Leveraging transportation providers to deploy lay first responder (LFR) programs in three sub-Saharan African countries without formal emergency medical services: Evaluating longitudinal impact and cost-effectiveness.

INTRODUCTION: In 2019, the World Health Assembly declared emergency care essential to achieve the 2030 Sustainable Development Goals. Few sub-Saharan African (SSA) countries have developed robust approaches to sustainably deliver emergency medical services (EMS) at scale, as high-income country models are financially impractical. Innovative reassessment of EMS delivery in resource-limited settings is necessary as timely emergency care access can substantially reduce mortality. MATERIALS AND METHODS: We developed the Lay First Responder (LFR) program by training 1,291 pre-existing motorcycle taxi drivers, a predominant form of short-distance transport in sub-Saharan Africa, to provide trauma care and transport for road traffic injuries. Three pilot programs were launched in staggered fashion between 2016 and 2019 in West, Central, and East Africa and a 5.5 h curriculum was iteratively developed to train first responders. Longitudinal data on patient impact (patient demographics, injury characteristics, and treatment rendered), emergency care knowledge acquisition/retention, and social/financial effects of LFR training were collected and pooled across three sites for collective analysis. Novel cost-effectiveness ratios were calculated based on prospective cost data from each site. Previously projected aggregate disability-adjusted life years (DALYs) addressable by LFRs were used to inform cost-effectiveness ratios($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP), following WHOCHOICE guidelines, which state ratios less than GDP per capita are "very cost-effective." RESULTS: In 2,171 total patient encounters across all three pilot sites, LFRs most frequently provided hemorrhage control in 61 % of patient encounters and patient transport by motorcycle in 98.5 %. Median pre-/post-test scores improved by 34.1 percentage points (39.5% vs.73.6 %, p < 0.0001) with significant knowledge retention at six months. 75 % of initial participants remain voluntarily involved 3 years post-course, reporting increased local stature and customer acquisition(income 32.0 % greater than non-trained counterparts). Locally sourced first-aid materials cost $6.54USD/participant. Cost-effectiveness analysis demonstrated cost per DALY averted=$51.65USD. CONCLUSION: LFR training is highly cost-effective according to WHOCHOICE guidelines and expands emergency care access. The LFR program may be an alternative approach to formal ambulance-reliant EMS that are cost-prohibitive in resource-limited, sub-Saharan African settings. A novel social/financial mechanism appears to incentivize long-term voluntary LFR involvement, which may sustain programs in resource-limited settings.

Prehospital hemorrhage management in low- and middle-income countries: A scoping review.

INTRODUCTION: Low- and middle-income countries (LMICs) account for 90% of deaths due to injury, largely due to hemorrhage. The increased hemorrhage mortality burden in LMICs is exacerbated by absent or ineffective prehospital care. Hemorrhage management (HM) is an essential component of prehospital care in LMICs, yet current practices for prehospital HM and outcomes from first responder HM training have yet to be summarized. METHODS: This review describes the current literature on prehospital HM and the impact of first responder HM training in LMICs. Articles published between January 2000 and January 2023 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for HM. Relevant articles were assessed for quality using the Newcastle-Ottawa scale. RESULTS: Of the initial 994 articles, 20 met inclusion criteria representing 16 countries. Studies included randomized control trials, cohort studies, case control studies, reviews, and epidemiological studies. Basic HM curricula were found in 15 studies and advanced HM curricula were found in six studies. Traumatic hemorrhage was indicated in 17 studies while obstetric hemorrhage was indicated in three studies. First responders indicated HM use in 55%-76% of encounters, the most frequent skill they reported using. Mean improvements in HM knowledge acquisition post-course ranged from 23 to 58 percentage points following training for pressure and elevation, gauze application, and tourniquet application. CONCLUSIONS: Our study summarizes the current literature on prehospital HM in LMICs pertaining to epidemiology, interventions, and outcomes. HM resources should be a priority for further development.

Evaluating a digital hybrid training-of-trainers (TOT) approach for lay first responder trauma education in urban Nigeria during the COVID-19 pandemic.

