Orthopedic trauma surgery and hospital cost analysis in refugees; the effect of the Syrian civil War

Antibiotic susceptibility patterns at the Médecins Sans Frontières (MSF) Acute Trauma Hospital in Aden, Yemen: a retrospective study from January 2018 to June 2021

Background

Antimicrobial resistance (AMR) is an urgent global health concern, especially in countries facing instability or conflicts, with compromised healthcare systems. Médecins Sans Frontières (MSF) established an acute trauma hospital in Aden, Yemen, treating mainly war-wounded civilians, and implemented an antimicrobial stewardship (AMS) programme. This study aimed to describe clinical characteristics and identify antibiotic susceptibility patterns representative of patients treated with antibiotics.

Methods

Retrospective cross-sectional study using routinely collected data from all patients treated with antibiotics in the MSF-Aden Acute Trauma hospital between January 2018 and June 2021. Routine clinical data from patients' files was entered into an AMS electronic database and microbiological data were entered into WHONET. Both databases were imported and merged in REDCap and analysed using RStudio.

Results

Three hundred and sixty-three of 481 (75%) included patients were injured by violence-related trauma. Most were men aged 19-45 years (n = 331; 68.8%). In total, 598 infections were diagnosed and treated. MDR organisms were identified in 362 (60.5%) infections in 311 (65%) patients. Skin and soft-tissue infections (SSTIs) (n = 143; 24%) were the most common, followed by osteomyelitis (n = 125; 21%) and intra-abdominal-infections (IAIs) (n = 116; 19%), and 111 (19%) secondary bloodstream infections were identified. Escherichia coli was the most frequently identified pathogen, causing IAI (n = 87; 28%) and SSTI (n = 43; 16%), while Staphylococcus aureus caused mainly osteomyelitis (n = 84; 19%). Most Gram-negatives were ESBL producers, including E. coli (n = 193; 81.4%), Klebsiella pneumoniae (n = 72; 77.4%) and Enterobacter cloacae (n = 39; 50%) while most S. aureus were methicillin resistant (n = 93; 72.6%).

Conclusions

High rates of MDR were found. This information will facilitate a comprehensive review of the empirical antibiotic treatment guidelines.

Medical aid to war victims in Syria in 2019: a report of organized healthcare support from a charity organization

Background

In 2011, a civil war started in Syria, which is on-going and has reached a death toll of over 400,000 people. Humanitarian organizations, including Aid to The Church in Need (ACN), have strived to provide help and medical support to the civilian victims.

Methods

We performed a retrospective analysis of data gathered in ACN projects in Syria in 2019. The datasets included descriptions of diseases, treatments, costs, cities, and hospitals. For each patient, we assigned the following additional categories: type of help (treatment, diagnosis, or nonmedical), type of treatment (medical or surgical), medical specialty, gross anatomic region, and presence of trauma.

Results

A total of 3835 patients benefited from ACN support in Syria in 2019. The majority of financial support went towards treatment (78.4%), while other support went towards nonmedical help (15.7%) or providing a diagnosis (5.9%). Among treatments, 66.6% were medical and 33.4% surgical. The most common medical specialty was internal medicine (48.4%), followed by public health (13.7%) and surgery (7.3%). Anatomic region was undefined in 68.3% of cases and, when defined, was most commonly the abdominal cavity and pelvis (13%). The vast majority of cases 95.1%) were not associated with trauma. Procedural costs were highest in the Valley of Christians region, and lowest in Tartous. Network graphs were used to visualize the three most common diagnoses and treatments for each medical specialty.

Conclusions

The present report describes the treatment of war victims in Syria in 2019. The patients lacked the most basic medical or surgical healthcare. Charity organizations, like ACN, constitute a valuable source of information about the healthcare of war victims. Unfortunately, the methods of describing medical treatment provided to civilian victims remain underdeveloped. Future studies will require the cooperation of healthcare providers, humanists, and social workers. The present findings can help to optimize the provision of humanitarian help by charity organizations, by tailoring projects to the specific needs of Syrian war victims.

Empirical Analysis of the Nursing Effect of Intelligent Medical Internet of Things in Postoperative Osteoarthritis

In order to analyze the effect of postoperative nursing for bones and joints, this paper combines the intelligent medical Internet of Things technology to construct a postoperative nursing system for bones and joints and conducts research on postoperative nursing methods for bones and joints. Moreover, this paper realizes the integration of “voice data + video data + software data” and the integration of “wired network + RFID sensor network + WIFI wireless network.” In this paper, this paper constructs an intelligent medical IoT nursing analysis system, combines actual cases to analyze the effect of postoperative nursing of bones and joints, and selects an intelligent IoT system and statistical software SPSS23.0 to complete statistical processing.

A strong reconstruction option for tissue loss on hand and wrist due to firearm injury in the Syrian war: Reverse posterior interosseous flap

All of the injuries were the open injuries with bone or tendon structures in the hand and wrist region as a result of the firearm injury (FI) in the Syria. In the study, we assessed the outcomes of the posterior interosseous flap (PIF) on hand and wrist that we used for the Syrian injured people including civilians and soldiers in this War. PIF was applied to 77 patients who composed of 43 female and 34 male that all patients were evaluated for tissue loss resulting from gunshot wounds and injured in the War between 2014 and 2020 years with tissue loss in hand and wrist as a result of FI. The flap survival rate was 100% for all the patients. The dimensions of flaps ranged from 4.1 cm × 2.2 cm to 9cm × 5.4 cm with 0.51 ± 0.12 cm thickness. The mean pedicle length was 6.33 ± 1.08 cm. The surgery for PIF took 68.8 ± 22.1 minutes, while blood loss was 60 ± 24 mL. We observed no palsy conditions including the posterior interosseous nerve. The donor sites were treated by primary intention in the patients. We found the superiority of PIF with the postoperative follow-up comfort, ease of fracture healing, easy and fast, easy-to-apply method and no second additional session requirement in FI patients. We did not detect flap necrosis in any patient or observe a flap-related complication. As a result of the present study, it strongly supports the thesis that PIF is the best option in these cases.

Injury characteristics and management of orthopaedic trauma in refugee children

PURPOSE

Several factors affect injury types in childhood. The aim of the study was to evaluate the musculoskeletal injury types, treatment modalities, and demographic characteristics of refugee children and to reveal the differences from native children.

METHODS

A total of 1297 patients (897 females, 400 males) treated in our clinic between January 2014 and January 2019 were included in the study. The mean age of the patients was 8.9 ± 5.1 in refugees and 7.5 ± 4.6 in the native group (range, 0-18 years). The patients were evaluated in terms of age, gender, mechanism of injury, location and type of fracture, presence of accompanying injuries, surgical technique, complications, and treatment modalities.

RESULTS

The trauma mechanism differed significantly between the groups, high-energy traumas such as falling from a height, fight/assault injury, gunshot injury, and work injury were found more frequently in the refugee group (p = 0.001). The rates of CRIF, ORIF, graft/flap surgery, and hospitalization time were observed to be significantly higher in the refugee group (p = 0.013). No significant difference was observed between groups in terms of demographic distribution, injury location, and complications.

CONCLUSION

This population-based, cross-sectional study emphasizes that the refugee children have different injury mechanisms. Improved living conditions may reduce musculoskeletal injury in this population.

Regenerative rehabilitation of catastrophic extremity injury in military conflicts and a review of recent developmental efforts

AIM OF THE REVIEW

This review aims to describe the current state of regenerative rehabilitation of severe military extremity injuries, and promising new therapies on the horizon.

DISCUSSION

The nature of warfare is rapidly shifting with information operations, autonomous weapons, and the threat of full-scale peer adversary conflicts threatening to create contested environments with delayed medical evacuation to definitive care. More destructive weapons will lead to more devastating injuries, creating new challenges for limb repair and restoration. Current paradigms of delayed rehabilitation following initial stabilization, damage control surgery, and prolonged antibiotic therapy will need to shift. Advances in regenerative medicine technologies offer the possibility of treatment along the continuum of care. Regenerative rehabilitation will begin at the point of injury and require a holistic, organ-systems approach.

CONCLUSIONS

Both technological improvements and a rapidly advancing understanding of injury pathophysiology will contribute to improved limb-salvage outcomes, and shift the calculus away from early limb amputation.

Management of orthopaedic injuries in Libyan civil war: experiences of a distant hospital

AIM OF THE STUDY

In this study, we aimed to evaluate the musculoskeletal injury types, infections, and treatments of the patients injured in Libyan civil war.

METHODS

A total of 291 patients (288 male, 3 female) treated in our clinic, between November 2011 and April 2020, were included in our retrospective study. Patients' age, injury severity score (ISS), injury type, mechanism, location, accompanying traumas, infection, and operations in Libya and in our clinic were evaluated.

RESULTS

Injuries were caused by gunshots in 172 patients, by explosives in 56, by missiles in eight, and by different mechanisms in the remaining 55 patients. Injuries were located mostly in lower extremities, followed by upper extremities and by both extremities. The most common fracture was tibial fractures, followed with femur and humerus. Plate-screw fixation was performed for 82 cases, intramedullary nailing for 42, external fixator for 41, K-wire fixation for 27, foreign body excisions for 26, arthrodesis for 15, amputation for , arthroplasty for 11, and soft tissue operations for 78. Infection was present among 50 (% 17.2) patients. Complications were seen in five patients. Three patients needed implant removal due to infection, one patient had a plate fracture, and one patient died because of sepsis.

