• Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial

      Älgå, A; Haweizy, R; Bashaireh, K; Wong, S; Lundgren, KC; von Schreeb, J; Malmstedt, J (Elsevier, 2020-03-01)
      Background: In armed conflict, injuries among civilians are usually complex and commonly affect the extremities. Negative pressure wound therapy (NPWT) is an alternative to standard treatment of acute conflict-related extremity wounds. We aimed to compare the safety and effectiveness of NPWT with that of standard treatment. Methods: In this pragmatic, randomised, controlled superiority trial done at two civilian hospitals in Jordan and Iraq, we recruited patients aged 18 years or older, presenting with a conflict-related extremity wound within 72 h after injury. Participants were assigned (1:1) to receive either NPWT or standard treatment. We used a predefined, computer-generated randomisation list with three block sizes. Participants and their treating physicians were not masked to treatment allocation. The primary endpoint was wound closure by day 5. The coprimary endpoint was net clinical benefit, defined as a composite of wound closure by day 5 and freedom from any bleeding, wound infection, sepsis, or amputation of the index limb. Analysis was by intention to treat. The trial is registered with ClinicalTrials.gov, number NCT02444598, and is closed to accrual. Findings: Between June 9, 2015, and Oct 24, 2018, 174 patients were randomly assigned to either the NPWT group (n=88) or the standard treatment group (n=86). Five patients in the NPWT group and four in the standard treatment group were excluded from the intention-to-treat analysis. By day 5, 41 (49%) of 83 participants in the NPWT group and 49 (60%) of 82 participants in the standard treatment group had closed wounds, with an absolute difference of 10 percentage points (95% CI -5 to 25, p=0·212; risk ratio [RR] 0·83, 95% CI 0·62 to 1·09). Net clinical benefit was seen in 33 (41%) of 81 participants in the NPWT group and 34 (44%) of 78 participants in the standard treatment group, with an absolute difference of 3 percentage points (95% CI -12 to 18, p=0·750; RR 0·93, 95% CI 0·65 to 1·35). There was one in-hospital death in the standard treatment group and none in the NPWT group. The proportion of participants with sepsis, bleeding leading to blood transfusion, and limb amputation did not differ between groups. Interpretation: NPWT did not yield superior clinical outcomes compared with standard treatment for acute conflict-related extremity wounds. The results of this study not only question the use of NPWT, but also question the tendency for new and costly treatments to be introduced into resource-limited conflict settings without supporting evidence for their effectiveness. This study shows that high-quality, randomised trials in challenging settings are possible, and our findings support the call for further research that will generate context-specific evidence. Funding: The Stockholm County Council, the Swedish National Board of Health and Welfare, and Médecins Sans Frontières.
    • North American pediatric surgery fellows' preparedness for humanitarian surgery

      Traynor, MD; Trelles, M; Hernandez, MC; Dominguez, LB; Kushner, AL; Rivera, M; Zielinski, MD; Moir, CR (Elsevier, 2019-11-29)
      Introduction: The overwhelming burden of pediatric surgical need in humanitarian settings has prompted mutual interest between humanitarian organizations and pediatric surgeons. To assess adequate fit, we correlated pediatric surgery fellowship case mix and load with acute pediatric surgical relief efforts in conflict and disaster zones. Methods: We reviewed pediatric (age < 18) cases logged by the Médecins Sans Frontières Operational Centre Brussels (MSF-OCB) from a previously validated and published database spanning 2008-2014 and cases performed by American College of Graduate Medical Education (ACGME) pediatric surgery graduates from 2008 to 2018. Non-operative management for trauma, endoscopic procedures, and basic wound care were excluded as they were not tracked in either dataset. ACGME procedures were classified under 1 of 32 MSF pediatric surgery procedure categories and compared using chi-squared tests. Results: ACGME fellows performed procedures in 44% of tracked MSF-OCB categories. Major MSF-OCB pediatric cases were comprised of 62% general surgery, 23% orthopedic surgery, 9% obstetrical surgery, 3% plastic/reconstructive surgery, 2% urogynecologic surgery, and 1% specialty surgery. In comparison, fellows' cases were 95% general surgery, 0% orthopedic surgery, 0% obstetrical surgery, 5% urogynecologic surgery, and 1% specialty surgery. Fellows more frequently performed abdominal, thoracic, other general surgical, urology/gynecologic, and specialty procedures, but performed fewer wound and burn procedures (all p < 0.05). Fellows received no experience in Cesarean section or open fracture repair. Fellows performed a greater proportion of surgeries for congenital conditions (p < 0.05). Conclusion: While ACGME pediatric surgical trainees receive significant training in general and urogynecologic surgical techniques, they lack sufficient case load for orthopedic and obstetrical care - a common need among children in humanitarian settings. Trainees and program directors should evaluate the fellow's role and scope in a global surgery rotation or provide advanced preparation to fill these gaps. Upon graduation, pediatric surgeons interested in humanitarian missions should seek out additional orthopedic and obstetrical training, or select missions that do not require such skillsets.
    • Open letter to young surgeons interested in humanitarian surgery

      Chu, K; South African Medical Unit, Médecins Sans Frontières, South Africa (2010-02-01)
    • Operative mortality in resource-limited settings: the experience of Medecins Sans Frontieres in 13 countries.

