Management and outcomes of firearm-related vascular injuries.

BACKGROUND: Violence due to firearms is a major global public health issue and vascular injuries from firearms are particularly lethal. The aim of this study was to analyse population-based epidemiology of firearm-related vascular injuries. METHODS: This was a retrospective nationwide epidemiological study including all patients with firearm injuries from the national Swedish Trauma Registry (SweTrau) from January 1, 2011 to December 31, 2019. There were 71,879 trauma patients registered during the study period, of which 1010 patients were identified with firearm injuries (1.4%), and 162 (16.0%) patients with at least one firearm-related vascular injury. RESULTS: There were 162 patients admitted with 238 firearm-related vascular injuries, 96.9% men (n = 157), median age 26.0 years [IQR 22-33]. There was an increase in vascular firearm injuries over time (P < 0.005). The most common anatomical vascular injury location was lower extremity (41.7%) followed by abdomen (18.9%) and chest (18.9%). The dominating vascular injuries were common femoral artery (17.6%, 42/238), superficial femoral artery (7.1%, 17/238), and iliac artery (7.1%, 17/238). Systolic blood pressure (SBP) < 90 mmHg or no palpable radial pulse in the emergency department was seen in 37.7% (58/154) of patients. The most common vascular injuries in this cohort with hemodynamic instability were thoracic aorta 16.5% (16/97), femoral artery 10.3% (10/97), inferior vena cava 7.2% (7/97), lung vessels 6.2% (6/97) and iliac vessels 5.2% (5/97). There were 156 registered vascular surgery procedures including vascular suturing (22%, 34/156) and bypass/interposition graft (21%, 32/156). Endovascular stent was placed in five patients (3.2%). The 30-day and 90-day mortality was 29.9% (50/162) and 33.3% (54/162), respectively. Most deaths (79.6%; 43/54) were within 24-h of injury. In the multivariate regression analysis, vascular injury to chest (P < 0.001) or abdomen (P = 0.002) and injury specifically to thoracic aorta (P < 0.001) or femoral artery (P = 0.022) were associated with 24-h mortality. CONCLUSIONS: Firearm-related vascular injuries caused significant morbidity and mortality. The lower extremity was the most common injury location but vascular injuries to chest and abdomen were most lethal. Improved early hemorrhage control strategies seem critical for better outcome.

A systematic review of hemorrhage and vascular injuries in civilian public mass shootings.

BACKGROUND: Civilian public mass shootings (CPMSs) are a major public health issue and in recent years several events have occurred worldwide. The aim of this systematic review was to characterize injuries and mortality after CPMSs focusing on in-hospital management of hemorrhage and vascular injuries. METHOD: A systematic review of all published literature was undertaken in Medline, Embase and Web of Science January 1st, 1968, to February 22nd, 2021, according to the PRISMA guidelines. Literature was eligible for inclusion if the CPMS included three or more people shot, injured or killed, had vascular injuries or hemorrhage. RESULTS: The search identified 2884 studies; 34 were eligible for inclusion in the analysis. There were 2039 wounded in 45 CPMS events. The dominating anatomic injury location per event was the extremity followed by abdomen and chest. The median number of operations and operated patients per event was 22 (5-101) and 10.5 (4-138), respectively. A total of 899 deaths were reported with a median mortality rate of 36.1% per event (15.9-71.4%) Thirty-eight percent (13/34) of all studies reported on vascular injuries. Vascular injuries ranged from 8 to 29%; extremity vascular injury the most frequent. Specific vascular injuries included thoracic aorta 18% (42/232), carotid arteries 6% (14/232), and abdominal aorta 5% (12/232). Vascular injuries were involved in 8.3%-10% of all deaths. CONCLUSION: This systematic review showed an overall high mortality after CPMS with injuries mainly located to the extremities, thorax and abdomen. About one quarter of deaths was related to hemorrhage involving central large vessel injuries. Further understanding of these injuries, and structured and uniform reporting of injuries and treatment protocols may help improve evaluation and management in the future. Level of Evidence Systematic review and meta-analysis, level III.

Impact of COVID-19 on the private and professional lives of highly educated women working in global health in Europe-A qualitative study.

Background: The COVID-19 pandemic has led to a deepening of existing inequalities and a rollback of achievements made in gender equality. Women in Global Health (WGH) is a global movement that aims to achieve gender equality in health and increase female leadership in global health. Here, the aim was to understand how the pandemic affects the private and professional lives of women working in global health in different European countries. Suggestions for future pandemic preparedness including how gender perspectives should be integrated into pandemic preparedness and how a women's network such as WGH helped them to overcome the impact of the pandemic were explored. Methods: Qualitative semi-structured interviews were conducted in September 2020 with a sample size of nine highly educated women with a mean age of 42.1 years from the different WGH European chapters. The participants were informed of the study and were formally asked for their consent. The interviews were held in English via an online videoconference platform and lasted 20-25 min each. The interviews were audio recorded and transcribed verbatim. Thematic analysis was conducted according to Mayring Qualitative Content Analysis using MAXQDA. Results: The pandemic has both positive and negative effects on the professional and private lives of women. It led to an increased workload and stress as well as pressure to publish on COVID-19-related themes. Increased childcare and household responsibilities represented a double burden. The available space was limited if other family members were also working from home. Positive aspects included more time for family or partners and reduced travel. The participants report on perceived gender differences in the experience of the pandemic. International cooperation is considered to be a key factor for future pandemic preparedness. Being part of a women's network such as WGH was perceived as being very supportive in difficult situations during the pandemic. Conclusion: This study provides unique insights into the experiences of women working in global health in different European countries. The COVID-19 pandemic influences their professional and private lives. Perceived gender differences are reported and suggest the need for integrating gender perspectives in pandemic preparedness. Networks for women, such as WGH, can facilitate the exchange of information in crises and provide women with professional and personal support.

Epidemiology of firearm injuries in Sweden.

BACKGROUND: Gun violence is a global health problem. Population-based research on firearm-related injuries has been relatively limited considering the burden of disease. The aim of this study was to analyze nationwide epidemiological trends of firearm injuries. METHODS: This is a retrospective nationwide epidemiological study including all patients with firearm injuries from the Swedish Trauma Registry (SweTrau) during the period 2011 and 2019. Registry data were merged with data from the Swedish National Council for Crime Prevention and the Swedish Police Authority. RESULTS: There were 1010 patients admitted with firearm injuries, 96.6% men and 3.4% women, median age 26.0 years [IQR 22.0-36.3]. The overall number of firearm injuries increased on a yearly basis (P < 0.001). The most common anatomical injury location was lower extremity (29.7%) followed by upper extremity (13.8%), abdomen (13.8%), and chest (12.5%). The head was the most severely injured body region with a median abbreviated injury scale (AIS) of 5 [IQR 3.2-5]. Vascular injuries were mainly located to the lower extremity (42%; 74/175). Majority of patients (51.3%) had more than one anatomic injury location. The median hospital length of stay was 3 days [IQR 2-8]. 154 patients (15.2%) died within 24 h of admission. The 30-day and 90-day mortality was 16.7% (169/1010) and 17.5% (177/1010), respectively. There was an association between 24-h mortality and emergency department systolic blood pressure < 90 mmHg [OR 30.3, 95% CI 16.1-56.9] as well as the following injuries with AIS ≥ 3; head [OR 11.8, 95% CI 7.5-18.5], chest [OR 2.3, 95% CI 1.3-4.1], and upper extremity [OR 3.6, CI 1.3-10.1]. CONCLUSIONS: This nationwide study shows an annual increase of firearm-related injuries and fatalities. Firearm injuries affect people of all ages but more frequently young males in major cities. One in six patients succumbed from their injuries within 30 days with most deaths occurring within 24 h of hospital admission. Given the impact of firearm-related injuries on society additional research on a national level is critical.

Towards equitable surgical systems: development and outcomes of a national surgical, obstetric and anaesthesia plan in Tanzania.

Despite emergency and essential surgery and anaesthesia care being recognised as a part of Universal Health Coverage, 5 billion people worldwide lack access to safe, timely and affordable surgery and anaesthesia care. In Tanzania, 19% of all deaths and 17 % of disability-adjusted life years are attributable to conditions amenable to surgery. It is recommended that countries develop and implement National Surgical, Obstetric and Anesthesia Plans (NSOAPs) to systematically improve quality and access to surgical, obstetric and anaesthesia (SOA) care across six domains of the health system including (1) service delivery, (2) infrastructure, including equipment and supplies, (3) workforce, (4) information management, (5) finance and (6) Governance. This paper describes the NSOAP development, recommendations and lessons learnt from undertaking NSOAP development in Tanzania. The NSOAP development driven by the Ministry of Health Community Development Gender Elderly and Children involved broad consultation with over 200 stakeholders from across government, professional associations, clinicians, ancillary staff, civil society and patient organisations. The NSOAP describes time-bound, costed strategic objectives, outputs, activities and targets to improve each domain of the SOA system. The final NSOAP is ambitious but attainable, reflects on-the-ground priorities, aligns with existing health policy and costs an additional 3% of current healthcare expenditure. Tanzania is the third country to complete such a plan and the first to report on the NSOAP development in such detail. The NSOAP development in Tanzania provides a roadmap for other countries wishing to undertake a similar NSOAP development to strengthen their SOA system.

The Situation of Safe Surgery and Anaesthesia in Tanzania: A Systematic Review.

BACKGROUND: Improvement in the surgical system requires intersectoral coordination. To achieve this, the development of National Surgical, Obstetric, and Anaesthesia Plans (NSOAPS) has been recommended. One of the first steps of NSOAP development is situational analysis. On the ground situational analyses can be resource intensive and often duplicative. In 2016, the Ministry of Health of Tanzania issued a directive for the creation of an NSOAP. This systematic review aimed to assess if a comprehensive situational analysis could be achieved with existing data. These data would be used for evidence-based priority setting for NSOAP development and streamline any additional data collection needed. METHODS: A systematic literature review of scientific literature, grey literature, and policy documents was performed as per PRISMA. Extraction was performed for all articles relating to the five NSOAPS domains: infrastructure, service delivery, workforce, information management, and financing. RESULTS: 1819 unique articles were generated. Full-text screening produced 135 eligible articles; 46 were relevant to surgical infrastructure, 53 to workforce, 81 to service delivery, 11 to finance, and 15 to information management. Rich qualitative and quantitative data were available for each domain. CONCLUSIONS: Despite little systematic data collection around SOA, a thorough literature review provides significant evidence which often have a broader scope, longer timeline and better coverage than can be achieved through snapshot-stratified samples of directed on the ground assessments. Evidence from the review was used during stakeholder discussion to directly inform the NSOAP priorities in Tanzania.