Global Emergency Medicine: A Review of the Literature From 2012

The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and grey literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a worldwide audience of academics and clinical practitioners. This year, our search identified 4,818 articles written in six languages. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Two additional reviewers searched and screened the grey literature. A total of 224 articles were deemed appropriate by at least one reviewer and were approved by their editor for formal scoring of overall quality and importance. Of the 224 articles that met our predetermined inclusion criteria, 56% were categorized as Emergency Care in Resource-limited Settings, 18% as EM development, and 26% as Disaster and Humanitarian Response. A total of 28 articles received scores of 16 or higher and were selected for formal summary and critique. Inter-rater reliability for two reviewers using our scoring system was good, with an intraclass correlation coefficient of 0.625 (95% confidence interval = 0.512 to 0.711). In 2012 there were more disaster and humanitarian response articles than in previous years. As in prior years, the majority of articles addressed the acute management of infectious diseases or the care of vulnerable populations such as children and pregnant women. La revisión de la literatura publicada en Medicina de Urgencias y Emergencias (MUE) global comporta una búsqueda anual de los trabajos relevantes para la MUE global, tanto publicados tras revisión por pares como corresponedientes a literatura gris. La finalidad es identificar, revisar y diseminar las investigaciones novedosas más importantes en este campoa médicos clínicos y universitarios de todo el mundo. Este año, nuestra búsqueda identificó 4.818 artículos escritos en seis lenguas. Estos artículos se distribuyeron entre 20 revisores para el despistaje inicial basándose en su relevancia para el campo de la MUE global. Dos revisores adicionales buscaron y filtraron la literatura gris. Un total de 224 artículos se consideraron apropiados por al menos un revisor, y se aprobaron por su editor para la puntuación formal de la calidad e importancia totales. De los 224 artículos que cumplieron nuestros criterios de inclusión predeterminados, un 56% se clasificaron como atención de urgencias y emergencias en ámbitos de recursos limitados, un 18% como desarrollo de la MUE y un 26% como catástrofes y respuesta humanitaria. Un total de 28 artículos recibieron una puntuación de 16 o más y se seleccionaron para el resumen y la crítica formal. La fiabilidad interobservador para los 2 revisores usando nuestro sistema de puntuación fue buena, con un coeficiente de correlación intraclase de 0,625 (IC 95% = 0,512 a 0,711). En 2012 hubo más artículos sobre catástrofes y respuesta humanitaria que en años anteriores. Como en los años previos, la mayoría de los artículos valoraron el manejo agudo de enfermedades infecciosas o la atención de poblaciones vulnerables como los niños y las mujeres embarazadas. In 2012, deadly earthquakes affected Iran, Afghanistan, and the Philippines, while Sri Lanka and southern India saw their deadliest tropical cyclone in years: Nilam. The most destructive storm of 2012, Hurricane Sandy, left a wake of destruction stretching from Jamaica to Quebec. Meanwhile, the ongoing conflict in Syria left thousands dead and contributed more than three million additional internally displaced people to the global total.1 At the same time, interest in formal education and training in emergency medicine (EM) continued to grow in breadth and intensity. In January, Dubai hosted the first Global Network Conference on Emergency Medicine.2 In October, Ghana and the African Federation of Emergency Medicine hosted the first African Conference on Emergency Medicine.3 As interest in the field of EM expands, the Global Emergency Medicine Literature Review (GEMLR) strives to ensure that emergency practitioners, from those in academic emergency departments (EDs) to those on the front lines of disaster care, have access to the most current and important research conducted on relevant topics around the world. The GEMLR began 8 years ago in an attempt to identify and consolidate the best global EM literature into a format that was easy for both academics and practitioners to access and comprehend. This year, our panel of seasoned reviewers includes physicians from Australia, China, Ghana, Lebanon, the United Kingdom, and the United States. The primary goals of the review are to illustrate best practices, stimulate research, and promote further professionalization in the field of global EM through the identification of important new publications that focus on emergency care in low-resource settings. At the same time, the review is not a formal systematic review, which aims to synthesize the published literature on a specific topic or research question. Each year, the number of quality articles in the field grows significantly, and thus the mission of the review becomes more challenging. The scope of global EM continues to stretch beyond its initial boundaries to include injury prevention, epidemiologic transition, and device implementation. For the 2012 review, we continue to include literature that falls into one of the three following categories: disaster and humanitarian response, emergency care in resource-limited settings, and EM development. This is the third year that grey literature was included