educational attainment, unemployment, lower household SES and alcohol use are risk factors for IPVRI in Cameroon. Future research should explore LMIC-appropriate interventions to address SDH risk factors for IPVRI., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Morbidity and mortality linked to injury has become an increasingly important public health concern worldwide, especially in developing countries. Despite the potentially severe nature of torso injury, little is known about the population-based epidemiology of torso injury in sub-Saharan Africa., Objectives: To determine the incidence, identify common mechanisms, and assess the socioeconomic consequences of torso injury in Cameroon., Methods: We performed a torso injury sub-analysis of a larger descriptive cross-sectional community-based study on injury epidemiology in the preceding 12 months in the Southwest region of Cameroon. Sampling was done using the three-stage cluster sampling technique. The differences between groups were evaluated using χ² and adjusted Wald tests., Results: We identified 39 cases of torso injuries out of 8 065 participants, providing a yearly incidence estimate of 488 (95% confidence interval (CI) 356 - 668) per 100 000 person-years. Road traffic injury was the most common mechanism of torso injury. The median (interquartile range (IQR)) cost of treatment for torso injury was USD58 (10 - 137), over four times the median (IQR) cost for non-torso injury at USD12 (3 - 43) ( p =0.0004). About half of affected households (51%) reported being unable to afford necessities such as rent and food after injury v. 33% of households with members with non-torso injuries ( p =0.018)., Conclusion: Torso injuries have an incidence of 488/100 000 person-years, and road traffic injuries account for the majority of the injuries. Road traffic control measures and trauma care strengthening may reduce the impact of torso injuries and injuries in Cameroon., Competing Interests: Conflicts of interest: None.

Background: The majority of studies investigating the epidemiology of traumatic brain injury (TBI) in sub-Saharan Africa are primarily hospital-based, missing fatal, mild, and other cases of TBI that do not present to formal care settings. This study aims to bridge this gap in data by describing the epidemiology of TBI in the Southwest Region of Cameroon., Methods: This was a cross-sectional community-based study. Using a three-stage cluster sampling, local research assistants surveyed households with a pre-tested questionnaire to identify individuals with symptoms of TBI in nine health districts in the Southwest Region of Cameroon from 2016 to 2017., Results: Data gathered on 8,065 individuals revealed 78 cases of suspected TBI. Road traffic injury (RTI) comprised 55% of subjects' mechanism of injury. Formal medical care was sought by 82.1% of subjects; three subjects died at the time of injury. Following injury, 59% of subjects reported difficulty affording basic necessities and 87.2% of subjects were unable to perform activities of their primary occupation., Conclusions: This study postulates an incidence of TBI in Southwest Cameroon of 975.57 per 100,000 individuals, significantly greater than prior findings. A large proportion of TBI is secondary to RTI.

