Publisher: Elsevier   (Total: 3161 journals)

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Showing 1 - 200 of 3161 Journals sorted alphabetically
Academic Pediatrics     Hybrid Journal   (Followers: 39, SJR: 1.655, CiteScore: 2)
Academic Radiology     Hybrid Journal   (Followers: 26, SJR: 1.015, CiteScore: 2)
Accident Analysis & Prevention     Partially Free   (Followers: 106, SJR: 1.462, CiteScore: 3)
Accounting Forum     Hybrid Journal   (Followers: 28, SJR: 0.932, CiteScore: 2)
Accounting, Organizations and Society     Hybrid Journal   (Followers: 44, SJR: 1.771, CiteScore: 3)
Achievements in the Life Sciences     Open Access   (Followers: 7)
Acta Anaesthesiologica Taiwanica     Open Access   (Followers: 6)
Acta Astronautica     Hybrid Journal   (Followers: 447, SJR: 0.758, CiteScore: 2)
Acta Automatica Sinica     Full-text available via subscription   (Followers: 2)
Acta Biomaterialia     Hybrid Journal   (Followers: 30, SJR: 1.967, CiteScore: 7)
Acta Colombiana de Cuidado Intensivo     Full-text available via subscription   (Followers: 3)
Acta de Investigación Psicológica     Open Access   (Followers: 2)
Acta Ecologica Sinica     Open Access   (Followers: 12, SJR: 0.18, CiteScore: 1)
Acta Histochemica     Hybrid Journal   (Followers: 5, SJR: 0.661, CiteScore: 2)
Acta Materialia     Hybrid Journal   (Followers: 325, SJR: 3.263, CiteScore: 6)
Acta Mathematica Scientia     Full-text available via subscription   (Followers: 5, SJR: 0.504, CiteScore: 1)
Acta Mechanica Solida Sinica     Full-text available via subscription   (Followers: 9, SJR: 0.542, CiteScore: 1)
Acta Oecologica     Hybrid Journal   (Followers: 12, SJR: 0.834, CiteScore: 2)
Acta Otorrinolaringologica (English Edition)     Full-text available via subscription  
Acta Otorrinolaringológica Española     Full-text available via subscription   (Followers: 2, SJR: 0.307, CiteScore: 0)
Acta Pharmaceutica Sinica B     Open Access   (Followers: 2, SJR: 1.793, CiteScore: 6)
Acta Psychologica     Hybrid Journal   (Followers: 26, SJR: 1.331, CiteScore: 2)
Acta Sociológica     Open Access   (Followers: 1)
Acta Tropica     Hybrid Journal   (Followers: 6, SJR: 1.052, CiteScore: 2)
Acta Urológica Portuguesa     Open Access   (Followers: 1)
Actas Dermo-Sifiliograficas     Full-text available via subscription   (Followers: 3, SJR: 0.374, CiteScore: 1)
Actas Dermo-Sifiliográficas (English Edition)     Full-text available via subscription   (Followers: 2)
Actas Urológicas Españolas     Full-text available via subscription   (Followers: 3, SJR: 0.344, CiteScore: 1)
Actas Urológicas Españolas (English Edition)     Full-text available via subscription   (Followers: 1)
Actualites Pharmaceutiques     Full-text available via subscription   (Followers: 7, SJR: 0.19, CiteScore: 0)
Actualites Pharmaceutiques Hospitalieres     Full-text available via subscription   (Followers: 3)
Acupuncture and Related Therapies     Hybrid Journal   (Followers: 8)
Acute Pain     Full-text available via subscription   (Followers: 15, SJR: 2.671, CiteScore: 5)
Ad Hoc Networks     Hybrid Journal   (Followers: 11, SJR: 0.53, CiteScore: 4)
Addictive Behaviors     Hybrid Journal   (Followers: 18, SJR: 1.29, CiteScore: 3)
Addictive Behaviors Reports     Open Access   (Followers: 9, SJR: 0.755, CiteScore: 2)
Additive Manufacturing     Hybrid Journal   (Followers: 13, SJR: 2.611, CiteScore: 8)
Additives for Polymers     Full-text available via subscription   (Followers: 22)
Advanced Drug Delivery Reviews     Hybrid Journal   (Followers: 190, SJR: 4.09, CiteScore: 13)
Advanced Engineering Informatics     Hybrid Journal   (Followers: 13, SJR: 1.167, CiteScore: 4)
Advanced Powder Technology     Hybrid Journal   (Followers: 17, SJR: 0.694, CiteScore: 3)
Advances in Accounting     Hybrid Journal   (Followers: 9, SJR: 0.277, CiteScore: 1)
Advances in Agronomy     Full-text available via subscription   (Followers: 17, SJR: 2.384, CiteScore: 5)
Advances in Anesthesia     Full-text available via subscription   (Followers: 30, SJR: 0.126, CiteScore: 0)
Advances in Antiviral Drug Design     Full-text available via subscription   (Followers: 2)
Advances in Applied Mathematics     Full-text available via subscription   (Followers: 12, SJR: 0.992, CiteScore: 1)
Advances in Applied Mechanics     Full-text available via subscription   (Followers: 12, SJR: 1.551, CiteScore: 4)
Advances in Applied Microbiology     Full-text available via subscription   (Followers: 24, SJR: 2.089, CiteScore: 5)
Advances In Atomic, Molecular, and Optical Physics     Full-text available via subscription   (Followers: 15, SJR: 0.572, CiteScore: 2)
Advances in Biological Regulation     Hybrid Journal   (Followers: 4, SJR: 2.61, CiteScore: 7)
Advances in Botanical Research     Full-text available via subscription   (Followers: 1, SJR: 0.686, CiteScore: 2)
