A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare.

Importance: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols.

Orthopaedic Trauma in Low-resource Settings: Measuring Value.

There is increasing recognition of both the impact and value of trauma care in low- and middle-income countries (LMICs). However, data supporting the value of musculoskeletal trauma care specifically are lacking. This review discusses methods of economic analysis relevant to low-resource settings and provides a review of cost studies related to orthopaedic trauma care in these settings.

Erratum: The Masquelet induced-membrane technique: an option for a tertiary-referral conflict setting.

[This corrects the article DOI: 10.1093/jscr/rjz149.].

The Masquelet induced-membrane technique: an option for a tertiary-referral conflict setting.

A post-traumatic, infected, non-union of a long bone is a significant challenge to orthopaedic surgeons, especially in zones of conflict and humanitarian settings. We describe a 32-year-old man treated with the two-stage Masquelet procedure for an infected non-union, and the processes required to achieve clinical bony union. The initial injury was a gunshot wound through the left proximal tibia, which lay untreated for three months before the first definitive surgical procedure.

Improving Management of Limb Injuries in Disasters and Conflicts.

It has become clear that disaster relief needs to transition from good intentions or a charity-based approach to a professional, outcome-oriented response. The practice of medicine in disaster and conflict is a profession practiced in environments where lack of resources, chaos, and unpredictability are the norm rather than the exception. With this consideration in mind, the World Health Organization (WHO; Geneva, Switzerland) and its partners set out to improve the disaster response systems.

An Estimation of the Burden of Sports Injuries among African Adolescents.

The extent to which sports injuries contribute to the burden of injury among adolescents in low- and middle-income countries (LMICs) is unknown. The goal of this study was to estimate the incidence of sports injuries among adolescents in Africa. Data from the World Health Organization Global School-Based Student Health surveys were used to estimate the annual number of African adolescents sustaining sports injuries.

Surgical Burden of Musculoskeletal Conditions in Low- and Middle-Income Countries.

Background: The burden of musculoskeletal conditions is growing worldwide. In low- and middle-income countries (LMIC), the burden cannot be fully estimated, due to paucity of credible data. Further, no attempt has been made so far to estimate surgical burden of musculoskeletal conditions.

Backlog and burden of fractures in Sierra Leone and Nepal: Results from nationwide cluster randomized, population-based surveys.

Background: The burden of injury is increasing worldwide; planning for its impact on population health and health systems is urgently needed, particularly in low- and middle-income countries (LMICs). This study aimed to model the burden of fractures and project costs to eliminate avertable fracture-related disability-adjusted life-years (i.e.

Cost Per DALY Averted in a Surgical Unit of a Private Hospital in India.

Backgrounds: Cost-effectiveness analysis plays an important role to guide resource allocation decisions, however, information on cost per disability-adjusted life year (DALY) averted by health facilities is not available in many developing economies, including India. We estimated cost per DALY averted for 2611 patients admitted for surgical interventions in a 106-bed private for-profit hospital in northern India.

Methods: Costs were calculated using standard costing methods for the financial year 2012-2013, and effectiveness was measured in DALYs averted using risk of death/disability, effectiveness of treatment and disability weights from 2010 global burden of disease study.

The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013.

Background: The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country.

Methods: Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition.

Background: The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

A systematic literature review of the quality of evidence for injury and rehabilitation interventions in humanitarian crises.

Introduction: Humanitarian crises continue to pose a significant threat to health; the United Nations estimates that 144 million people are directly affected by conflict or environmental disasters. During most humanitarian crises, surgical and rehabilitative interventions remain a priority.

Objectives: This review assessed the quality of evidence that informs injury and physical rehabilitation interventions in humanitarian crises.

Estimating the effectiveness of a hospital's interventions in India: impact of the choice of disability weights.

Objective: To calculate the effect of using two different sets of disability weights for estimates of disability-adjusted life-years (DALYs) averted by interventions delivered in one hospital in India.

Methods: DALYs averted by surgical and non-surgical interventions were estimated for 3445 patients who were admitted to a 106-bed private hospital in a semi-urban area of northern India in 2012-2013. Disability weights were taken from global burden of disease (GBD) studies.

Estimation of Surgery Capacity in Haiti: Nationwide Survey of Hospitals.

Background: Haiti's surgical capacity was significantly strained by the 2010 earthquake. As the government and its partners rebuild the health system, emergency and essential surgical care must be a priority.

Methods: A validated, facility-based assessment tool developed by WHO was completed by 45 hospitals nationwide.

What factors influence the production of orthopaedic research in East Africa? A qualitative analysis of interviews.