Objectives: To establish the prevalence of self-reported vision impairment (VI) in Southwest Cameroon and describe associated care-seeking practices, functional limitations and economic hardships., Design: A three-stage clustered sampling household community-based survey., Setting: The Southwest region of Cameroon., Participants: 8046 individuals of all ages residing in the Southwest region of Cameroon., Primary and Secondary Outcome Measures: Prevalence of self-reported VI, onset of vision loss, care-seeking practices, diagnosis and treatment, functional limitations, economic hardships on household, beliefs about surgical treatability of blindness and barriers to surgical care., Results: The estimated prevalence of self-reported VI in Southwest Cameroon was 0.87% (95% CI 0.62 to 1.21). Among participants aged ≥40 years, the prevalence increased to 2.61% (95% CI 1.74 to 3.90). Less than a quarter of affected participants reported difficulty working (20.5%) or trouble going to school (12.0%) as a result of their VI. Yet, over half (52%, n=43) of affected households experienced significant economic hardships due to the VI. Residing in an urban setting (aOR 1.16, 95% CI 1.04 to 1.30) and belonging to a higher socioeconomic status (aOR 1.13, 95% CI 1.02 to 1.26) were factors associated with the belief that certain types of blindness were surgically reversible. Formal care was not sought by 16.3% (n=8) of affected participants. Cataracts was the leading diagnosis among participants who did seek formal care (43.2%, n=16), although 93.8% of these cases were not surgically treated, primarily due to a lack of perceived need., Conclusion: The prevalence of individuals who report vision impairment in Southwest Cameroon is considerably lower than prior published estimates based on visual physical examinations. Routine community-level screening and cost financing schemes could improve detection of pre-clinical eye disease and the utilisation of surgical care. It could also pre-empt disability and economic hardships associated with advanced VI in the region., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Half of the global population is at risk for catastrophic health expenditure (CHE) in the event that they require surgery. Universal health coverage fundamentally requires protection from CHE, particularly in low- and middle-income countries (LMICs). Financial risk protection reports in LMICs covering surgical care are limited. We explored the relationship between financial risk protection and hospital admission among injured patients in Cameroon to understand the role of health insurance in addressing unmet need for surgery in LMICs., Methods: The Cameroon National Trauma Registry, a database of all injured patients presenting to the emergency departments (ED) of three Cameroonian hospitals, was retrospectively reviewed between 2015 and 2017. Multivariate regression analysis identified predictors of hospital admission after injury and of patient report of cost inhibiting their care., Results: Of the 7603 injured patients, 95.7% paid out-of-pocket to finance ED care. Less than two percent (1.42%) utilized private insurance, and more than half (54.7%) reported that cost inhibited their care. In multivariate analysis, private insurance coverage was a predictor of hospital admission (OR 2.17, 95% CI: 1.26, 3.74) and decreased likelihood of cost inhibiting care (OR 0.34, 95% CI: 0.20, 0.60) when compared to individuals paying out-of-pocket., Conclusion: The prevalence of out-of-pocket spending among injured patients in Cameroon highlights the need for financial risk protection that encompasses surgical care. Patients with private insurance were more likely to be admitted to the hospital, and less likely to report that cost inhibited care, supporting private health insurance as a potential financing strategy.

Background: Injury disproportionately affects persons in low- and middle-income countries (LMIC). Most LMIC lack capacity for routine follow-up care, likely resulting in complications and disability. Cellular telephones may provide a new tool to improve health outcomes. The objective of this study was to establish the feasibility of a mobile health follow-up program after injury in Cameroon., Methods: Between February and October 2017, all injured patients admitted to a regional hospital in Cameroon were asked for mobile phone numbers as part of an existing trauma registry. Patients were contacted 2 weeks after leaving the hospital discharge to participate in a short triage survey. Data on program feasibility and patient condition were collected., Results: Of 1180 injured patients who presented for emergency care, 83% provided telephone numbers, 62% were reached, and 48% (565) of all injured patients ultimately participated in telephone follow-up. Successfully contacted patients were reached after an average of 1.76 call attempts (SD 1.91) and median call time was 4.43 min (IQR 3.67-5.36). Five patients (1%) had died from their injuries at the time of follow-up. Among surveyed patients, 27% required ongoing assistance to complete activities of daily living. Nearly, half (47%) of patients reported inability to take medicines or care for their injury as instructed at discharge. Adequate pain control was achieved in only 38% of discharged patients., Conclusion: Pilot data suggest considerable under treatment of injury in Cameroon. Mobile telephone follow-up demonstrates potential as a feasible tool for screening discharged patients who could benefit from further care.