DISCUSSION

Difficulties in the treatment of war injuries begin in the battlefield. Patients' transfers and treatments may not be provided properly due to unsuitable conditions. Hospitals in neighbouring and distant countries can be helpful for supporting the treatment of increased numbers of injured patients.

CONCLUSION

Wars cause excessive numbers of injuries. In this study, we want to show that hospitals far from war zones can be considered as alternatives for treatment of these injuries.

Laparotomy Due to War-Related Penetrating Abdominal Trauma in Civilians: Experience From Syria 2011-2017

OBJECTIVES

Penetrating abdominal trauma is one of the injuries that could affect civilians in wartime. This retrospective study investigates the commonly injured abdominal organs, and the impact of multiple injured organs on mortality.

METHODS

We reviewed the operating room (OR) logs of patients who presented to the surgical emergency department (SED) at Al-Mouwasat University Hospital with war-related abdominal penetrating trauma requiring exploratory laparotomy between April 1, 2011 and December 31, 2017.

RESULTS

Of 7826 patients with traumatic injuries, 898 patients (11.5%) required exploratory laparotomy. Of all patients who had an exploratory laparotomy (n = 898), 58 patients (6.5%) died in the perioperative period. Regarding complete laparotomies (n = 873 patients), small intestines, large intestines, and liver were the most commonly affected organs (36.4%, 33%, 22.9%, respectively). A total of 92 patients (10.2%) had negative laparotomy in which all the abdominal organs were not injured. The perioperative mortality rate (POMR) increased when more organs/organ systems were injured per patient reaching a peak at 3 organs/organ systems injuries with a POMR of 8.3%. POMR was highest in patients with musculoskeletal injuries (18.2%), followed by vascular injuries (11.8%), and liver injuries (7%).

CONCLUSIONS

The management of civilians' abdominal injuries remains a challenge for general and trauma surgeons, especially the civilian trauma team. The number and type of injured organs and their correlation with mortality should be considered during surgical management of penetrating abdominal injuries.

Orthopedic treatment, complications, and cost analysis of 67 soldiers injured in a three-month period

OBJECTIVES

This study aims to analyze the musculoskeletal injury types, injury mechanisms, treatment modalities, complications, and costs of 67 consecutive soldiers wounded in the battlefield in Syria civil war over a period of three months.

PATIENTS AND METHODS

This retrospective study was conducted between January 2018 and March 2018 at Kilis State Hospital. The study included 67 male patients (median age 28.5 years; range, 15 to 46 years). Patients' ages, injury mechanisms, fracture types, fracture locations, injury severity scores, mangled extremity severity scores, complications, and treatment costs were evaluated.

RESULTS

Twenty-three patients were injured due to handmade explosives, 21 patients due to gunshots, 16 patients due to landmines, five patients due to rockets, and two patients due to grenades. A total of 35.8% of the patients (n=24) had concomitant trauma. The mean hospitalization period was 10.2 days (range, 1-45 days). A total of 88 treatments were performed on these patients. Thirty-six of these treatments were external fixators, 21 were amputations, 12 were open reduction internal fixations, seven were closed reduction internal fixations, five were intramedullary nailings, three were cannulated screws, three were fasciotomies, and one was an arthrodesis. The treatment costs ranged from 1,577 to 296,286 Turkish Liras. Complications were observed in 17 patients and 11 of them developed infections, three of them had compartment syndrome, and three died during the hospitalization period.

CONCLUSION

The increase in warfare technology is correlated with the severity of military injuries in the battlefields. These injuries still lead to high traumatic amputation rates, high-risk complications, and high costs.

Emergency department visits of Syrian refugees and the cost of their healthcare

The aim of this study was to evaluate the demographic and clinical characteristics of Emergency Department (ED) visits made by Syrian refugees and to assess the cost of their healthcare. This retrospective study was conducted in adult Syrians who visited the ED of Adiyaman University Training and Research Hospital, Adiyaman Province, Turkey, between 01 January and 31 December 2015. We evaluated 10,529 Syrian refugees who visited the ED, of whom 9,842 were included in the study. The number of ED visits significantly increased in 2015 compared with 2010; the increase in the proportion of total ED visits was 8% (n = 11,275, dif: 8%, CI 95%: 7.9- 8.2, p < 0.001). Of this 8%, 6.5% were visits made by Syria refugees and the remaining 1.5% accounted for the visits made by other individuals. Upper respiratory tract infections (URTI) were the diseases most frequently presented (n = 4,656; 47.3%), and 68.5% of ED visits were inappropriate (n = 6,749). The median ED length of stay (LOS) of the Syrian refugees was significantly longer than that of the other individuals visiting the ED (p < 0.001). The total cost of the healthcare of the Syrian refugees who visited the ED was calculated as US$ 773,374.63. This study showed that Syrian refugees have increased the proportion of ED visits and the financial healthcare burden. The majority of ED visits made by Syrian refugees were inappropriate. In addition, their ED LOS was longer than that of other individuals making ED visits.