Vismodegib in Gorlin-Goltz syndrome: A systematic review.

Treatment with Hedgehog Inhibitors in Gorlin-Goltz syndrome (GGS) yields favourable objective clinical responses, yet secondary resistance and class-related toxicity restrict treatment duration. This study aims to review current data on GGS patients undergoing vismodegib therapy, focusing on treatment duration, clinical outcomes and schedule modifications. A systematic search of the PubMed database was conducted for English articles from 1993 to 2023, identifying 31 papers suitable for inclusion. A total of 351 patients, with a mean age of 52 years, were analysed. The average treatment duration was 9.3 months for patients who discontinued treatment, and 25.1 months for those who continued vismodegib at the time this study was published. Vismodegib achieved a complete response rate of 44%. Treatment interruption predominantly occurred due to side effects (69.1%) and secondary resistance (9.1%). The use of alternative regimens, although not compromising efficacy, may enhance treatment compliance. Further investigations are warranted to ascertain the optimal treatment regimen and timeline for GGS patients. Schedule modifications offer promise in ameliorating side effects and facilitating long-term treatment.

Crystalloid resuscitation is associated with decreased treatment delays and improved systolic blood pressures in a blood-constrained setting.

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.

Feasibility and acceptability of mobile phone-based triage tool to identify discharged trauma patients in need of further care in Cameroon.

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.

Failure to receive prescribed imaging is associated with increased early mortality after injury in Cameroon.

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.

The CBS test: Development, evaluation & cross-validation of a community-based injury severity scoring system in Cameroon.

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.

Back to the basics: Clinical assessment yields robust mortality prediction and increased feasibility in low resource settings.

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.

A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective.

BACKGROUND: The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures. METHODS: This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data. RESULTS: Among the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained. CONCLUSION: Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.

In-Hospital Obstetric Delays in Rural Uganda: A Cross-Sectional Analysis of a Hospital Cohort.

BACKGROUND: Deaths related to pregnancy and childbirth are extremely high in low-resource countries such as Uganda. Maternal mortality in low- and middle-income countries is related to delays in seeking, reaching, and receiving adequate health care. This study aimed to investigate the in-hospital delays to surgical care for women in labor arriving to Soroti Regional Referral Hospital (SRRH). METHODS: From January 2017 to August 2020, we collected data on obstetric surgical patients in labor using a locally developed, context-specific obstetrics surgical registry. Data regarding patient demographics, clinical and operative characteristics, as well as delays in care and outcomes were documented. Descriptive and multivariate statistical analyses were conducted. RESULTS: A total of 3189 patients were treated during our study period. Median age was 23 years, most gestations were at term (97%) at the time of operation, and nearly all patients underwent Cesarean Section (98.8%). Notably, 61.7% of patients experienced at least one delay in their surgical care at SRRH. Lack of surgical space was the greatest contributor to delay (59.9%), followed by lack of supplies or personnel. The significant independent predictors of delayed care were having a prenatal acquired infection (AOR 1.73, 95% CI 1.43-2.09) and length of symptoms less than 12 h (AOR 0.32, 95% CI 0.26-0.39) or greater than 24 h (AOR 2.61, 95% CI 2.18-3.12). CONCLUSION: In rural Uganda, there is a significant need for financial investment and commitment of resources to expand surgical infrastructure and improve care for mothers and neonates.

Chronic Disease Comorbidities Among Injured Patients in Cameroon: A Retrospective Cohort Study.

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.

The Third Delay in General Surgical Care in a Regional Referral Hospital in Soroti, Uganda.

BACKGROUND: Building capacity for surgical care in low-and-middle-income countries is essential for the improvement of global health and economic growth. This study assesses in-hospital delays of surgical services at Soroti Regional Referral Hospital (SRRH), a tertiary healthcare facility in Soroti, Uganda. METHODS: A prospective general surgical database at SRRH was analyzed. Data on patient demographics, surgical characteristics, delays of care, and adverse clinical outcomes of patients seen between January 2017 and February 2020 were extracted and analyzed. Patient characteristics and surgical outcomes, for those who experienced delays in care, were compared to those who did not. RESULTS: Of the 1160 general surgery patients, 263 (22.3%) experienced at least one delay of care. Deficits in infrastructure, particularly lacking operating theater space, were the greatest contributor to delays (n = 192, 73.0%), followed by shortage of equipment (n = 52, 19.8%) and personnel (n = 37, 14.1%). Male sex was associated with less delays of care (OR 0.63) while undergoing emergency surgeries (OR 1.65) and abdominal surgeries (OR 1.44) were associated with more frequent delays. Delays were associated with more adverse events (10.3% vs. 5.0%), including death (4.2% vs. 1.6%). Emergency surgery, unclean wounds, and comorbidities were independent risk factors of adverse events. DISCUSSION: Patients at SRRH face significant delays in surgical care from deficits in infrastructure and lack of capacity for emergency surgery. Delays are associated with increased mortality and other adverse events. Investing in solutions to prevent delays is essential to improving surgical care at SRRH.