      Chu, K M; Ford, N; Trelles, M; Medecines Sans Frontieres (2010-08)
      OBJECTIVE: To determine operative mortality in surgical programs from resource-limited settings. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study of 17 surgical programs in 13 developing countries by 1 humanitarian organization, Médecins Sans Frontières, was performed between January 1, 2001, and December 31, 2008. Participants included patients undergoing surgical procedures. MAIN OUTCOME MEASURE: Operative mortality. Determinants of mortality were modeled using logistic regression. RESULTS: Between 2001 and 2008, 19,643 procedures were performed on 18,653 patients. Among these, 8329 procedures (42%) were emergent; 7933 (40%) were for obstetric-related pathology procedures and 2767 (14%) were trauma related. Operative mortality was 0.2% (31 deaths) and was associated with programs in conflict settings (adjusted odds ratio [AOR] = 4.6; P = .001), procedures performed under emergency conditions (AOR = 20.1; P = .004), abdominal surgical procedures (AOR = 3.4; P = .003), hysterectomy (AOR = 12.3; P = .001), and American Society of Anesthesiologists classifications of 3 to 5 (AOR = 20.2; P < .001). CONCLUSIONS: Surgical care can be provided safely in resource-limited settings with appropriate minimum standards and protocols. Studies on the burden of surgical disease in these populations are needed to improve service planning and delivery. Quality improvement programs are needed for the various stakeholders involved in surgical delivery in these settings.
    • Operative Procedures in the Elderly in Low-Resource Settings: A Review of Médecins Sans Frontières Facilities

      Wong, E G; Trelles, M; Dominguez, L; Mupenda Mwania, J; Kasonga Tshibangu, C; Haq Saqeb, S; Hazrati, K U R; Gupta, S; Burnham, G; Kushner, A L (SpringerLink, 2014-12-02)
      As the demographic transition occurs across developing countries, an increasing number of elderly individuals are affected by disasters and conflicts. This study aimed to evaluate the elderly population that underwent an operative procedure at MSF facilities.
    • Operative Procedures in the Elderly in Low-Resource Settings: A Review of Médecins Sans Frontières Facilities: Reply

      Wong, E G; Trelles, M; Dominguez, L; Mupenda Mwania, J; Kasonga Tshibangu, C; Saqeb, S H; Hazrati, K U R; Gupta, S; Burnham, G; Kushner, A L (SpringerLink, 2015-04-22)
    • Operative trauma in low-resource settings: The experience of Médecins Sans Frontières in environments of conflict, postconflict, and disaster

      Wong, Evan G; Dominguez, Lynette; Trelles, Miguel; Ayobi, Samir; Hazraty, Khalil Rahman; Kasonga, Cheride; Basimuoneye, Jean-Paul; Santiague, Lunick; Kamal, Mustafa; Rahmoun, Alaa; et al. (Elsevier - We regret that this article is behind a paywall., 2015-05)
      Conflicts and disasters remain prevalent in low- and middle-income countries, and injury remains a leading cause of death worldwide. The objective of this study was to describe the operative procedures performed for injury-related pathologies at facilities supported by Médecins Sans Frontières (MSF) to guide the planning of future responses.
    • [Orthopedic Surgery with Limited Resources After Mass Disasters and During Armed Conflicts : First International Guidelines for the Management of Limb Injuries and the Experience of Doctors Without Borders]

      Osmers, I (SpringerLink, 2017-08-29)
      Disasters and armed conflicts are often the unfortunate basis for aid projects run by Doctors Without Borders/Médecins Sans Frontières (MSF). The nature of war and disasters means that surgery is an integral part of this medical emergency aid. In these situations, resources are usually limited. As a result, surgical work in these contexts differs significantly from the daily routine of a surgeon working in a highly resourced hospital. The principles of surgery do not change but surgeons must adapt their tactical approach to the changed context otherwise there is a high risk of failing to improve the health of patients and potentially jeopardizing their prospects for recovery. Every experienced war surgeon has learned new skills the hard way. The Field Guide to Manage Limb Injury in Disaster and Conflict has been written to help new surgeons who may face the challenges of disaster and war surgery and to avoid unnecessary suffering for patients ( https://icrc.aoeducation.org ). Under the guidance of the International Committee of the Red Cross (ICRC), with participation of the World Health Organization (WHO), financed by the AO Foundation, and featuring the experiences of experts from different organizations (amongst them MSF), the book details techniques and guidelines for surgery in low resource settings. The following article provides a short summary of some of the surgical challenges when working with limited resources and reflects on a few specific recommendations for so-called war surgery.
    • Pain in traumatic upper limb amputees in Sierra Leone.

      Lacoux, P; Crombie, I K; Macrae, W A; Medecins Sans Frontieres, 8, Rue St Sabin, Paris XI, France. (2002-09)
      Data on 40 upper limb amputees (11 bilateral) with regard to stump pain, phantom sensation and phantom pain is presented. All the patients lost their limbs as a result of violent injuries intended to terrorise the population and were assessed 10-48 months after the injury. All amputees reported stump pain in the month prior to interview and ten of the 11 bilateral amputees had bilateral pain. Phantom sensation was common (92.5%), but phantom pain was only present in 32.5% of amputees. Problems in translation and explanation may have influenced the low incidence of phantom pain and high incidence of stump pain. In the bilateral amputees phantom sensation, phantom pain and telescoping all showed bilateral concordance, whereas stump pain and neuromas did not show concordance. About half the subjects (56%) had lost their limb at the time of injury (primary) while the remainder had an injury, then a subsequent amputation in hospital (secondary). There was no association between the incidence of phantom pain and amputation irrespective of being primary or secondary.
    • Providing Anesthesia Care in Resource-limited Settings: A 6-year Analysis of Anesthesia Services Provided at Médecins Sans Frontières Facilities

      Ariyo, P; Trelles, M; Helmand, R; Amir, Y; Hassani, G H; Mftavyanka, J; Nzeyimana, Z; Akemani, C; Ntawukiruwabo, I B; Charles, A; et al. (Lippincott Williams & Wilkins, 2016-03-01)
      Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures.
    • Providing surgical care in Somalia: A model of task shifting.

      Chu, K M; Ford, N P; Trelles, M; Médecins sans Frontières, 49 Jorrisen St, Braamfontein 2017, Johannesburg, South Africa. kathryn_chu@yahoo.com. (2011-07)
      ABSTRACT:
    • Quality of Care in Humanitarian Surgery

      Chu, K M; Trelles, M; Ford, N P; Médecins Sans Frontières-South Africa, Johannesburg, South Africa; Department of Surgery, Johns Hopkins University, Baltimore, MD, USA; Médecins Sans Frontières–Belgium, Brussels, Belgium (2011-04-13)
      Humanitarian surgical programs are set up de novo, within days or hours in emergency or disaster settings. In such circumstances, insuring quality of care is extremely challenging. Basic structural inputs such as a safe structure, electricity, clean water, a blood bank, sterilization equipment, a post-anesthesia recovery unit, appropriate medications should be established. Currently, no specific credentials are needed for surgeons to operate in a humanitarian setting; the training of more humanitarian surgeons is desperately needed. Standard perioperative protocols for the humanitarian setting after common procedures such as Cesarean section, burn care, open fractures, and amputations and antibiotic prophylaxis, and post-operative pain management must be developed. Outcome data, especially long-term outcomes, are difficult to collect as patients often do not return for follow-up and may be difficult to trace; standard databases for post-operative infections and mortality rates should be established. Checklists have recently received significant attention as an instrument to support the improvement of surgical quality; knowing which items are most applicable to humanitarian settings remains unknown. In conclusion, the quality of surgical services in humanitarian settings must be regulated. Many other core medical activities of humanitarian organizations such as therapeutic feeding, mass vaccination, and the treatment of infectious diseases, such as tuberculosis and human immunodeficiency virus, are subject to rigorous reporting of quality indicators. There is no reason why surgery should be exempted from quality oversight. The surgical humanitarian community should pull together before the next disaster strikes.
    • "Reality rarely looks like the guidelines": a qualitative study of the challenges hospital-based physicians encounter in war wound management

      Älgå, A; Karlow Herzog, K; Alrawashdeh, M; Wong, S; Khankeh, H; Stålsby Lundborg, C (BioMed Central, 2018-06-27)
      Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use.
    • Reconstruction of Nonunion Tibial Fractures in War-Wounded Iraqi Civilians, 2006-2008: Better Late Than Never