Advances in Cancer Research     Full-text available via subscription   (Followers: 35, SJR: 3.043, CiteScore: 6)
Advances in Carbohydrate Chemistry and Biochemistry     Full-text available via subscription   (Followers: 9, SJR: 1.453, CiteScore: 2)
Advances in Catalysis     Full-text available via subscription   (Followers: 5, SJR: 1.992, CiteScore: 5)
Advances in Cell Aging and Gerontology     Full-text available via subscription   (Followers: 5)
Advances in Cellular and Molecular Biology of Membranes and Organelles     Full-text available via subscription   (Followers: 14)
Advances in Chemical Engineering     Full-text available via subscription   (Followers: 29, SJR: 0.156, CiteScore: 1)
Advances in Child Development and Behavior     Full-text available via subscription   (Followers: 11, SJR: 0.713, CiteScore: 1)
Advances in Chronic Kidney Disease     Full-text available via subscription   (Followers: 11, SJR: 1.316, CiteScore: 2)
Advances in Clinical Chemistry     Full-text available via subscription   (Followers: 26, SJR: 1.562, CiteScore: 3)
Advances in Colloid and Interface Science     Full-text available via subscription   (Followers: 21, SJR: 1.977, CiteScore: 8)
Advances in Computers     Full-text available via subscription   (Followers: 14, SJR: 0.205, CiteScore: 1)
Advances in Dermatology     Full-text available via subscription   (Followers: 16)
Advances in Developmental Biology     Full-text available via subscription   (Followers: 14)
Advances in Digestive Medicine     Open Access   (Followers: 13)
Advances in DNA Sequence-Specific Agents     Full-text available via subscription   (Followers: 7)
Advances in Drug Research     Full-text available via subscription   (Followers: 26)
Advances in Ecological Research     Full-text available via subscription   (Followers: 45, SJR: 2.524, CiteScore: 4)
Advances in Engineering Software     Hybrid Journal   (Followers: 30, SJR: 1.159, CiteScore: 4)
Advances in Experimental Biology     Full-text available via subscription   (Followers: 9)
Advances in Experimental Social Psychology     Full-text available via subscription   (Followers: 52, SJR: 5.39, CiteScore: 8)
Advances in Exploration Geophysics     Full-text available via subscription   (Followers: 2)
Advances in Fluorine Science     Full-text available via subscription   (Followers: 9)
Advances in Food and Nutrition Research     Full-text available via subscription   (Followers: 68, SJR: 0.591, CiteScore: 2)
Advances in Fuel Cells     Full-text available via subscription   (Followers: 17)
Advances in Genetics     Full-text available via subscription   (Followers: 21, SJR: 1.354, CiteScore: 4)
Advances in Genome Biology     Full-text available via subscription   (Followers: 12, SJR: 12.74, CiteScore: 13)
Advances in Geophysics     Full-text available via subscription   (Followers: 8, SJR: 1.193, CiteScore: 3)
Advances in Heat Transfer     Full-text available via subscription   (Followers: 26, SJR: 0.368, CiteScore: 1)
Advances in Heterocyclic Chemistry     Full-text available via subscription   (Followers: 11, SJR: 0.749, CiteScore: 3)
Advances in Human Factors/Ergonomics     Full-text available via subscription   (Followers: 26)
Advances in Imaging and Electron Physics     Full-text available via subscription   (Followers: 3, SJR: 0.193, CiteScore: 0)
Advances in Immunology     Full-text available via subscription   (Followers: 37, SJR: 4.433, CiteScore: 6)
Advances in Inorganic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 1.163, CiteScore: 2)
Advances in Insect Physiology     Full-text available via subscription   (Followers: 2, SJR: 1.938, CiteScore: 3)
Advances in Integrative Medicine     Hybrid Journal   (Followers: 6, SJR: 0.176, CiteScore: 0)
Advances in Intl. Accounting     Full-text available via subscription   (Followers: 3)
Advances in Life Course Research     Hybrid Journal   (Followers: 9, SJR: 0.682, CiteScore: 2)
Advances in Lipobiology     Full-text available via subscription   (Followers: 1)
Advances in Magnetic and Optical Resonance     Full-text available via subscription   (Followers: 8)
Advances in Marine Biology     Full-text available via subscription   (Followers: 21, SJR: 0.88, CiteScore: 2)
Advances in Mathematics     Full-text available via subscription   (Followers: 17, SJR: 3.027, CiteScore: 2)
Advances in Medical Sciences     Hybrid Journal   (Followers: 9, SJR: 0.694, CiteScore: 2)
Advances in Medicinal Chemistry     Full-text available via subscription   (Followers: 6)
Advances in Microbial Physiology     Full-text available via subscription   (Followers: 5, SJR: 1.158, CiteScore: 3)
Advances in Molecular and Cell Biology     Full-text available via subscription   (Followers: 26)
Advances in Molecular and Cellular Endocrinology     Full-text available via subscription   (Followers: 8)
Advances in Molecular Toxicology     Full-text available via subscription   (Followers: 7, SJR: 0.182, CiteScore: 0)