Background: Research addressing the burden of musculoskeletal disease in low- and middle-income countries does not reflect the magnitude of the epidemic in these countries as only 9% of the world's biomedical resources are devoted to addressing problems that affect the health of 90% of the world's population. Little is known regarding the barriers to and drivers of orthopaedic surgery research in such resource-poor settings, the knowledge of which would help direct specific interventions for increasing research capacity and help surgeons from high-income countries support the efforts of our colleagues in low- and middle-income countries.

Purpose: We sought to identify through surveying academic orthopaedic surgeons in East Africa: (1) barriers impeding research, (2) factors that support or drive research, and (3) factors that were identified by some surgeons as barriers and others as drivers (what we term barrier-driver overlap) as they considered the production of clinical research in resource-poor environments.

The Academic Half-Day redesigned: Improving generalism, promoting CanMEDS and developing self-directed learners.

Background: The Montreal Children's Hospital Pediatric Residency Program redesigned its Academic Half-Day based on program concerns consistent with the published literature. These concerns included inadequate preparation for general paediatric practice, gaps in CanMEDS education and exclusive use of didactic lectures. Novel instructional methods included monthly simulation sessions to learn CanMEDS competencies, increased use of general paediatricians as instructors, implementation of a 'systems-based' curriculum and development of self-directed learning skills through activities such as 'Residents as Teachers'.

The burden of musculoskeletal disease in Sierra Leone.

Background: Musculoskeletal disease is a major cause of disability in the global burden of disease, yet data regarding the magnitude of this burden in developing countries are lacking. The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey was designed to measure the incidence and prevalence of surgically treatable conditions, including musculoskeletal conditions, in patients in low- and middle-income countries, and was administered in the West African nation of Sierra Leone in 2012.

Purpose: We attempted to quantify the burden of potentially treatable musculoskeletal conditions in patients in Sierra Leone.

Volunteer opportunities for orthopaedic surgeons in the developing world.

Orthopaedic surgeons have consistently shown interest in volunteering to aid needy populations throughout the world. Service missions, building surgical capacity, and disaster relief have benefited from the volunteer efforts of orthopaedic surgeons. The burden of musculoskeletal disease is high and will continue to increase as motorization and development reach more people.

Chronic osteomyelitis management in austere environments: the International Committee of the Red Cross experience.

Background: Chronic osteomyelitis (COM) causes major physical disability. In situations of limited resources and war zones, western world treatments are neither affordable nor sustainable. The International Committee of the Red Cross has established a COM treatment project in the Democratic Republic of Congo, with emphasis on affordability and sustainability.

Burden, need, or backlog: a call for improved metrics for the global burden of surgical disease.

The global burden of disease (GBD) has been measured primarily through the use of the DALY metric. Using this approach, preliminary estimates were that 11% of the GBD is surgical. However, prior work has questioned specific aspects of the GBD methodology as well as its practicality.

Development and validation of a self-efficacy scale for clinical decision-making in general paediatrics.

Background: Success in a task is not only related to skill, but it is also related to 'self-efficacy', or belief in one's capability to perform that task. No tool currently exists to measure self-efficacy in clinical decision-making in general paediatrics.

Objective: To develop and provide validity evidence for the General Pediatrics-specific Self-Efficacy (GPedsSE) scale.

Time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems.

Objective: To investigate the use of time intervals in the treatment of fractured femurs as indicators of the quality of trauma systems.

Methods: Time intervals from injury to admission, admission to surgery and surgery to discharge for patients with isolated femur fractures in four low- and middle-income countries were compared with the corresponding values from one German hospital, an Israeli hospital and the National Trauma Data Bank of the United States of America by means of Student's t-tests. The correlations between the time intervals recorded in a country and that country's expenditure on health and gross domestic product (GDP) were also evaluated using Pearson's product moment correlation coefficient.

A square peg in a round hole? Challenges with DALY-based "burden of disease" calculations in surgery and a call for alternative metrics.

Introduction: In recent years, surgical providers and advocates have engaged in a growing effort to establish metrics to estimate capacity for surgical services as well the burden of surgical diseases in resource-limited settings. The burden of disease (BoD) studies have established the disability-adjusted life year (DALY) as the primary metric to measure both disability and premature mortality. Nonetheless, DALY-based approaches present methodological challenges, some of which are unique to surgical conditions, not fully addressed through the multiple iterations of the BoD studies, including the most recent study.

The state of US health, 1990-2010: burden of diseases, injuries, and risk factors.

Importance: Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy.

Objectives: To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries.

Design: We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries.