News & Features — 9 November 2022 at 4:16 pm

Evidence explorer: Updates and news from the academic community, Autumn 2023

Dr Holly Andrews / Anaesthetics trainee / Evidence Explorer lead / Cornwall //

Jonathan Knight / Final year medical student / UCL //

A final year medical student at UCL, Jonathan has interests in public and global health, and is currently planning his elective to Argentina. He joined the team for this quarter’s global health edit and was invaluable utilising skills in literature review and his linguistics degree to contribute to the release. 

An expedition team making their steady way to over 4000m in the French Alps by Dr Alastair Burden.

It’s been an incredibly fruitful Autumn in the academic community and here at Adventure Medic we’ve had a hard time choosing which releases to include in our quarterly highlight. As such, this time, we’ve included our extended ‘long-list’ at the foot of the page to include all articles and publications in both expedition medicine and global health that have peaked our interest over the past few months. Before that, we present a handful of what we believe are some of the most relevant and interesting publications along with a summary paragraph for those reading in a rush.

As always, do get in contact if you’d like to get involved with contributing to future releases of this feature – we always look forward to hearing from you.

Happy Reading!

Expedition and Wilderness Medicine

Trekking over a cloud inversion by Andy Rogers

This quarter we present a few papers highlighting women as a focus, not only for their involvement in and contribution to expedition medicine but we also begin to delve into the evidence that is emerging behind some of the gender inequalities in the receipt of emergency healthcare. We present not only the original research but some interesting commentary in the form of an editorial piece on the gender differences in the administration of Tranexamic Acid in major trauma. Some interesting research on the management of shoulder dislocation follows and a helpful article on the use of different types of analgesia for headache that is very translatable from the Emergency Department to the field. An article on pulmonary vascular disease at altitude is arguably the most academic paper presented this quarter but written in a manner digestible for all from the respiratory physician through to the novice doctor on their first expedition. Finally, the UIAA’s recent conference ‘Women going to altitude’ has kindly been recorded and made available to all – a must watch.

Use of tranexamic acid in major trauma: a sex-disaggregated analysis of the Clinical Randomisation of an Antifibrinolytic in significant haemorrhage (CRASH-2 and 3 trials) and UK trauma registry (trauma and audit research network) data
Nutbeam T, Roberts I, Weeked L et al. British Journal of Anaesthesia. August 2022. 

Inequalities in healthcare exist in many forms both nationally and globally. Not only are they the product of large-scale political and financial difficulties but often many can be attributed to the complex interactions of our own everyday unconscious bias. This analysis article uses the well-known CRASH-2 and 3 data along with the huge database of the Trauma and Audit Research Network to investigate and present how the use of Tranexamic Acid (TXA) in the trauma patient varies due to sex.
Firstly they provided evidence that the use of TXA in polytrauma and traumatic brain injury serves the same reduction in mortality benefit for males and females. They then move on to analyse data from over 216 000 patients with a trauma severity score of >9 and present surprising findings…
TXA was received by 7.3% of the females and 16.8% of the males. Women are treated less frequently than men regardless of their risk of bleeding or severity of injuries. The authors go on to reference many other studies of similar nature and magnitude stating that in fact, women are less likely to receive certain treatments over men in a multitude of settings.
The discussion talks a little about the authors’ postulations for this disparity. They name strict prehospital SOPs to be one possible cause but otherwise speculate it to be the product of clinicians’ unconscious bias compounded by education and the stereotypes laid out in simulation. Certainly an interesting read and a reminder to us all to be aware of all types of unconscious bias in our working world. 

Our friends and colleagues over at Endeavour Medical have just released a full critical appraisal of this paper, head to their website here to read more. 

Sex discrimination after injury: is inequity in TXA administration just the tip of the iceberg?
Cole E, Curry N, Davenport R. British Journal of Anaesthesia. August 2022

This editorial summaries Nutbeam et al’s study well, presenting the key statistics and outcomes, discussing the limitations and strengths and presenting additional data on the sex-related differences in coagulation and immunology that could play a part in the wider picture of this discussion.
The authors reference further studies stating that women also receive lower emergency health prioritisation than their male counterparts, are less likely to be triaged to a major trauma centre, and are less commonly admitted to critical care.
Although unproven, these findings may present a significant decision to treat bias. Globally there is strong evidence that gender equality, in general, has been improving over the years and we in healthcare must not fall behind.