in our search strategy. Grey literature has been defined as any material produced by an organization whose primary function is not publication.4 Our goal in performing a grey literature search was to identify new global EM research conducted by government agencies, local or international nongovernment organizations, or other entities that may not have been published in peer-reviewed journals. Each year, the GEMLR editorial board revises a procedure manual that outlines in detail the methodology for its search, screening, scoring, and reviewing processes.5 Because the GEMLR is a review article, no prior ethical or institutional review board approval was sought for this manuscript. There were nine editors, four advisors, one Academic Emergency Medicine representative, and 20 reviewers. As reviewers and editors could not be blinded to the authors of the articles included in the review or their affiliations, both reviewers and editors were recused from scoring or reviewing any articles in which they may have been directly or indirectly involved. The initial search was conducted in two blocks: the first from January 1 to August 31, 2012, and the second from September 1 to December 31, 2012. We used PubMed to search Medline for original research or review articles that contained at least one “global” search term and one “emergency medicine” search term (Table 1). A hand search of journals that published significant numbers of articles that were included in our prior reviews was also performed. This year, the following journals were included in the hand search: Bulletin of the World Health Organization, Academic Emergency Medicine, Prehospital and Disaster Medicine, Annals of Emergency Medicine, Emergency Medicine Journal, and The Lancet. Based on the linguistic capacity of our reviewers and editors, our search this year was limited to articles published in English, French, German, Spanish, Italian, and Chinese. All studies were limited to human subjects only; news articles and letters were excluded. Articles that had been e-published ahead of print in 2011 and had thus been included in the 2011 review were also excluded. The total number of articles produced by our PubMed search for 2012 was 2,098: 2,001 English, 31 French, 17 German, 15 Spanish, three Chinese, and three Italian. The total number of articles produced by our hand search for 2012 was 2,748. The 4,818 articles produced by these two searches were divided among the 20 reviewers for initial screening based on their relevance to the field of global EM (as defined by the criteria listed above). A total of 209 articles were each deemed appropriate for formal scoring of their overall quality and importance by at least one reviewer and approved by his or her editor. For the grey literature search, we used a preidentified list of academic, government, and nongovernment organizations known to be conducting global health research or investigations as part of their work (Table 2). Two reviewers were assigned to systematically search the websites of these organizations for needs assessments, program monitoring, evaluation reports, topic reviews, white papers, conference proceedings, and other types of articles that met the predefined screening criteria for relevance to the field of global EM. Through our grey literature search process, we found 15 additional global EM research articles that met the inclusion criteria. These were combined with those identified by the Medline search to create a database of 224 research articles for formal scoring. Once selected for scoring, the full-text article was obtained and classified as either an original research or review article. Each article was also categorized as emergency care in resource-limited settings, EM development, or disaster and humanitarian response. Emergency care in resource limited settings includes trauma care, acute medical care, triage, and prehospital care in low- and middle-income countries or resource-limited settings of high-income countries. EM development includes research on the development of EM as a specialty, EM educational programs, or emergency medical care systems outside of North America, regardless of the national income level. Disaster and humanitarian response includes research on the care of civilian populations in conflict; disaster mitigation, assessment, and response; and health care of refugees and internally displaced persons. Each article was then scored by two separate reviewers using a predefined grading scale that assessed for clarity, design, ethics, importance, and impact. Final scoring ranged from 0 to 20 (Table 3), with the mean of the two scores used as the final score for the article. Any article with a score difference between reviewers of greater than two standard deviations above the median score difference was rescored by an editor. The new score was then used as the final score for the article. Twenty-eight articles had final scores of 16 or greater and were selected for formal review. These articles were then distributed to reviewers who produced summaries and critiques of each article. Of the 224 articles that met our predetermined inclusion criteria, 56% were categorized as emergency care in resource-limited settings, 18% as EM development, and 26% as disaster and humanitarian response. Approximately 64% of the articles were original research, while the remaining 36% were review articles. The median final score for all articles was 12.5, ranging from 4.5 to 19. The