Mobile telephone follow-up assessment of postdischarge death and disability due to trauma in Cameroon: a prospective cohort study.

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.

Evaluating Shifts in Perception After a Pilot Trauma Quality Improvement Training Course in Cameroon.

INTRODUCTION: Trauma is a major contributor to the global burden of disease, with low- and middle-income countries (LMICs) being disproportionately affected. Trauma Quality Improvement (QI) initiatives could potentially save an estimated two million lives each year. Successful trauma QI initiatives rely on adequate training and a culture of quality among hospital staff. This study evaluated the effect of a pilot trauma QI training course on participants' perceptions on leadership, medical errors, and the QI process in Cameroon. METHODS: Study participants took part in a three-day, eight-module course training on trauma QI methods and applications. Perceptions on leadership, medical errors, and QI were assessed pre and post-course using a 15-item survey measured on a five-point Likert scale. Median pre- and post-course scores were compared using the Wilcoxon signed-rank test. Knowledge retention and course satisfaction were also evaluated in a post-course survey and evaluation. RESULTS: A majority of the 25 course participants completed pre-course (92%) and post-course (80%) surveys. Participants' perceptions of safety and comfort discussing medical errors at work significantly increased post-course (pre-median = 5, IQR [4-5]; post-median = 5, IQR [5-5]; P = 0.046). The belief that individuals responsible for medical error should be held accountable significantly decreased after the course (pre-median = 3, IQR [2-4]; post-median = 1, IQR [1-2]; P < 0.001). Overall satisfaction with the course was high with median scores ≥4. CONCLUSIONS: These initial results suggest that targeted trauma QI training effectively influences attitudes about QI. Further investigation of the effect of the trauma QI training on hospital staff in larger courses is warranted to assess reproducibility of these findings.

Associations between social determinants of health and interpersonal violence-related injury in Cameroon: a cross-sectional study.

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 χ2 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.

The societal cost and economic impact of surgical care on patients' households in rural Uganda; a mixed method study.

BACKGROUND: The epidemiology and cost of surgical care delivery in low-and middle-income countries (LMICs) is poorly understood. This study characterizes the cost of surgical care, rate of catastrophic medical expenditure and medical impoverishment, and impact of surgical hospitalization on patients' households at Soroti Regional Referral Hospital (SRRH), Uganda. METHODS: We prospectively collected demographic, clinical, and cost data from all surgical inpatients and caregivers at SRRH between February 2018 and January 2019. We conducted and thematically analyzed qualitative interviews to discern the impact of hospitalization on patients' households. We employed the chi-square, t-test, ANOVA, and Bonferroni tests and built regression models to identify predictors of societal cost of surgical care. Out of pocket spending (OOPS) and catastrophic expenses were determined. RESULTS: We encountered 546 patients, mostly male (62%) peasant farmers (42%), at a median age of 22 years; and 615 caregivers, typically married (87%), female (69%), at a median age of 35 years. Femur fractures (20.4%), soft tissue infections (12.3%), and non-femur fractures (11.9%) were commonest. The total societal cost of surgical care was USD 147,378 with femur fractures (USD 47,879), intestinal obstruction (USD 18,737) and non-femur fractures (USD 10,212) as the leading contributors. Procedures (40%) and supplies (12%) were the largest components of societal cost. About 29% of patients suffered catastrophic expenses and 31% were medically impoverished. CONCLUSION: Despite free care, surgical conditions cause catastrophic expenses and impoverishment in Uganda. Femur fracture is the most expensive surgical condition due to prolonged hospitalization associated with traction immobilization and lack of treatment modalities with shorter hospitalization.

Prevalence, care-seeking practices and impact of self-reported vision impairment in Southwest Cameroon: a community-based study.

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.

Baseline Patient Safety Culture in Cameroon: Setting a Foundation for Trauma Quality Improvement.