INTRODUCTION: Road traffic injuries (RTIs) are the largest contributor to the global burden of injury, and in 2016 were among the five leading causes of global disability-adjusted life years (DALYs). In regions with limited emergency medical services (EMS), training lay first responders (LFRs) has been shown to increase availability of prehospital care for RTIs, but sustainable mechanisms to scale these programs remain unstudied. METHODS: Using a training of trainers (TOT) model, a 5.5-h LFR training program was launched in Lagos, Nigeria. The course was taught in a hybrid fashion with primary didactics using videoconferencing software and practical breakout sessions in-person concurrently. Thirty TOTs proceeded to train 350 transportation providers as LFRs over one month. A 23-question, pre- and post-assessment was administered digitally to assess knowledge acquisition. Participants responded to a five-point Likert survey assessing instruction quality and post-course confidence. RESULTS: TOTs scored a median of 56.5 % (IQR:43.5 %,71.7 %) and 91.3 % (IQR:88.0 %,95.7 %) on the pre- and post-assessments, respectively, with bleeding control scores increasing most (+69.4 %). LFR course trainees scored a median of 34.8 % (IQR: 26.0 %, 43.5 %) and 73.9 % (IQR: 65.2 %, 82.6 %) on the pre- and post-assessments respectively, with airway and breathing increasing the most (+48.6 %). All score increases were statistically significant with p < 0.001. All 30 TOT trainers instructed at least one training session after their initial session. LFR participants' rated confidence in first aid skills went from 3/5 (IQR 3, 4) pre-course to 5/5 (IQR:5,5) post-course, and in emergency transportation it went from 4/5 (IQR:3, 4) to 5/5 (IQR:5, 5), (p < 0.001). LFR course participants rated the quality of education content and TOT instructors to be 5/5 (IQR:5,5). 144 responders provided emergency care in the six-months following training for a total of 351 interventions. Active responders provided a median of 2 (IQR:1,3) interventions. CONCLUSIONS: This is the first time that a digital hybrid instruction for first responder trainers in low- and middle-income countries has been investigated. Our findings demonstrate negligible attrition, high educational quality ratings, equally effective knowledge acquisition to that of prior in-person courses, and high post-training skill usage. Future work will examine the cost-effectiveness of the training of LFRs and the effect of LFRs on trauma outcomes.

Role of succinate in airway epithelial cell regulation following traumatic lung injury.

Lung contusion and gastric aspiration (LC and GA) are major risk factors for developing acute respiratory distress following trauma. Hypoxia from lung injury is mainly regulated by hypoxia-inducible factor 1α (HIF-1α). Published data from our group indicate that HIF-1α regulation in airway epithelial cells (AEC) drives the acute inflammatory response following LC and GA. Metabolomic profiling and metabolic flux of Type II AEC following LC revealed marked increases in glycolytic and TCA intermediates in vivo and in vitro that were HIF-1α dependent. GLUT-1/4 expression was also increased in HIF-1α+/+ mice, suggesting that increased glucose entry may contribute to increased intermediates. Importantly, lactate incubation in vitro on Type II cells did not significantly increase the inflammatory byproduct IL-1ß. Contrastingly, succinate had a direct proinflammatory effect on human small AEC by IL-1ß generation in vitro. This effect was reversed by dimethylmalonate, suggesting an important role for succinate dehydrogenase in mediating HIF-1α effects. We confirmed the presence of the only known receptor for succinate binding, SUCNR1, on Type II AEC. These results support the hypothesis that succinate drives HIF-1α-mediated airway inflammation following LC. This is the first report to our knowledge of direct proinflammatory activation of succinate in nonimmune cells such as Type II AEC in direct lung injury models.

The Intersection of Pulmonary Vascular Disease and Hypoxia-Inducible Factors.

Hypoxia-inducible factors (HIFs) are a family of nuclear transcription factors that serve as the master regulator of the adaptive response to hypoxia. In the lung, HIFs orchestrate multiple inflammatory pathways and signaling. They have been reported to have a major role in the initiation and progression of acute lung injury, chronic obstructive pulmonary disease, pulmonary fibrosis, and pulmonary hypertension. Although there seems to be a clear mechanistic role for both HIF 1α and 2α in pulmonary vascular diseases including PH, a successful translation into a definitive therapeutic modality has not been accomplished to date.

Polymer Lung Surfactants Attenuate Direct Lung Injury in Mice.