Risk factors for the presence of important fractures in ED patients with shoulder dislocation: a retrospective cohort study
Henri Houze-Cerfon C, Le Gourrierec T, Charpentier S et al. Emergency Medicine Journal. August 2022

Whether you are the medic supporting a long-distance cycle tour, manning a mountain rescue hut for the winter climbing season, or taking a group of school children on a tall ship for a few weeks, as an expedition medic you are more than likely to encounter a dislocated shoulder in the field at some point. There are a whole host of eponymously named manoeuvres for popping them back in but what about the risk of a fracture dislocation? Something that is always on our minds when dangling arms strapped to tins of beans over a bed frame miles from the nearest possibility of an X-Ray.
This digestible, retrospective cohort study looked at around 600 patients presenting to the ED with shoulder dislocation. They screened for the presence of a clinically important associated fracture and then analysed the patient demographics of those patients to present these 3 independent risk factors for fracture-dislocation:

1) Age >40years
2) Traumatic mechanism of dislocation
3) First incident

They go on to say that in the absence of these risk factors ‘pre-reduction radiography may be safely avoided’. Timely relocation is essential for patient comfort and minimising risk of long-standing musculoskeletal damage. This study adds some evidence to help us in the assessment of these patients and in making decisions to relocate in the field or facilitate evacuation and transfer to hospital. 

Paracetamol, ketorolac, and morphine in post-trauma headache in emergency department: a double blind randomized clinical trial 
Azimi Far A, Abdoli A, Poorolajal J, Salimi R. Emergency Medicine Journal. July 2022

The ‘Global Emergency Highlights’ from the EMJ is always an interesting feature, summarised in digestible abstracts to gain some insight into emergency medicine research across the world. This randomised clinical trial (RCT) comes from Hong Kong and provides some interesting evidence on how best to treat headache after traumatic head injury. Despite relatively small numbers (n=105), they found that IV paracetamol and ketorolac provided better analgesia (measured with a patient-reported headache severity score) than IV morphine. These results were statistically significant when measured at both 15 and 30mins post-administration. They measured secondary outcomes as side effects of the analgesia and as expected, the incidence of adverse effects in the morphine group was significantly higher. Useful data for when managing headache after trauma in the field where we are often devoid of strong opiates. 

Clinician’s corner: counseling patients with pulmonary vascular disease travelling to high altitude
Ulrich S, Lichtblau M, Schneider S et al. High Altitude Medicine and Biology. Sept 2022

With the increasing popularity of travel to previously inaccessible environments, we are seeing that it’s not just the fittest and athletic types that embark on an adventurous expedition. More and more we, as the expedition medic, are seeing clients with a multitude of chronic disease and our job includes counselling and keeping them safe in austere environments.
Managing patients with pulmonary vascular disease (PVD) poses a challenge to any clinician regardless of speciality and the thought of taking someone who has a predisposition to hypoxemia to altitude would certainly pose some serious consideration. This article is incredibly helpful in quantifying the risk to patients with PVD in short trips to medium to high altitude and in fact stating that the vast majority of patients with PVD can tolerate short-term exposure to moderate altitudes up to 2,500 m. Equally, for the roughly 10% of patients with stable disease who do develop severe hypoxemia when ascending to 2,500 m, they respond well to low-level supplemental oxygen support. The authors also present a good revision of the physiology of PVD and a detailed yet digestible explanation of the effects of hypoxia on pulmonary physiology. They include a helpful table written by a GP in conjunction with a pulmonary hypertension unit on what to include in a pre-trip counselling consultation for patients with PVD. 

International Climbing and Mountaineering Federation: UIAA Medcom.
Video of ‘Women Going to Altitude’ conference:

Held in the Swiss mountains in September this inspiring conference has been made available to watch by the UIAA with the suggestion that you might donate to the federation should you enjoy what is over 5 hours of quality and inspirational talks and discussion.
In 2008 the UIAA Medcom released a consensus document entitled ‘Women Going To Altitude’ which covers considerations such as contraception, menopause and pregnancy at altitude. The conference aimed to follow on and expand upon this release and brings together some truly inspiring women from across the world.
The conference centre was accessed by either cable car or a 2.5hr hike and booking fees included a glacier walk … definitely one to keep in the diary for the future.
Watch here

Global Health and Humanitarian Medicine

Clinic room in a refugee medical facility in Lesvos, Greece

Some important and eye opening publications in the Global Health sector this quarter with presentation of health data from the Russia-Ukraine war to some shocking statistics about the global burden of neglected tropical diseases. We also highlight a paper detailing the use of the ‘WHO non communicable disease kit’ which certainly sparks some thought to the less well advertised aspects of humanitarian care. Read on to learn more on the fight to eliminate measles and rubella worldwide and digestible synopses on some of the most current issues in global health.