difference in mean scores between Medline (12.6) and grey literature (11.5) articles was not significant (p = 0.069), nor was the difference in mean scores between original research (12.5) and review (12.4) articles (p = 0.700) or the differences in mean scores between emergency care in resource-limited settings (12.4), EM development (13.2), and disaster and humanitarian response (12.1) articles (p = 0.199). Inter-rater reliability for reviewer scoring, measured using the intraclass correlation coefficient, was 0.625 (95% confidence interval = 0.512 to 0.711), considered “good” reliability in the literature. The top 28 global EM articles for 2012 are listed in Table 4.6-34 The complete database of all 224 global EM articles for 2012, as well as full summaries and critical analyses of the top 28 global EM of articles of 2012, can be found in Data Supplements S1 and S2 (available as supporting information in the online version of this article). The most notable difference in the 2012 review, in comparison to previous reviews, was the inclusion of an article from the grey literature. This represented the first time a grey literature article scored above the predefined cutoff for full review. In addition, there were many more disaster and humanitarian response articles than had been selected for final review in previous years. While historically there have been more review articles, this year the majority of the chosen articles were original research articles. Below we summarize some of the 2012 trends in global EM research. As in years past, this category of articles remains the most represented among articles chosen for full review (66%). Highlighting the continued global focus placed on child and maternal mortality, most of the articles were centered on pediatric infectious disease or obstetric care. Diarrheal illnesses continue to be a major cause of morbidity and mortality worldwide; several of the 2012 articles focused on the diagnosis and management of diarrhea. Lazzerini and Ronfani6 performed a systematic review on zinc supplementation in children with acute diarrhea. The authors found that in children less than 6 months of age, there is evidence that zinc supplementation is not beneficial and may even be harmful. In children older than 6 months, however, zinc supplementation may shorten the course of diarrhea by 10 hours and reduce the number of children who have continued diarrhea at 7 days. In the subpopulation of children greater than 6 months of age with moderate malnutrition, there is high-quality evidence that zinc supplementation may reduce the length of the episode by slightly more than a day. Furthermore, in their randomized, double-blinded controlled trial, Riaz et al.7 found that administration of the probiotic Saccharomyces boulardii shortened the course of diarrhea by 12 hours. Page et al.8 evaluated crystal VC immunochromatography as a rapid diagnostic test for cholera in the Democratic Republic of Congo. In comparison to a modified reference standard, the rapid diagnostic test was reported to have high sensitivity and specificity, making it a potentially useful adjunct in identifying cholera outbreaks. Pneumonia is also an important cause of worldwide morbidity and mortality, particularly in children. Two of the 2012 articles examined pneumonia. Das et al.9 performed a meta-analysis of the evidence for administering zinc in the treatment of lower respiratory tract infections in children less than 5 years of age, finding that zinc does not improve outcomes in these patients. Singhi et al.10 examined the incidence of developing hypoxemia in pediatric patients with severe pneumonia. The authors found that over half of initially normoxemic patients in the study cohort became hypoxemic during their hospital stays, suggesting the need for close monitoring of children under 5 years of age admitted with severe pneumonia. A number of additional articles included in this year's review focused on communicable diseases. Coulborn et al.11 found that the use of teleradiology in Malawi had a significant effect on the diagnosis and management of tuberculosis. Vinnemeier et al.12 attempted to create an age-dependent clinical decision algorithm for the diagnosis of Plasmodium falciparum malaria in children in endemic areas. Although such a rule would suffer from poor sensitivity, their study does highlight the importance of using palmar pallor as an indicator of anemia secondary to malaria in their study population. Tougher et al.13 also focused their research on malaria and found that a subsidy program had a significant impact on the price, availability, and market share of for antimalarial combination therapies in seven countries. Cilliers et al.14 performed a systematic literature review on the use of anti-inflammatory medications for acute rheumatic fever, finding no evidence to support the use of corticosteroids or intravenous immunoglobulins to prevent or reduce cardiac disease. A systematic literature review of community-acquired bacteremia in admitted febrile patients in South and Southeast Asia identified Salmonella typhi as the most common cause of community acquired bacteremia.15 Furthermore, they reported that nearly half of S. typhi strains were resistant to first-line drugs. Maternal mortality continues to be a heavy burden of disease around the world, and several of the 2012 articles focused on the acute management of obstetric emergencies. 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