If not properly managed, acute lung injuries, either through direct or indirect causes, have the potential to present serious risk for many patients worldwide. One of the mechanisms for the transition from acute lung injury (ALI) to the more serious acute respiratory distress syndrome (ARDS) is the deactivation of the native lung surfactant by injury-induced infiltrates to the alveolar space. Currently, there are no surfactant replacement therapies that are used to treat ALI and subsequent ARDS. In this paper, we present an indepth efficacy study of using a novel polymer lung surfactant (PLS, composed of poly(styrene-block-ethylene glycol) (PS-PEG) block copolymer micelles), which has unique properties compared to other tested surfactant replacements, in two different mouse models of lung injury. The results demonstrate that pharyngeal administration of PLS after the instillation of either acid (HCl) or lipopolysaccharide (LPS) can decrease the severity of lung injury as measured by multiple injury markers.

Hypoxia-Inducible Factor 1α and Its Role in Lung Injury: Adaptive or Maladaptive.

Hypoxia-inducible factors (HIFs) are transcription factors critical for the adaptive response to hypoxia. There is also an essential link between hypoxia and inflammation, and HIFs have been implicated in the dysregulated immune response to various insults. Despite the prevalence of hypoxia in tissue trauma, especially involving the lungs, there remains a dearth of studies investigating the role of HIFs in clinically relevant injury models. Here, we summarize the effects of HIF-1α on the vasculature, metabolism, inflammation, and apoptosis in the lungs and review the role of HIFs in direct lung injuries, including lung contusion, acid aspiration, pneumonia, and COVID-19. We present data that implicates HIF-1α in the context of arguments both in favor and against its role as adaptive or injurious in the propagation of the acute inflammatory response in lung injuries. Finally, we discuss the potential for pharmacological modulation of HIFs as a new class of therapeutics in the modern intensive care unit.

Therapeutic potential of curcumin in ARDS and COVID-19.

Curcumin is a safe, non-toxic, readily available and naturally occurring compound, an active constituent of Curcuma longa (turmeric). Curcumin could potentially treat diseases, but faces poor physicochemical and pharmacological characteristics. To overcome these limitations, we developed a stable, water-soluble formulation of curcumin called cyclodextrin-complexed curcumin (CDC). We have previously shown that direct delivery of CDC to the lung following lipopolysaccharides exposure reduces acute lung injury (ALI) and effectively reduces lung injury, inflammation and mortality in mice following Klebsiella pneumoniae. Recently, we found that administration of CDC led to a significant reduction in angiotensin-converting enzyme 2 and signal transducer and activator of transcription 3 expression in gene and protein levels following pneumonia, indicating its potential in treating coronavirus disease 2019 (COVID-19). In this review, we consider the clinical features of ALI and acute respiratory distress syndrome (ARDS) and the role of curcumin in modulating the pathogenesis of bacterial/viral-induced ARDS and COVID-19.

Evaluating feasibility of a novel mobile emergency medical dispatch tool for lay first responder prehospital response coordination in Sierra Leone: A simulation-based study.

INTRODUCTION: The global injury burden, driven by road traffic injuries, disproportionately affects low- and middle-income countries, which lack robust emergency medical services (EMS) to address injury. The WHO recommends training lay first responders (LFRs) as the first step toward formal EMS development. Emergency medical dispatch (EMD) systems are the recognized next step but whether small groups of LFRs equipped with mobile dispatch infrastructure can efficiently respond to geographically-dispersed emergencies in a timely fashion and the quality of prehospital care provided is unknown. MATERIALS AND METHODS: We piloted an EMD system utilizing a mobile phone application in Sierra Leone. Ten LFRs were randomly selected from a pool of 61 highly-active LFRs trained in 2019 and recruited to participate in an emergency simulation-based study. Ten simulation scenarios were created matching proportions of injury conditions across 1,850 previous incidents (June-December 2019). Fifty total simulations were launched in randomized order over 3 months, randomized along 10 km of highway in Makeni. Replicating real-world conditions, highly-active LFR participants were blinded to randomized dispatch timing/scenario to assess response time and skill performance under direct observation with a checklist using standardized patient actors. We used novel cost data tracked during EMD pilot implementation to inform the calculation of a new cost-effectiveness ratio ($USD cost per disability-adjusted life year averted (DALY)) for LFR programs equipped with dispatch, following WHOCHOICE guidelines, which state cost-effectiveness ratios less than gross domestic product (GDP) per capita are considered "very cost-effective." RESULTS: Median total response interval (notification to arrival) was 5 min 39 s (IQR:0:03:51, 0:09:18). LFRs initially trained with a 5-hour curriculum and refresher training provide high-quality prehospital care during simulated emergencies. Median first aid skill checklist completion was 89% (IQR: 78%, 90%). Cost-effectiveness equals $179.02USD per DALY averted per 100,000 people, less than Sierra Leonean GDP per capita ($484.52USD). CONCLUSION: LFRs equipped with mobile dispatch demonstrate appropriate response times and effective basic initial management of simulated emergencies. Training smaller cohorts of highly-active LFRs equipped with mobile dispatch appears highly cost-effective and may be a feasible model to facilitate efficient dispatch to expand emergency coverage while conserving valuable training resources in resource-limited settings.