The human toll and humanitarian crisis of the Russia-Ukraine war: the first 162 days
Haque U, Naeem A, Wang S et al. British Medical Journal: Global Health. Sept 2022

This review of data is a thoughtful and comprehensive witness to the disruption and destruction of the healthcare infrastructure in Ukraine as a result of the 2022 war. The data measures the toll on healthcare during this ongoing conflict. The author’s systematic approach attempts to collate data from several sources to sum up casualties and infrastructure destruction from every single day in the period studied. Naturally, the true scale of the human cost of the war and the long-term effects on the healthcare system will take more time to characterise. The article underlines the importance of continued surveillance on the impact that conflict and war have on healthcare – a difficult yet necessary testimony. 

Assessment of the non-communicable diseases kit for humanitarian emergencies in Yemen and Libya
Kiapi L, Hecham Alani A, Ahmed I et al. British Medical Journal: Global Health. July 2022

This article gives an assessment of the ‘WHO non-communicable diseases (NCD) kit’ that was provided to health clinics in Libya and Yemen during acute humanitarian emergencies. It is a relatively new development, having only existed for 5 years and was developed to cover the emerging gap in humanitarian response to treating chronic disease in emergency settings. The kit is useful for maintaining continuity of care for common NCD conditions such as asthma, diabetes and hypertension, but was not designed for long-term use or to weather supply chain collapse. This practice paper provides a good insight into an often-overlooked part of humanitarian work – helping to manage NCDs with continuity of care as well as treating exacerbations. It is useful to know the level of awareness of the kit, how it fits into use in complex humanitarian situations, limitations of the kit and potential ideas for better practice to improve use. This is a good paper to read for anyone considering humanitarian work or looking to evaluate these or similar systems in other countries. 

Dealing with difficult choices: a qualitative study of experiences and consequences of moral challenges among disaster healthcare responders
Gustavsson M, Juth N, Arnberg F et al. Conflict and Health. May 2022

Working in a disaster environment as a healthcare worker presents a number of moral challenges and stressors. These challenges can be relevant both to our practice in our home countries (for example, during the COVID-19 pandemic) as well as overseas humanitarian work. This detailed qualitative analysis provides a framework that might be useful in understanding the way that we as individuals respond to these challenges. While it is a qualitative analysis of a relatively small group (n=12) of workers from one country, Sweden, the themes that are touched on are likely to be relevant for anyone who wants to understand not only how to support responders on an organisation level but also how they might react to similar situations themselves. The authors conclude that the most useful support was that from other colleagues in the same situation, followed by psychosocial support from someone with similar experiences. The introduction to the concept of ‘moral distress’ at the start of this research publication is particularly interesting and a good insight for anyone involved in humanitarian healthcare.

Neglected tropical disease elimination is a relay race – let’s not drop the baton
Downs P, Bush S, Bannerman R et al. International Health. Sept 2022

This is a retrospective analysis of the achievements and methods of ‘Ascend’, a major UK aid-funded project in west African countries that aimed to treat 5 neglected tropical diseases (NTDs). It demonstrates the impact that such a targeted project can have. It carries a focus on the handover to local partners after a flagship project in order to achieve long-term improvements in care and provision. The project was prematurely closed due to UK Foreign, Commonwealth and Development Office’s funding cuts; the authors note their view of these cuts as unwise. It shows, to some degree, how vulnerable government aid projects are to political changes. Reading the author’s summary of how the project was planned and executed is a good insight into how humanitarian projects work at a broader organisational level. It’s useful to learn the context around a major foreign aid project that has been working for the last few years. The authors highlight and expand upon the need to ‘not drop the baton and maintain the momentum of NTD elimination during times of global disruption. A powerful analogy and one which leaves readers with a greater understanding of just how powerful UK aid investment can be in strengthening health systems to fight public health problems.