Advances in Nanoporous Materials     Full-text available via subscription   (Followers: 5)
Advances in Oncobiology     Full-text available via subscription   (Followers: 2)
Advances in Organ Biology     Full-text available via subscription   (Followers: 2)
Advances in Organometallic Chemistry     Full-text available via subscription   (Followers: 18, SJR: 1.875, CiteScore: 4)
Advances in Parallel Computing     Full-text available via subscription   (Followers: 7, SJR: 0.174, CiteScore: 0)
Advances in Parasitology     Full-text available via subscription   (Followers: 6, SJR: 1.579, CiteScore: 4)
Advances in Pediatrics     Full-text available via subscription   (Followers: 27, SJR: 0.461, CiteScore: 1)
Advances in Pharmaceutical Sciences     Full-text available via subscription   (Followers: 19)
Advances in Pharmacology     Full-text available via subscription   (Followers: 17, SJR: 1.536, CiteScore: 3)
Advances in Physical Organic Chemistry     Full-text available via subscription   (Followers: 10, SJR: 0.574, CiteScore: 1)
Advances in Phytomedicine     Full-text available via subscription  
Advances in Planar Lipid Bilayers and Liposomes     Full-text available via subscription   (Followers: 3, SJR: 0.109, CiteScore: 1)
Advances in Plant Biochemistry and Molecular Biology     Full-text available via subscription   (Followers: 11)
Advances in Plant Pathology     Full-text available via subscription   (Followers: 6)
Advances in Porous Media     Full-text available via subscription   (Followers: 5)
Advances in Protein Chemistry     Full-text available via subscription   (Followers: 19)
Advances in Protein Chemistry and Structural Biology     Full-text available via subscription   (Followers: 20, SJR: 0.791, CiteScore: 2)
Advances in Psychology     Full-text available via subscription   (Followers: 69)
Advances in Quantum Chemistry     Full-text available via subscription   (Followers: 7, SJR: 0.371, CiteScore: 1)
Advances in Radiation Oncology     Open Access   (Followers: 3, SJR: 0.263, CiteScore: 1)
Advances in Small Animal Medicine and Surgery     Hybrid Journal   (Followers: 3, SJR: 0.101, CiteScore: 0)
Advances in Space Biology and Medicine     Full-text available via subscription   (Followers: 7)
Advances in Space Research     Full-text available via subscription   (Followers: 430, SJR: 0.569, CiteScore: 2)
Advances in Structural Biology     Full-text available via subscription   (Followers: 6)
Advances in Surgery     Full-text available via subscription   (Followers: 13, SJR: 0.555, CiteScore: 2)
Advances in the Study of Behavior     Full-text available via subscription   (Followers: 37, SJR: 2.208, CiteScore: 4)
Advances in Veterinary Medicine     Full-text available via subscription   (Followers: 20)
Advances in Veterinary Science and Comparative Medicine     Full-text available via subscription   (Followers: 15)
Advances in Virus Research     Full-text available via subscription   (Followers: 6, SJR: 2.262, CiteScore: 5)
Advances in Water Resources     Hybrid Journal   (Followers: 57, SJR: 1.551, CiteScore: 3)
Aeolian Research     Hybrid Journal   (Followers: 6, SJR: 1.117, CiteScore: 3)
Aerospace Science and Technology     Hybrid Journal   (Followers: 396, SJR: 0.796, CiteScore: 3)
AEU - Intl. J. of Electronics and Communications     Hybrid Journal   (Followers: 8, SJR: 0.42, CiteScore: 2)
African J. of Emergency Medicine     Open Access   (Followers: 6, SJR: 0.296, CiteScore: 0)
Ageing Research Reviews     Hybrid Journal   (Followers: 12, SJR: 3.671, CiteScore: 9)
Aggression and Violent Behavior     Hybrid Journal   (Followers: 488, SJR: 1.238, CiteScore: 3)
Agri Gene     Hybrid Journal   (Followers: 1, SJR: 0.13, CiteScore: 0)
Agricultural and Forest Meteorology     Hybrid Journal   (Followers: 18, SJR: 1.818, CiteScore: 5)
Agricultural Systems     Hybrid Journal   (Followers: 32, SJR: 1.156, CiteScore: 4)
Agricultural Water Management     Hybrid Journal   (Followers: 47, SJR: 1.272, CiteScore: 3)
Agriculture and Agricultural Science Procedia     Open Access   (Followers: 4)
Agriculture and Natural Resources     Open Access   (Followers: 3)
Agriculture, Ecosystems & Environment     Hybrid Journal   (Followers: 58, SJR: 1.747, CiteScore: 4)
Ain Shams Engineering J.     Open Access   (Followers: 5, SJR: 0.589, CiteScore: 3)
Air Medical J.     Hybrid Journal   (Followers: 8, SJR: 0.26, CiteScore: 0)
AKCE Intl. J. of Graphs and Combinatorics     Open Access   (SJR: 0.19, CiteScore: 0)
Alcohol     Hybrid Journal   (Followers: 12, SJR: 1.153, CiteScore: 3)
Alcoholism and Drug Addiction     Open Access   (Followers: 12)
Alergologia Polska : Polish J. of Allergology     Full-text available via subscription   (Followers: 1)
Alexandria Engineering J.     Open Access   (Followers: 2, SJR: 0.604, CiteScore: 3)
Alexandria J. of Medicine     Open Access   (Followers: 1, SJR: 0.191, CiteScore: 1)
Algal Research     Partially Free   (Followers: 11, SJR: 1.142, CiteScore: 4)
Alkaloids: Chemical and Biological Perspectives     Full-text available via subscription   (Followers: 2)
Allergologia et Immunopathologia     Full-text available via subscription   (Followers: 1, SJR: 0.504, CiteScore: 1)
Allergology Intl.     Open Access   (Followers: 5, SJR: 1.148, CiteScore: 2)
Alpha Omegan     Full-text available via subscription   (SJR: 3.521, CiteScore: 6)
ALTER - European J. of Disability Research / Revue Européenne de Recherche sur le Handicap     Full-text available via subscription   (Followers: 11, SJR: 0.201, CiteScore: 1)
Alzheimer's & Dementia     Hybrid Journal   (Followers: 55, SJR: 4.66, CiteScore: 10)
Alzheimer's & Dementia: Diagnosis, Assessment & Disease Monitoring     Open Access   (Followers: 6, SJR: 1.796, CiteScore: 4)
Alzheimer's & Dementia: Translational Research & Clinical Interventions     Open Access   (Followers: 6, SJR: 1.108, CiteScore: 3)
Ambulatory Pediatrics     Hybrid Journal   (Followers: 5)
American Heart J.     Hybrid Journal   (Followers: 58, SJR: 3.267, CiteScore: 4)
American J. of Cardiology     Hybrid Journal   (Followers: 67, SJR: 1.93, CiteScore: 3)
American J. of Emergency Medicine     Hybrid Journal   (Followers: 48, SJR: 0.604, CiteScore: 1)
American J. of Geriatric Pharmacotherapy     Full-text available via subscription   (Followers: 13)
American J. of Geriatric Psychiatry     Hybrid Journal   (Followers: 15, SJR: 1.524, CiteScore: 3)
American J. of Human Genetics     Hybrid Journal   (Followers: 40, SJR: 7.45, CiteScore: 8)
American J. of Infection Control     Hybrid Journal   (Followers: 29, SJR: 1.062, CiteScore: 2)
American J. of Kidney Diseases     Hybrid Journal   (Followers: 37, SJR: 2.973, CiteScore: 4)
American J. of Medicine     Hybrid Journal   (Followers: 50)
American J. of Medicine Supplements     Full-text available via subscription   (Followers: 3, SJR: 1.967, CiteScore: 2)
American J. of Obstetrics and Gynecology     Hybrid Journal   (Followers: 266, SJR: 2.7, CiteScore: 4)
American J. of Ophthalmology     Hybrid Journal   (Followers: 67, SJR: 3.184, CiteScore: 4)
American J. of Ophthalmology Case Reports     Open Access   (Followers: 5, SJR: 0.265, CiteScore: 0)
American J. of Orthodontics and Dentofacial Orthopedics     Full-text available via subscription   (Followers: 6, SJR: 1.289, CiteScore: 1)
American J. of Otolaryngology     Hybrid Journal   (Followers: 25, SJR: 0.59, CiteScore: 1)
American J. of Pathology     Hybrid Journal   (Followers: 32, SJR: 2.139, CiteScore: 4)
American J. of Preventive Medicine     Hybrid Journal   (Followers: 30, SJR: 2.164, CiteScore: 4)
American J. of Surgery     Hybrid Journal   (Followers: 39, SJR: 1.141, CiteScore: 2)
American J. of the Medical Sciences     Hybrid Journal   (Followers: 12, SJR: 0.767, CiteScore: 1)
Ampersand : An Intl. J. of General and Applied Linguistics     Open Access   (Followers: 7)
Anaerobe     Hybrid Journal   (Followers: 4, SJR: 1.144, CiteScore: 3)
Anaesthesia & Intensive Care Medicine     Full-text available via subscription   (Followers: 67, SJR: 0.138, CiteScore: 0)
Anaesthesia Critical Care & Pain Medicine     Full-text available via subscription   (Followers: 25, SJR: 0.411, CiteScore: 1)
Anales de Cirugia Vascular     Full-text available via subscription   (Followers: 1)
Anales de Pediatría     Full-text available via subscription   (Followers: 3, SJR: 0.277, CiteScore: 0)
Anales de Pediatría (English Edition)     Full-text available via subscription  
Anales de Pediatría Continuada     Full-text available via subscription  
Analytic Methods in Accident Research     Hybrid Journal   (Followers: 6, SJR: 4.849, CiteScore: 10)
Analytica Chimica Acta     Hybrid Journal   (Followers: 44, SJR: 1.512, CiteScore: 5)
Analytica Chimica Acta : X     Open Access  
Analytical Biochemistry     Hybrid Journal   (Followers: 214, SJR: 0.633, CiteScore: 2)
Analytical Chemistry Research     Open Access   (Followers: 13, SJR: 0.411, CiteScore: 2)
Analytical Spectroscopy Library     Full-text available via subscription   (Followers: 14)
Anesthésie & Réanimation     Full-text available via subscription   (Followers: 2)
Anesthesiology Clinics     Full-text available via subscription   (Followers: 25, SJR: 0.683, CiteScore: 2)
Angiología     Full-text available via subscription   (SJR: 0.121, CiteScore: 0)
Angiologia e Cirurgia Vascular     Open Access   (Followers: 1, SJR: 0.111, CiteScore: 0)
Animal Behaviour     Hybrid Journal   (Followers: 238, SJR: 1.58, CiteScore: 3)
Animal Feed Science and Technology     Hybrid Journal   (Followers: 7, SJR: 0.937, CiteScore: 2)
Animal Reproduction Science     Hybrid Journal   (Followers: 7, SJR: 0.704, CiteScore: 2)
Annales d'Endocrinologie     Full-text available via subscription   (Followers: 3, SJR: 0.451, CiteScore: 1)

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Similar Journals
African Journal of Emergency Medicine
Journal Prestige (SJR): 0.296
Number of Followers: 6  

  This is an Open Access Journal Open Access journal
ISSN (Print) 2211-419X
Published by Elsevier Homepage  [3161 journals]
  • Impact of traffic, poverty and facility ownership on travel time to
           emergency care in Nairobi, Kenya

    • Abstract: Publication date: Available online 14 January 2020Source: African Journal of Emergency MedicineAuthor(s): Maya S. Fraser, Benjamin W. Wachira, Abraham D. Flaxman, Aaron Y. Lee, Herbert C. DuberAbstractBackgroundIn many low and middle-income countries (LMICs), timely access to emergency healthcare services is limited. In urban settings, traffic can have a significant impact on travel time, leading to life-threatening delays for time-sensitive injuries and medical emergencies. In this study, we examined travel times to hospitals in Nairobi, Kenya, one of the largest and most congested cities in the developing world.MethodsWe used a network approach to estimate average minimum travel times to different types of hospitals (e.g. ownership and level of care) in Nairobi under both congested and uncongested traffic conditions. We also examined the correlation between travel time and socioeconomic status.ResultsWe estimate the average minimum travel time during uncongested traffic conditions to any level 4 health facility (primary hospitals) or above in Nairobi to be 4.5 min (IQR 2.5–6.1). Traffic added an average of 9.0 min (a 200% increase). In uncongested conditions, we estimate an average travel time of 7.9 min (IQR 5.1–10.4) to level 5 facilities (secondary hospitals) and 11.6 min (IQR 8.5–14.2) to Kenyatta National Hospital, the only level 6 facility (tertiary hospital) in the country. Traffic congestion added an average of 13.1 and 16.0 min (166% and 138% increase) to travel times to level 5 and level 6 facilities, respectively. For individuals living below the poverty line, we estimate that preferential use of public or faith-based facilities could increase travel time by as much as 65%.ConclusionAverage travel times to health facilities capable of providing emergency care in Nairobi are quite low, but traffic congestion double or triple estimated travel times. Furthermore, we estimate significant disparities in timely access to care for those individuals living under the poverty line who preferentially seek care in public or faith-based facilities.
       
  • Bull horn injury causing traumatic tooth intrusion – ultrasound and
           CT imaging

    • Abstract: Publication date: Available online 8 January 2020Source: African Journal of Emergency MedicineAuthor(s): Rohan Bhoil, Manmohan Bramta, Rohit BhoilAbstractIntroductionTraumatic injury to upper alveolus may result in apical displacement of the affected tooth/teeth into the underlying alveolar bone. The tooth while being driven into the socket under the upwardly directed impact force usually causes a crushing fracture of the alveolar socket bone. The tooth may also be displaced through the labial plate of bone or may even impinge upon the bud of the permanent tooth.Case reportWe present a case of tooth intrusion due to bull horn injury and its imaging features on ultrasound and CT scan.DiscussionMost common teeth involved in dental trauma in children of 6 to 12 year age group, are the maxillary anteriors, and this age group also constitutes the most common group in whom tooth intrusion is seen. Tooth intrusion usually involves a single dental element. Common etiologic causes are injuries, falls, sports accidents, violence and traffic accidents. Traumatic intrusion due to injury by animals is rarely described and is more commonly seen in less developed areas that too in rural set-up where man-animal encounters are frequent.ConclusionIn such cases, whenever the conventional imaging modalities like the X-rays such as intra oral peri-apical views and orthopantomograms are unavailable, or where use of ionizing radiation is a grave concern (especially in children and pregnant patients), ultrasonography offers a non-invasive diagnostic imaging method which helps in diagnosis of the condition and also helps in supplementing the clinical information, thereby helping in better understanding of the underlying condition.
       