Association of Patient Belief About Success of Antibiotics for Appendicitis and Outcomes: A Secondary Analysis of the CODA Randomized Clinical Trial.

Importance: A patient's belief in the likely success of a treatment may influence outcomes, but this has been understudied in surgical trials. Objective: To examine the association between patients' baseline beliefs about the likelihood of treatment success with outcomes of antibiotics for appendicitis in the Comparison of Outcomes of Antibiotic Drugs and Appendectomy (CODA) trial. Design, Setting, and Participants: This was a secondary analysis of the CODA randomized clinical trial. Participants from 25 US medical centers were enrolled between May 3, 2016, and February 5, 2020. Included in the analysis were participants with appendicitis who were randomly assigned to receive antibiotics in the CODA trial. After informed consent but before randomization, participants who were assigned to receive antibiotics responded to a baseline survey including a question about how successful they believed antibiotics could be in treating their appendicitis. Interventions: Participants were categorized based on baseline survey responses into 1 of 3 belief groups: unsuccessful/unsure, intermediate, and completely successful. Main Outcomes and Measures: Three outcomes were assigned at 30 days: (1) appendectomy, (2) high decisional regret or dissatisfaction with treatment, and (3) persistent signs and symptoms (abdominal pain, tenderness, fever, or chills). Outcomes were compared across groups using adjusted risk differences (aRDs), with propensity score adjustment for sociodemographic and clinical factors. Results: Of the 776 study participants who were assigned antibiotic treatment in CODA, a total of 425 (mean [SD] age, 38.5 [13.6] years; 277 male [65%]) completed the baseline belief survey before knowing their treatment assignment. Baseline beliefs were as follows: 22% of participants (92 of 415) had an unsuccessful/unsure response, 51% (212 of 415) had an intermediate response, and 27% (111 of 415) had a completely successful response. Compared with the unsuccessful/unsure group, those who believed antibiotics could be completely successful had a 13-percentage point lower risk of appendectomy (aRD, -13.49; 95% CI, -24.57 to -2.40). The aRD between those with intermediate vs unsuccessful/unsure beliefs was -5.68 (95% CI, -16.57 to 5.20). Compared with the unsuccessful/unsure group, those with intermediate beliefs had a lower risk of persistent signs and symptoms (aRD, -15.72; 95% CI, -29.71 to -1.72), with directionally similar results for the completely successful group (aRD, -15.14; 95% CI, -30.56 to 0.28). Conclusions and Relevance: Positive patient beliefs about the likely success of antibiotics for appendicitis were associated with a lower risk of appendectomy and with resolution of signs and symptoms by 30 days. Pathways relating beliefs to outcomes and the potential modifiability of beliefs to improve outcomes merit further investigation. Trial Registration: ClinicalTrials.gov Identifier: NCT02800785.

Hypoxia-inducible factor (HIF)-1α-induced regulation of lung injury in pulmonary aspiration is mediated through NF-kB.

Aspiration-induced lung injury is a common grievance encountered in the intensive care unit (ICU). It is a significant risk factor for improving ventilator-associated pneumonia (VAP) and acute respiratory distress syndrome (ARDS). Hypoxia-inducible factor (HIF)-1α is one of the primary transcription factors responsible for regulating the cellular response to changes in oxygen tension. Here, we sought to determine the role of HIF-1α and specifically the role of type 2 alveolar epithelial cells in generating the acute inflammatory response following acid and particles (CASP) aspiration. Previous studies show HIF-1 α is involved in regulating the hypoxia-stimulated expression of MCP-1 in mice and humans. The CASP was induced in C57BL/6, ODD-Luc, HIF-1α (+/+) control, and HIF-1α conditional knockout (HIF-1α (-/-) mice). Following an injury in ODD mice, explanted organs were subjected to IVIS imaging to measure the degree of hypoxia. HIF-1α expression, BAL albumin, cytokines, and histology were measured following CASP. In C57BL/6 mice, the level of HIF-1α was increased at 1 h after CASP. There were significantly increased levels of albumin and cytokines in C57BL/6 and ODD-Luc mice lungs following CASP. HIF-1α (+/+) mice given CASP demonstrated a synergistic increase in albumin leakage, increased pro-inflammatory cytokines, and worse injury. MCP-1 antibody neutralized HIF-1α (+/+) mice showed reduced granuloma formation. The NF-κB expression was increased substantially in the HIF-1α (+/+) mice following CASP compared to HIF-1α (-/-) mice. Our data collectively identify that HIF-1α upregulation of the acute inflammatory response depends on NF-κB following CASP.

The holy basil administration diminishes the NF-kB expression and protects alveolar epithelial cells from pneumonia infection through interferon gamma.

Bacterial pneumonia is one of the most important causes of mortality in the United States. The bacteria Klebsiella pneumoniae (KP) accounts for a significant proportion of community and hospital-acquired infections. Here, we determine that the holy basil (Ocimum sanctum) extract improves cell viability and dampens the proinflammatory cytokine response in an in vitro model of pneumonia. For this, A549, a human alveolar basal epithelial cell line, was subjected to a lethal KP model following a 24-hr pretreatment with basil extract. Bacteremia, cell viability, apoptosis, MTT assay, phagocytic capacity, cytokines, and Khe gene expression were assessed in these cells following pneumonia. Cell morphology analysis showed that holy basil protected A549 cells from KP infection-mediated effects by inhibiting cell death due to apoptosis. Additionally, in the presence of basil, A549 cells demonstrated significantly higher bactericidal capacity and phagocytosis. Administration of holy basil led to reduced expression of hypoxia-inducible factor-1/2a, nuclear factor kappa B, and Khe in the KP-infected cells while increasing interferon (IFN)-γ expression. Our results suggest that basil significantly reduced cell death in the setting of KP infection, likely via attenuation of cytokine and IFN-γ mediated signaling pathways. Holy basil is a promising therapeutic agent for managing and treating bacterial pneumonia based on its potency.

Prehospital Airway Management for Trauma Patients by First Responders in Six Sub-Saharan African Countries and Five Other Low- and Middle-Income Countries: A Scoping Review.

The global injury burden disproportionately affecting low- and middle-income countries (LMICs) is exacerbated by a lack of robust emergency medical services. Though airway management (AM) is an essential component of prehospital emergency care, the current standard of prehospital AM training and resources for first responders in LMICs is unknown. This scoping review includes articles published between January 2000 and June 2021, identified using PMC, MEDLINE, and SCOPUS databases, following PRISMA-ScR guidelines. Inclusion criteria spanned programs training formal or informal prehospital first responders. Included articles were assessed for quality using the Newcastle-Ottawa scale. Relevant characteristics were extracted by multiple authors to assess prehospital AM training. Of the initial 713 articles, 17 met inclusion criteria, representing 11 countries. Basic AM curricula were found in 11 studies and advanced AM curricula were found in nine studies. 35.3% (n = 6) of first responder programs provided no equipment to basic life support (BLS) AM training participants, reporting a median cost of $7.00USD per responder trained. Median frequency of prehospital AM intervention was reported in 31.0% (IQR: 6.0, 50.0) of patient encounters (advanced life support trainees: 12.1%, BLS trainees: 32.0%). In three studies, adverse event frequencies during intubation occurred with a median frequency of 22.0% (IQR: 21.0, 22.0). The training deficit in advanced AM interventions in LMICs suggests BLS AM courses should be prioritized, especially in sub-Saharan Africa. Prehospital AM resources are sparse and should be a priority for future development.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial.

STUDY DESIGN: Non-inferiority trial. OBJECTIVE: Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels. SETTING: Washington University in St. Louis. METHODS: Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states. RESULTS: C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CSseated = 0.89, CSsupine = 0.47). Foam neck braces are inferior (CSseated = 2.35, CSsupine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior. CONCLUSIONS: Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Identifying a 'super-responder' phenomenon in three African countries: Implications for prehospital emergency care training.

BACKGROUND: Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The WHO recommends training lay first responders (LFRs) as the first step toward EMS development while Disease Control Priorities (DCP) suggests training 0.5%-1% of a population for adequate emergency catchment. After launching three LFR programs in Africa, this study investigated subsequent skill usage and conducted demographic analyses to inform future recruitment of high-responding LFRs. METHODS: Demographic characteristics and individual LFR intervention frequencies were collected from a pooled sample of 887 of 1,291 total LFRs (68.7%) trained across programs launched in a staggered fashion between 2016-2019 in Uganda, Chad, and Sierra Leone. A Kruskal-Wallis Rank-Sum test assessed between-group differences among demographics in each location. Spearman's r was used to determine the relationship between response frequency and LFR characteristics. RESULTS: Most LFRs trained did not use skills post-training (median LFR interventions=0.0 interventions/year [IQR:0.0,5.0]). Right-skewed intervention frequency distributions demonstrate high-responding outlier responder groups do exist in all locations (p<0.0001). Median LFR interventions of the top quartile of these active LFRs ("super-responders") was 26.0 interventions/year (IQR:16.7,35.0). "Super-responders" witnessed more road traffic injuries (RTIs) prior to training (p=0.033). LFRs who never responded were significantly younger (p=0.0020). Significant correlations were demonstrated between pooled RTIs witnessed and intervention frequency (r=0.13, p=0.032) and age and intervention frequency in Sierra Leone (r=-0.15, p=0.019). CONCLUSION: Current DCP-recommended training of 0.5-1% of a given population for adequate emergency catchment may be an inefficient means of building emergency care capacity. Recruiting "super-responders" with select characteristics may achieve similar coverage while conserving valuable training resources in resource-limited African settings.

Cost-Effectiveness of Lay First Responders Addressing Road Traffic Injury in Sub-Saharan Africa.

BACKGROUND: To investigate the cost-effectiveness of training lay first responders (LFRs) to address road traffic injury (RTI) in sub-Saharan Africa (SSA) as the first step toward formal emergency medical services (EMS) development. MATERIALS/METHODS: Cost data from five LFR programs launched between 2008 and 2019 in SSA was collected for LFR cost estimation, including three prospective collections from our group. We systematically reviewed literature and projected aggregate disability-adjusted life years (DALYs) from RTI in SSA that are addressable by LFRs to inform cost-effectiveness ratios ($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP) to determine the cost-effectiveness of LFRs addressing RTIs in SSA, following WHO-CHOICE guidelines, which state cost-effectiveness ratios less than GDP per capita are considered "very cost-effective." RESULTS: Average annual cost per LFR trained across five programs was calculated to be 16.32USD (training=4.04USD, supplies=12.28USD). Following WHO and Disease Control Priorities recommendations for adequate emergency catchment, initial training of 750 LFRs per 100,000 people would cost 12,239.47USD with projected total annual DALYs averted equal to 227.7 per 100,000. Cost per DALY averted would therefore be 53.75USD with appropriate LFR availability, less than sub-Saharan African GDP per capita (1,585.40USD) and the lowest sub-Saharan African GDP per capita (Burundi, 261.20USD). CONCLUSION: Following WHO-CHOICE guidelines, training LFRs can be a highly cost-effective means to address RTI morbidity and mortality across sub-Saharan Africa. With EMS unavailable for 91.3% of the African population, training LFRs can be an affordable first step toward formal EMS development.

One-Year Functional, Cognitive, and Psychological Outcomes Following the Use of Extracorporeal Membrane Oxygenation in Coronavirus Disease 2019: A Prospective Study.