Importance: Despite the highest injury rates worldwide, formal medical care is not often sought after injuries in Sub-Saharan Africa. Unaffordable costs associated with trauma care might inhibit injured patients from seeking care., Objectives: To (1) determine the injury epidemiology in Cameroon using population-representative data, (2) identify the barriers to use of formal health care after injury, and (3) determine the association between use of care and economic outcomes after injury., Design, Setting, and Participants: This mixed-methods, cross-sectional study included a population-representative, community-based survey and nested qualitative semistructured interviews in the urban-rural Southwest Region of Cameroon. Three-stage cluster sampling was used to select target households. Data were collected from January 3 to March 14, 2017, and analyzed from March 3, 2017, to March 3, 2019., Exposures: Injuries occurring in the preceding 12 months., Main Outcomes and Measures: Postinjury use of health care services, disability, and economic outcomes. All survey data were adjusted for cluster sampling., Results: Of 1551 total households approached, 1287 (83.0%) were surveyed for a total sample size of 8065 participants. The 8065 individuals surveyed included 4181 women (52.0%), with a mean age of 23.9 (standard error [SE], 0.2) years. A total of 503 injuries were identified among 471 unique participants, including 494 nonfatal injuries. Among these, 165 (34.6%) did not seek formal medical services. Disability occurred after 345 injuries (68.6%) and resulted in 11 941 lost days of work in the sample. Family economic hardship after injury was substantially increased among the injured cohort who used formal medical care. Injuries brought to formal medical care, compared with those that were note, incurred higher mean treatment costs ($101.08 [SE, $236.23] vs $12.13 [SE, $36.78]; P < .001), resulted in higher rates of lost employment (19.9% [SE, 3.6%] vs 5.6% [SE, 1.6%]; P = .004), and more frequently led affected families to use economic coping strategies, such as borrowing money (26.2% [SE, 2.7%] vs 7.1% [SE, 1.2%]; P < .001). After adjusting for age and severity, use of formal medical care in Cameroon was independently associated with severe economic hardship after injury, defined as a new inability to afford food or rent (adjusted odds ratio, 1.67; 95% CI, 1.05-2.65)., Conclusions and Relevance: In this study, injury in Southwestern Cameroon was associated with significant disability and lost productivity. Formal medical treatment of injury was associated with significant financial consequences for households of injured patients. Primary prevention of road traffic injuries and financial restructuring of emergency care could improve trauma care access in Cameroon and reduce the societal effects of injury.

Background: Hernias are one of the most commonly encountered surgical conditions, and every year, more than 20 million hernia repairs are performed worldwide. The surgical management of hernia, however, is largely neglected as a public health priority in developing countries, despite its cost-effectiveness. To date, the prevalence and impact of hernia have not been formally studied in a community setting in Cameroon. The aim of this study was to determine the prevalence and characteristics of untreated hernia in the Southwest region of Cameroon., Methods: This study was a subanalysis of a cross-sectional community-based survey on injury in Southwest Cameroon. Households were sampled using a three-stage cluster sampling method. Household representatives reported all untreated hernias occurring in the past year. Data on socioeconomic factors, hernia symptoms, including the presence of hernia incarceration, and treatment attempts were collected between January 2017 and March 2017., Results: Among 8065 participants, 73 persons reported symptoms of untreated hernia, resulting in an overall prevalence of 7.4 cases per 1000 persons (95% confidence limit 4.98-11.11). Groin hernias were most commonly reported (n = 49, 67.1%) and predominant in young adult males. More than half of persons with untreated hernia (56.7%) reported having symptoms of incarceration, yet 42.1% (n = 16) of these participants did not receive any surgical treatment. Moreover, 21.9% of participants with untreated hernias never presented to formal medical care, primarily because of the high-perceived cost of care. Untreated hernias caused considerable disability, as 21.9% of participants were unable to work because of their symptoms, and 15.1% of households earned less money., Conclusions: Hernia is a significant surgical problem in Southwest Cameroon. Despite over half of those with unrepaired hernias reporting symptoms of incarceration, home treatment and nonsurgical management were common. Costs associated with formal medical services are a major barrier to obtaining consultation and repair. Greater awareness of hernia complications and cost restructuring should be considered to prevent disability and mortality due to hernia., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Populations in Cameroon, a lower middle-income country in Central Africa, have a higher than average burden of traumatic injury, suffer from more severe injuries, and face substantial barriers to accessing formal health care services after injury. The aim of this study was to identify and describe how recently injured Cameroonians use and adapt the formal and informal medical systems and what motivates these transitions., Materials and Methods: Recently injured people or their surrogates residing in Southwest Region, Cameroon, were recruited from a larger community-based survey on injury. Semistructured interviews were conducted with 39 recently injured persons or their adult family members. Interviews were recorded, transcribed, and iteratively coded to identify major themes., Results: Most injured persons had complex therapeutic itineraries involving one or more transitions, and nine of 35 injured persons used formal care exclusively. Transitions away from formal care were driven by (1) anticipated costs beyond means, (2) unacceptable length of proposed treatment, (3) poorly supported referrals, (4) dissatisfaction with treatment progress or outcome, and (5) belief that traditional methods work additively with formal care. Factors motivating people to engage with formal care included (1) perceived high value of care for cost, (2) desire for reliable diagnostic tests, (3) social support during hospitalization, and (4) financial support from family or a stranger responsible for the injury., Conclusions: These results highlight specific opportunities to improve engagement in formal care after injury and better support injured Cameroonians through the strengthening of the formal care referral process and health financing organization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Trauma-induced coagulopathy can present as abnormalities in a conventional or viscoelastic coagulation assay or both. We hypothesized that patients with discordant coagulopathies reflect different clinical phenotypes., Methods: Blood samples were collected prospectively from critically injured patients upon arrival at two urban Level I trauma centers. International normalized ratio (INR), partial thromboplastin time (PTT), thromboelastography (TEG), and coagulation factors were assayed., Results: 278 patients (median ISS 17, mortality 26%) were coagulopathic: 20% with isolated abnormal INR and/or PTT (CONVENTIONAL), 49% with isolated abnormal TEG (VISCOELASTIC), and 31% with abnormal INR/PTT and TEG (BOTH). Compared with VISCOELASTIC, CONVENTIONAL and BOTH had higher ISS, lower GCS, larger base deficit, and decreased factor activities (all p < 0.017). They received more blood products and had more ICU/ventilation days (all p < 0.017). Mortality was higher in CONVENTIONAL (40%) and BOTH (49%) than VISCOELASTIC (6%, p < 0.017)., Conclusions: Although TEG-guided resuscitation improves survival after injury, INR and PTT identify coagulopathic patients with highest mortality regardless of TEG and likely represent distinct mechanisms independent of biochemical clot strength., (Copyright © 2019 Elsevier Inc. All rights reserved.)

In the original article, Ziad C. Sifri's first and last names were interchanged. It is correct as reflected here.

Objective: Machine learning techniques have demonstrated superior discrimination compared to conventional statistical approaches in predicting trauma death. The objective of this study is to evaluate whether machine learning algorithms can be used to assess risk and dynamically identify patient-specific modifiable factors critical to patient trajectory for multiple key outcomes after severe injury., Methods: SuperLearner, an ensemble machine-learning algorithm, was applied to prospective observational cohort data from 1494 critically-injured patients. Over 1000 agnostic predictors were used to generate prediction models from multiple candidate learners for outcomes of interest at serial time points post-injury. Model accuracy was estimated using cross-validation and area under the curve was compared to select among predictors. Clinical variables responsible for driving outcomes were estimated at each time point., Results: SuperLearner fits demonstrated excellent cross-validated prediction of death (overall AUC 0.94-0.97), multi-organ failure (overall AUC 0.84-0.90), and transfusion (overall AUC 0.87-0.9) across multiple post-injury time points, and good prediction of Acute Respiratory Distress Syndrome (overall AUC 0.84-0.89) and venous thromboembolism (overall AUC 0.73-0.83). Outcomes with inferior data quality included coagulopathic trajectory (AUC 0.48-0.88). Key clinical predictors evolved over the post-injury timecourse and included both anticipated and unexpected variables. Non-random missingness of data was identified as a predictor of multiple outcomes over time., Conclusions: Machine learning algorithms can be used to generate dynamic prediction after injury while avoiding the risk of over- and under-fitting inherent in ad hoc statistical approaches. SuperLearner prediction after injury demonstrates promise as an adaptable means of helping clinicians integrate voluminous, evolving data on severely-injured patients into real-time, dynamic decision-making support., Competing Interests: The authors have declared that no competing interests exist.

Global health is transitioning toward a focus on building strong and sustainable health systems in developing countries; however, resources, funding, and agendas continue to concentrate on "vertical" (disease-based) improvements in care. Surgical care in low- and middle-income countries (LMICs) requires the development of health systems infrastructure and can be considered an indicator of overall system readiness. Improving surgical care provides a scalable gateway to strengthen health systems in multiple domains. In this position paper by the Society of University Surgeons' Committee on Global Academic Surgery, we propose that health systems development appropriately falls within the purview of the academic surgeon. Partnerships between academic surgical institutions and societies from high-income and resource-constrained settings are needed to strengthen advocacy and funding efforts and support development of training and research in LMICs.