BACKGROUND: Trauma quality improvement (QI) has resulted in decreased trauma mortality and morbidity in high-income countries and has the potential to do the same in low- and middle-income countries. Effective implementation of QI programs relies on a foundational culture of patient safety; however, studies on trauma-related patient safety culture in Sub-Saharan Africa remain scarce. This study assesses baseline patient safety culture in Cameroon to best identify opportunities for improvement. MATERIALS AND METHODS: Over a 3-week period, the Hospital Survey on Patient Safety Culture was administered in three hospitals in the Littoral region of Cameroon. Percentages of positive responses (PPRs) were calculated across 42 items in 12 survey dimensions. A mixed-effects logistic regression model was used to summarize dimension-level percentages and confidence intervals. RESULTS: A total of 179 trauma-related hospital personnel were surveyed with an overall response rate of 76.8%. High PPRs indicate favorable patient safety culture. Of the 12 dimensions evaluated by the Hospital Survey on Patient Safety Culture, nine had a PPR below 50%. Dimensions particularly pertinent in the context of QI include Nonpunitive Response to Errors with a PPR of 25.8% and Organization Learning-Continuous Improvement with a PPR of 64.7%. CONCLUSIONS: The present study elucidates an opportunity for the development of trauma patient safety culture in Cameroon. Low PPR for Nonpunitive Response to Errors indicates a need to shift cultural paradigms from ascribing individual blame to addressing systemic shortcomings of patient care. Moving forward, data from this study will inform interventions to cultivate patient safety culture in partnering Cameroonian hospitals.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review.

BACKGROUND: About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings. MATERIALS AND METHODS: This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score's capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized. RESULTS: Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility. CONCLUSIONS: The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective. PROSPERO REGISTRATION NUMBER: CRD42017064600.

Diagnosis and management of surgical disease at Ethiopian health centres: cross-sectional survey of resources and barriers to care.

OBJECTIVES: The aim of this study was to characterise the resources and challenges for surgical care and referrals at health centres (HCs) in South Wollo Zone, Ethiopia. SETTING: Eight primary HCs in South Wollo Zone, Ethiopia. PARTICIPANTS: Eight health officers and nurses staffing eight HCs completed a survey. DESIGN: The study was a survey-based, cross-sectional assessment of HCs in South Wollo Zone, Ethiopia and data were collected over a 30-day period from November 2014 to January 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Survey assessed human and material resources, diagnostic capabilities and challenges and patient-reported barriers to care. RESULTS: Eight HCs had an average of 18 providers each, the majority of which were nurses (62.2%) and health officers (20.7%). HCs had intermittent availability of clean water, nasogastric tubes, rectal tubes and suturing materials, none of them had any form of imaging. A total of 168 surgical patients were seen at the 8 HCs; 58% were referred for surgery. Most common diagnoses were trauma/burns (42%) and need for caesarean section (9%). Of those who did not receive surgery, 32 patients reported specific barriers to obtaining care (91.4%). The most common specific barriers were patients not being decision makers to have surgery, lack of family/social support and inability to afford hospital fees. CONCLUSIONS: HCs in South Wollo Zone, Ethiopia are well-staffed with nurses and health officers, however they face a number of diagnostic and treatment challenges due to lack of material resources. Many patients requiring surgery receive initial diagnosis and care at HCs; sociocultural and financial factors commonly prohibit these patients from receiving surgery. Further study is needed to determine how such delays may impact patient outcomes. Improving material resources at HCs and exploring community and family perceptions of surgery may enable more streamlined access to surgical care and prevent delays.

Geospatial Analysis of Trauma Burden and Surgical Care Capacity in Teso Sub-region of Eastern Uganda.

INTRODUCTION: Over 90% of injury-related deaths occur in low- and middle-income countries. Relating spatial distribution of injury burden and trauma care capacity is crucial for effective resource allocation. Our study assesses trauma burden and emergency and essential surgical care (EESC) quality in Teso Sub-region Eastern Uganda through a spatial analysis of trauma burden in relation to surgical capacity at the district level. METHODS: In this study, we surveyed trauma patients presenting at Soroti Regional Referral Hospital (SRRH) and assessed EESC capacity of district hospitals. We used geospatial techniques to relate trauma burden and capacity and characterized delay using the three-delay framework. RESULTS: We surveyed 131 trauma patients presenting to SRRH for trauma-related injuries from June 1 to July 15, 2017. Almost all trauma incidents (n = 129, 98.4%) occurred within a 2-h ideal drive time to SRRH. From time of injury to receiving care, median time totaled to approximately 9.25 h. District hospital exhibited decreased EESC capacity (personnel, infrastructure, procedures, equipment, and supplies (PIPES) score range 2.2-5.5, mean 4.2) compared to SRRH (PIPES score 8.1). CONCLUSION: Trauma patients face delays in each step of the care-seeking process from deciding to seek care, arriving at care site, and receiving treatment. Synergistic effects of a poor prehospital care, EESC deficiencies on district and regional levels, cost of seeking care contribute to delays that likely result in increased morbidity and mortality. Improved resource allocation, training at the district level, and strengthening system-level organization of emergency medical services could avert preventable death and disability.

The Prevalence and Characteristics of Untreated Hernias in Southwest Cameroon.

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.