To prospectively describe 1-year outcomes, with a focus on functional outcome, cognitive outcome, and the burden of anxiety, depression, and post-traumatic stress disorder, in coronavirus disease 2019 patients managed with extracorporeal membrane oxygenation. DESIGN: Prospective case series. SETTING: Tertiary extracorporeal membrane oxygenation center in the United States. PATIENTS: Adult coronavirus disease 2019 acute respiratory distress syndrome patients managed with extracorporeal membrane oxygenation March 1, 2020, to July 31, 2020. INTERVENTIONS: Baseline variables, treatment measures, and short-term outcomes were obtained from the medical record. Survivors were interviewed by telephone, a year following the index intensive care admission. Functional outcome was assessed using the modified Rankin Scale and the World Health Organization Disability Assessment Scale 2.0. Cognitive status was assessed with the 5-minute Montreal Cognitive Assessment. The Hospital Anxiety and Depression Scale was used to screen for anxiety and depression. Screening for post-traumatic stress disorder was performed with the Posttraumatic Stress Disorder Checklist 5 instrument. MEASUREMENTS AND MAIN RESULTS: Twenty-three patients were managed with extracorporeal membrane oxygenation, 14 (61%) survived to hospital discharge. Thirteen (57%) were alive at 1 year. One patient was dependent on mechanical ventilation, another intermittently required supplemental oxygen at 1 year. The median modified Rankin Scale score was 2 (interquartile range, 1-2), median World Health Organization Disability Assessment Scale 2.0 impairment score was 21% (interquartile range, 6-42%). Six of 12 previously employed individuals (50%) had returned to work, and 10 of 12 (83%) were entirely independent in activities of daily living. The median Montreal Cognitive Assessment score was 14 (interquartile range, 13-14). Of 10 patients assessed with Hospital Anxiety and Depression Scale, 4 (40%) screened positive for depression and 6 (60%) for anxiety. Four of 10 (40%) screened positive for post-traumatic stress disorder. CONCLUSIONS: Functional impairment was common a year following the use of extracorporeal membrane oxygenation in coronavirus disease 2019, although the majority achieved independence in daily living and about half returned to work. Long-term anxiety, depression, and post-traumatic stress disorder were common, but cognitive impairment was not.

Prehospital care for traumatic spinal cord injury by first responders in 8 sub-Saharan African countries and 6 other low- and middle-income countries: A scoping review.

INTRODUCTION: Traumatic spinal cord injury (TSCI) constitutes a considerable portion of the global injury burden, disproportionately affecting low- and middle-income countries (LMICs). Prehospital care can address TSCI morbidity and mortality, but emergency medical services are lacking in LMICs. The current standard of prehospital care for TSCI in sub-Saharan Africa and other LMICs is unknown. METHODS: This review sought to describe the state of training and resources for prehospital TSCI management in sub-Saharan Africa and other LMICs. Articles published between 1 January 1995 and 1 March 2020 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for TSCI. Two reviewers assessed full texts meeting inclusion criteria for quality using the Newcastle-Ottawa Scale and extracted relevant characteristics to assess trends in the state of prehospital TSCI care in sub-Saharan Africa and other LMICs. RESULTS: Of an initial 482 articles identified, 23 met inclusion criteria, of which ten were set in Africa, representing eight countries. C-spine immobilization precautions for suspected TSCI patients is the most prevalent prehospital TSCI intervention for and is in every LMIC first responder program reviewed, except one. Numerous first responder programs providing TSCI care operate without C-collar access (n = 13) and few teach full spinal immobilization (n = 5). Rapid transport is most frequently reported as the key mortality-reducing factor (n = 11). Despite more studies conducted in the Southeast Asia/Middle East (n = 13), prehospital TSCI studies in Africa are more geographically diverse, but responder courses are shorter, produce fewer professional responders, and have limited C-collar availability. DISCUSSION: Deficits in training and resources to manage TSCI highlights the need for large prospective trials evaluating alternative C-spine immobilization methods for TCSI that are more readily available across diverse LMIC environments and the importance of understanding resource variability to sustainably improve prehospital TSCI care.

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhage.

Acute hemorrhagic cholecystitis is a rare, life-threatening condition that can be further complicated by perforation of the gallbladder. We describe a patient with clinical and radiologic findings of acute cholecystitis with a gallbladder rupture and massive intra-abdominal bleeding. Our patient is a 67-year-old male who presented with an ischemic stroke and was treated with early tissue plasminogen activator. His hospital course was complicated by a fall requiring posterior spinal fusion surgery. He recovered well, but several days later developed subxiphoid and right upper quadrant pain and an episode of hemobilia and melena. A computed tomography scan revealed an inflamed, distended gallbladder with indistinct margins and a large hematoma in the gallbladder fossa extending to the right paracolic gutter. The patient also developed hemodynamic instability concerning for hemorrhagic shock. He underwent an emergent laparoscopic converted to open subtotal fenestrating cholecystectomy with abdominal washout for management of his acute hemorrhagic cholecystitis with massive intra-abdominal hemorrhage. Prompt recognition of this lethal condition in high-risk patients is crucial for optimizing patient care.