Introduction: Despite the rising trend in breast cancer incidence and mortality across Sub-Saharan Africa, there remains a critical knowledge gap about the burden and patterns of breast disease and breast cancer screening practices at the population level. This study aimed to identify socioeconomic factors associated with knowledge and practice of breast self-examination (BSE) as well as assess the prevalence of breast disease symptoms among a mixed urban-rural population of women in the Southwest region of Cameroon., Methods: We conducted a household-level community-based study in Southwest Cameroon between January and March 2017, using a three-stage cluster sampling framework. We surveyed 1287 households and collected self-reported data on 4208 female subjects, 790 of whom were household representatives. Each household representative provided information on behalf of all female household members about any ongoing breast disease symptoms. Moreover, female household representatives were questioned about their own knowledge and practice of BSE., Results: Women demonstrated low frequency of knowledge of BSE, as 25% (n=201) of household representatives reported any knowledge of BSE; and among these only 15% (n=30) practiced BSE on a monthly basis. Age (aOR: 1.04), usage of Liquid Petroleum Gas fuel, a marker of higher socioeconomic status (aOR: 1.86), and speaking English as a primary language in the household (aOR: 1.59) were significant predictors of knowledge of BSE. Eleven women reported ongoing breast disease symptoms resulting in an overall prevalence of 2.3 cases of breast disease symptoms per 1000 women., Conclusions: Socioeconomic disparities in access to health education may be a determinant of knowledge of BSE. Community-based strategies are needed to improve dissemination of breast cancer screening methods, particularly for women who face barriers to accessing care.

Background: Injuries are a leading cause of death and disability worldwide. Developing countries account for 90% of injury-related deaths globally. Trauma audit filters can facilitate trauma quality improvement initiatives and reduce the injury burden. Little is known about context-appropriate trauma audit filters for developing countries such as Cameroon. This study aimed to (1) develop context-appropriate trauma audit filters for the setting of a regional referral hospital in Cameroon and (2) to assess the barriers and facilitators to their implementation., Methods: Feasible audit filters were identified by a panel of Cameroonian surgeons using the Delphi technique. A Likert scale (1 to 5, with 5 as "Most Useful") was used to rank the filters for utility in a regional referral hospital setting, analyzed using the median and interquartile range. Semistructured interviews were conducted with 16 health care providers from three hospital facilities to explore their perceptions of supervision and support they receive from hospital administration, availability of resources, their work environment, and potential concerns and impacts of trauma audit filters. Interviews were coded and thematically analyzed., Results: Within a panel of seven surgeons, 23 of 40 trauma audit filter variables met majority consensus criteria. Twenty-one of these, comprising mostly of primary survey and basic resuscitation techniques, had a median score of ≥4. Filters meeting consensus include, but are not limited to, vitals obtained, breathing assessment made, and two large bore intravenous established within 15 min of arrival; patient with open fracture receives intravenous antimicrobials within 1 h of arrival; patients with suspected spine injury are immobilized and given X-ray. The provider interviews revealed that the barriers to providing quality care were limited human and material resources and patients' inability to pay. Regular staff training in trauma care and the belief that trauma audit filters would potentially streamline work practices and improve the quality of care were cited as promoters of successful implementation., Conclusions: Primary survey and basic resuscitative techniques are key elements of context-appropriate audit filters in Cameroon. Such audit filters may not be costly, require complex infrastructure, or equipment that exceed the site's capabilities. Proper staff orientation and participation in the use of trauma audit filters, as quality improvement tools, are key to local buy-in and implementation success., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Mortality prediction aids clinical decision making and is necessary for quality improvement initiatives. Validated metrics rely on prespecified variables and often require advanced diagnostics, which are unfeasible in resource-constrained contexts. We hypothesize that machine learning will generate superior mortality prediction in both high-income and low- and middle-income country cohorts., Methods: SuperLearner, an ensemble machine-learning algorithm, was applied to data from three prospective trauma cohorts: a highest-activation cohort in the United States, a high-volume center cohort in South Africa (SA), and a multicenter registry in Cameroon. Cross-validation was used to assess model discrimination of discharge mortality by site using receiver operating characteristic curves. SuperLearner discrimination was compared with standard scoring methods. Clinical variables driving SuperLearner prediction at each site were evaluated., Results: Data from 28,212 injured patients were used to generate prediction. Discharge mortality was 17%, 1.3%, and 1.7% among US, SA, and Cameroonian cohorts. SuperLearner delivered superior prediction of discharge mortality in the United States (area under the curve [AUC], 94-97%) and vastly superior prediction in Cameroon (AUC, 90-94%) compared with conventional scoring algorithms. It provided similar prediction to standard scores in the SA cohort (AUC, 90-95%). Context-specific variables (partial thromboplastin time in the United States and hospital distance in Cameroon) were prime drivers of predicted mortality in their respective cohorts, whereas severe brain injury predicted mortality across sites., Conclusions: Machine learning provides excellent discrimination of injury mortality in diverse settings. Unlike traditional scores, data-adaptive methods are well suited to optimizing precise site-specific prediction regardless of diagnostic capabilities or data set inclusion allowing for individualized decision making and expanded access to quality improvement programming., Level of Evidence: Prognostic and therapeutic, level II and III.

Background: Recent studies have demonstrated the vital influence of commensal microbial communities on human health. The central role of the gut in the response to injury is well described; however, no prior studies have used culture-independent profiling techniques to characterize the gut microbiome after severe trauma. We hypothesized that in critically injured patients, the gut microbiome would undergo significant compositional changes in the first 72 hours after injury., Methods: Trauma stool samples were prospectively collected via digital rectal examination at the time of presentation (0 hour). Patients admitted to the intensive care unit (n=12) had additional stool samples collected at 24 hours and/or 72 hours. Uninjured patients served as controls (n=10). DNA was extracted from stool samples and 16S rRNA-targeted PCR amplification was performed; amplicons were sequenced and binned into operational taxonomic units (OTUs; 97% sequence similarity). Diversity was analyzed using principle coordinates analyses, and negative binomial regression was used to determine significantly enriched OTUs., Results: Critically injured patients had a median Injury Severity Score of 27 and suffered polytrauma. At baseline (0 hour), there were no detectable differences in gut microbial community diversity between injured and uninjured patients. Injured patients developed changes in gut microbiome composition within 72 hours, characterized by significant alterations in phylogenetic composition and taxon relative abundance. Members of the bacterial orders Bacteroidales, Fusobacteriales and Verrucomicrobiales were depleted during 72 hours, whereas Clostridiales and Enterococcus members enriched significantly., Discussion: In this initial study of the gut microbiome after trauma, we demonstrate that significant changes in phylogenetic composition and relative abundance occur in the first 72 hours after injury. This rapid change in intestinal microbiota represents a critical phenomenon that may influence outcomes after severe trauma. A better understanding of the nature of these postinjury changes may lead to the ability to intervene in otherwise pathological clinical trajectories., Level of Evidence: III., Study Type: Prognostic/epidemiological., Competing Interests: Competing interests: None declared.

Background: International normalized ratio (INR) and partial thromboplastin time (PTT) are used interchangeably to diagnose acute traumatic coagulopathy but reflect disparate activation pathways. In this study, we identified injury/patient characteristics and coagulation factors that drive contact pathway, tissue factor pathway (TF), and common pathway dysfunction by examining injured patients with discordant coagulopathies. We hypothesized that patients with INR/PTT discordance reflect differing phenotypes representing contact versus tissue factor pathway perturbations and that characterization will provide targets to guide individualized resuscitation., Methods: Plasma samples were prospectively collected from 1,262 critically injured patients at a single Level I trauma center. Standard coagulation measures and an extensive panel of procoagulant and anticoagulant factors were assayed and analyzed with demographic and outcome data., Results: Fourteen percent of patients were coagulopathic on admission. Among these, 48% had abnormal INR and PTT (BOTH), 43% had isolated prolonged PTT (PTT-CONTACT), and 9% had isolated elevated INR (INR-TF). PTT-CONTACT and BOTH had lower Glasgow Coma Scale score than INR-TF (p < 0.001). INR-TF had decreased factor VII activity compared with PTT-CONTACT, whereas PTT-CONTACT had decreased factor VIII activity compared with INR-TF. All coagulopathic patients had factor V deficits, but activity was lowest in BOTH, suggesting an additive downstream effect of disordered activation pathways. Patients with PTT-CONTACT received half as much packed red blood cell and fresh frozen plasma as did the other groups (p < 0.001). Despite resuscitation, mortality was higher for coagulopathic patients; mortality was highest in BOTH and higher in PTT-CONTACT than in INR-TF (71%, 60%, 41%; p = 0.04)., Conclusions: Discordant phenotypes demonstrate differential factor deficiencies consistent with dysfunction of contact versus tissue factor pathways with additive effects from common pathway dysfunction. Recognition and treatment of pathway-specific factor deficiencies driving different coagulopathic phenotypes in injured patients may individualize resuscitation and improve outcomes., Level of Evidence: Prognostic/epidemiological study, level II.