      Fakri, R M; Al Ani, A M K; Rose, A M C; Alras, M S; Daumas, L; Baron, E; Khaddaj, S; Hérard, P; Médecins sans Frontières, Paris, France; Chronic Disease Research Centre, University of the West Indies, Bridgetown, Barbados; Epicentre, Paris, France; Women and Health Alliance (WAHA) International, Paris, France (Lippincott Williams & Wilkins, 2012-01-10)
      OBJECTIVE
    • Reconstruction of Residual Mandibular Defects by Iliac Crest Bone Graft in War-wounded Iraqi civilians, 2006-2011

      Guerrier, G; Alaqeeli, A; Al Jawadi, A; Foote, N; Baron, E; Albustanji, A; Epicentre, 8 rue Saint Sabin, 75011 Paris, France. Electronic address: guerriergilles@gmail.com. (2012-06-28)
      Our aim was to assess the long-term results, complications, and factors associated with failure of mandibular reconstructions among wounded Iraqi civilians with mandibular defects. Success was measured by the quality of bony union, and assessed radiographically and by physical examination. Failures were defined as loss of most or all of the bone graft, or inability to control infection. During the 6-year period (2006-2011), 35 Iraqi patients (30 men and 5 women, mean age 33 years, range 15-57) had residual mandibular defects reconstructed by iliac crest bone grafts. The causes were bullets (n=29), blasts (n=3), and shrapnel (n=3). The size of the defect was more than 5cm in 19 cases. Along the mandible the defect was lateral (n=14), central/lateral (n=5), lateral/central/lateral in continuity (n=6), and central in continuity (n=10). The mean time from injury to operation was 548 days (range 45-3814). All but 2 patients had infected lesions on admission. Bony fixation was ensured by locking reconstruction plates (n=27), non-locking reconstruction plates (n=6), and miniplates (n=2). Complications were associated with the reconstruction plate in 2 cases, and donor-site morbidity in 5. After a mean follow-up of 17 months (range 6-54), bony union was achieved in 28 (80%). The quality of the bone was adequate for dental implants in 23 cases (66%). Our results suggest that war-related mandibular defects can be reconstructed with non-vascularised bone grafts by multistage procedures with good results, provided that the soft tissues are in good condition, infection is controlled, and the method of fixation is appropriate. Further studies are needed to assess the role of vascularised free flaps in similar conditions.
    • Regional Anesthesia for Painful Injuries after Disasters (RAPID): Study Protocol For A Randomized Controlled Trial

      Levine, AC; Teicher, C; Aluisio, AR; Wiskel, T; Valles, P; Trelles, M; Glavis-Bloom, J; Grais, RFF (BioMed Central, 2016-11-14)
      Lower extremity trauma during earthquakes accounts for the largest burden of disaster-related injuries. Insufficient pain management is common in resource-limited disaster settings, and regional anesthesia (RA) may reduce pain in injured patients beyond current standards of care. To date, no controlled trials have been conducted to evaluate the use of RA for pain management in a disaster setting.
    • Rethinking surgical care in conflict.

      Chu, K; Trelles, M; Ford, N; Médecins Sans Frontières, Braamfontein 2017, Johannesburg, Gauteng, South Africa. (2010-01-23)
    • Saving life and limb: limb salvage using external fixation, a multi-centre review of orthopaedic surgical activities in Médecins Sans Frontières

      Bertol, M J; Van den Bergh, R; Trelles Centurion, M; Kenslor Ralph D, H; Basimuoneye Kahutsi, J-P; Qayeum Qasemy, A; Jean, J; Majuste, A; Kubuya Hangi, T; Safi, S (Springer Berlin Heidelberg, 2014-07-20)
      While the orthopaedic management of open fractures has been well-documented in developed settings, limited evidence exists on the surgical outcomes of open fractures in terms of limb salvage in low- and middle-income countries. We therefore reviewed the Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB) orthopaedic surgical activities in the aftermath of the 2010 Haiti earthquake and in three non-emergency projects to assess the limb salvage rates in humanitarian contexts in relation to surgical staff skills.
    • The short musculoskeletal functional assessment (SMFA) score amongst surgical patients with reconstructive lower limb injuries in war wounded civilians

      Teicher, C; Foote, N L; Al Ani, A M K; Alras, M S; Alqassab, S I; Baron, E; Ahmed, K; Herard, P; Fakhri, R M (Elsevier, 2014-10-24)
      The MSF programme in Jordan provides specialized reconstructive surgical care to war-wounded civilians in the region. The short musculoskeletal functional assessment score (SMFA) provides a method for quantitatively assessing functional status following orthopaedic trauma. In June 2010 the Amman team established SMFA as the standard for measuring patients' functional status. The objective of this retrospective study is to evaluate whether the SMFA scores can be useful for patients with chronic war injuries.