Investing in global measles and rubella elimination is needed to avert deaths and advance health equity
Raghunathan P, Orenstein W. The Lancet Global Health. October 2022.

This Lancet comment article is a succinct summary of the modelling and work surrounding rubella and measles eradication. After polio and guinea worm disease, rubella and measles will hopefully be the next two infectious diseases targeted to be totally eradicated in a global program. The paper examines the tailored approach that will be needed in the program to eliminate these conditions. Rubella eradication is thought to be more feasible than measles due to the lower transmission rate but with a particular focus on geographical areas where ‘zero dose’ children exist the chance of eradication markedly increases. Equity in healthcare access and targeting these low-coverage areas have been highlighted as particularly important methods in measles to reduce the risk of its reintroduction from endemic areas.
A good preview of some of the groundwork for what are likely to be major global health projects in the rest of the 2020s and 2030s.

The long-list

Here we present the articles that didn’t quite make the cut but are definitely worth a read for those with a little more time on their hands:

Intranasal topical application of tranexamic acid in atraumatic anterior epistaxis: A double – blind randomised clinical trial
Hosseinialhashemi M, Jahangiri R, Faramarzi A, et al. Emergency Medicine Journal. September 2022

The ethical considerations for emergency care research in low and middle income countries: A scoping review of the published literature
Hirner S, Saunders C, Stassen W. African journal of Emergency Medicine (EMJ, Global Emergency Highlights). March 2022. September 2022

Influence of prehospital management on the outcome of spinal cord decompression sickness in scuba divers
Andre S, Lehot H, Morin J, et al. Emergency Medicine Journal. October 2022

Non-sterile gloves and dressing versus sterile gloves, dressings and drapes for suturing of traumatic wounds in the emergency department: a non-inferiority multicentre randomised controlled trial
Zwaans J,  Raven W,  Rosendaal A et al. Emergency Medicine Journal. September 2022

A randomized non-inferiority pilot study on the use of methoxyflurane (Penthrox) for pain control in the emergency department
Wong K, Lau J, Siu A et al.  Emergency Medicine Journal. July 2022

Gender equity in membership, leadership and award recognition in the Wilderness Medical Society
Shlein S, Pollock N, Polukoff N et al. Wilderness and Environmental Medicine Journal. Sept 2022

Gender distribution within the journal Wilderness and Environmental Medicine
Keyes L, Schlein S, Brown A et al. Wilderness and Environmental Medicine Journal. Sept 2022

Pulmonary embolism at extreme high altitude: a study of seven cases
Wu J, Haiwen X, Wang L et al. HIgh Altitude Medicine and Biology. Sept 2022

Reimagining human rights in global health: what will it take?
Khosla R, Allotey P, Gruskin S. British Medical Journal: Global Health. August 2022

Medical educators’ perspectives on the barriers and enablers of teaching public health in the undergraduate medical schools: a systematic review
Kadir N, Schutze H. Global Health Action. Sept 2022

Culturally relevant COVID-19 vaccine acceptance strategies in sub-Saharan Africa
Ajeigbe O, Arage G, Besong M et al. The Lancet Global Health. June 2022

Keeping an eye on pink eye; global conjunctivitis outbreak expert survey
Kaur G, Seitzman G, Lietman T et al. International Health. Sept 2022

Association between triage level and outcomes at Médecins Sans Frontières trauma hospital in Kunduz, Afghanistan
Latif Daebes H, Latifa Tounsi L, Nerlander M et al. Emergency Medicine Journal. August 2022

The Global Retinoblastoma Outcome Study: a prospective, cluster-based analysis of 4064 patients from 149 countries
The Global Retinoblastoma Study Group. August 2022. The Lancet Global Health

“See one, do one, teach one”: Balancing patient care and surgical training in an emergency trauma department
Ayub S. Journal of Global Health. July 2022

Primary Healthcare Quality in Conflict and Fragility: a subnational analysis of disparities using Population Health surveys
Ramadan M, Tappis H, Brieger W. Conflict and Health. June 2022

Monkeypox outbreak: Preventing another episode of stigmatization
Chang C, Thum C, Jie Lim X et al. Tropical medicine and international health. July 2022