Background: Acute traumatic coagulopathy affects 20% to 30% of trauma patients, but the extensive collinearity of the coagulation cascade complicates attempts to clarify global clotting factor dysfunction. This study aimed to characterize phenotypes of clotting factor dysfunction and their contributions to mortality after major trauma., Methods: This prospective cohort study examines all adult trauma patients of the highest activation level presenting to San Francisco General Hospital between February 2005 and February 2015. Factors II, V, VII, VIII, IX, and X and protein C activity on admission and mortality status at 28 days were assessed. Predictors of 28-day mortality in univariate analysis were included in multiple logistic regression controlling for traumatic brain injury (TBI), acidosis, age, and mechanism of injury. Principal component analysis was utilized to identify phenotypic coagulation., Results: Complete coagulation factor data were available for 876 (61%) of 1,429 patients. In multiple logistic regression, factors V (odds ratio [OR], 0.86; 95% confidence interval [CI], 0.76-0.97), VIII (OR, 0.97; 95% CI, 0.95-0.99), and X (OR, 0.79; 95% CI, 0.68-0.92) and protein C (OR, 1.17; 95% CI, 1.05-1.30) significantly predicted 28-day mortality after controlling for age, base deficit, mechanism of injury, and TBI. Principal component analysis identified two significant principal components (Phenotypes 1 and 2) that accounted for 66.3% of the total variance. Phenotype 1 (factors II, VII, IX, and X and protein C abnormalities) explained 49.3% and was associated with increased injury, coagulopathy, TBI, and mortality. Phenotype 2 (factors V and VIII abnormalities) explained 17.0% and was associated with increased coagulopathy, blunt injury, and mortality. Only Phenotype 2 remained significantly associated with 28-day mortality in multiple logistic regression., Conclusions: Principal component analysis identified two distinct phenotypes within the entirety of global clotting factor abnormalities, and these findings substantiate the crucial association of factors V and VIII on mortality following trauma. This may be the first step toward identifying unique phenotypes after injury and personalizing hemostatic resuscitation., Level of Evidence: Prognostic study, level III.

Coagulopathy is common after injury and develops independently from iatrogenic, hypothermic, and dilutional causes. Despite considerable research on the topic over the past decade, trauma-induced coagulopathy (TIC) continues to portend poor outcomes, including decreased survival. We review the current evidence regarding the diagnosis and mechanisms underlying trauma induced coagulopathy and summarize the debates regarding optimal management strategy including product resuscitation, potential pharmacologic adjuncts, and targeted approaches to hemostasis. Throughout, we will identify areas of continued investigation and controversy in the understanding and management of TIC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Coagulopathy following injury is common and it predicts poor outcomes and increased mortality. For many decades, coagulopathy in trauma was considered as an iatrogenic phenomenon, and clinical practice focused on a resuscitation strategy using large volume crystalloid and packed red blood cells. The discovery of Acute Traumatic Coagulopathy as a distinct pathophysiologic state coupled with a transition towards balanced product resuscitation has fundamentally changed the paradigm of trauma care and represents one of the most active areas of current research in the field of trauma. In this review, we examine the development and current understanding of the mechanisms, implicated mediators, and physiology of Acute Traumatic Coagulopathy, with an emphasis on the role of the activated Protein C pathway. We will also review the state of resuscitation practice including the evidence for balanced product administration and the previously under-appreciated importance of platelet count and function. Importantly, we highlight ongoing knowledge deficits in traumatic coagulopathy and resuscitation as directions for future investigation in order to facilitate further insight into these rapidly evolving fields., (Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.)