  • The effect of clinical simulation assessment on stress and anxiety
           measures in emergency care students

    • Abstract: Publication date: Available online 7 January 2020Source: African Journal of Emergency MedicineAuthor(s): Christopher SteinAbstractBackgroundClinical simulation has become widespread as a training and assessment tool across a range of health professions, including emergency care. As with any form of assessment, simulations may be associated with stress and anxiety (“distress”) which may have a negative effect on student performance if demands required by the simulation outweigh the available resources. This study aimed to assess the effect of participation by students in an emergency care simulation on an objective measure of stress and a subjective measure of anxiety.MethodsHeart rate variability (HRV) and scores from a validated state anxiety instrument (the State-Trait Anxiety Inventory) were assessed in 36 emergency medical care students participating in scheduled simulation assessments. Data recorded during a resting control period were used for comparison.ResultsHRV variables showed changes in the simulation assessment group suggesting decreased variability and parasympathetic withdrawal, however these were not significantly different to control. Heart rate in the simulation assessment group increased significantly (73.5/min vs. 107.3/min, p 
       
  • Self-assessed competencies of nurses at an emergency department in Ghana

    • Abstract: Publication date: Available online 22 November 2019Source: African Journal of Emergency MedicineAuthor(s): Victoria Bam, Abigail Kusi-Amponsah Diji, Ernest Asante, Alberta Yemotsoo Lomotey, Pearl Adade, Berlinda Asante AkyeampongAbstractIntroductionThe nature and scope of emergency nursing exposes nurses to a wide array of patient populations with rapidly changing and unexpected clinical conditions, sophisticated logistics and procedures. Hence, emergency centre (EC) nurses ought to be ready to face diverse clinical challenges and deliver care to patients in a timely cost-effective manner and with the needed competence. The current study aimed at examining the self-assessed competencies of nurses, and comparing ratings among certified emergency nurses (ENs) and general nurses (GNs) working at an EC of a tertiary hospital in Ghana.MethodsA descriptive cross-sectional quantitative study was carried out among 109 conveniently sampled nurses. Participants evaluated their perceived competencies on a validated instrument under five domains, namely: diagnostic function (DF), administering and monitoring therapeutic interventions (AMTI), effective management of rapidly changing situations (EMRCS), organisational and work load competency (OWLC), and the helping role (HR). Descriptive and inferential data analyses were by SPSS version 25.ResultsParticipants generally had good competencies in the performance of emergency nursing procedures. Highest scores were obtained in OWLC (median score of 83.3%) while EMRCS recorded the least scores (median score of 57.9%). With the exception of the DF domain (p = 0.166), ENs perceived themselves as significantly more competent than their counterpart GNs in 4 (OWLC, HR, AMTI, EMRCS) out of the five studied domains (p 
       
  • Looking back over a decade with the African Journal of Emergency Medicine

    • Abstract: Publication date: Available online 22 November 2019Source: African Journal of Emergency MedicineAuthor(s): Stevan R. Bruijns
       
  • The Urgent Need for Postgraduate Medical Training in Emergency Medicine in
           Nigeria

    • Abstract: Publication date: Available online 18 November 2019Source: African Journal of Emergency MedicineAuthor(s): Adebayo DaCosta, Ayokunle Osonuga, Oluwaseyitan Adesegun
       
  • High-anion gap hyperchloremic acidosis mimicking diabetic ketoacidosis on
           initial presentation – Case report

    • Abstract: Publication date: Available online 17 November 2019Source: African Journal of Emergency MedicineAuthor(s): Esmail Sangey, Kishan ChudasamaAbstractIntroductionDiabetic ketoacidosis (DKA) often becomes the primary focus and in turn masks a similar serious condition like hyperchloremic metabolic acidosis.Case reportA 20 years old female with type 1 diabetes mellitus presented to the emergency department (ED) with signs and symptoms corresponding to DKA. Initial pH, HCO3, Na and Cl concentrations were 6.83, 3.6 mmol/l, 143 mmol/l and 122 mmol/l respectively; anion gap 17.4 mmol/l and absent urinary ketones. DKA regime showed no improvement in the measured parameters nor the patient. The diagnosis changed to hyperchloremic high-anion gap acidosis and treatment modifications were made by adding sodium bicarbonate infusion. There was significant improvement in the clinical status of the patient and the calculated parameters.DiscussionHyperchloremic acidosis is associated with a non-anion gap, decrease in plasma bicarbonate and increase in plasma chloride. Rarely, as with this case, it may present with a high-anion gap. The use of bicarbonate therapy has shown improvement in cases of non-anion gap acidosis however there is very little data to support its role in high-anion gap hyperchloremic metabolic acidosis.
       
  • For the students, by the students: Student perceptions of low cost medical
           moulage in a resource-constrained environment

    • Abstract: Publication date: Available online 31 October 2019Source: African Journal of Emergency MedicineAuthor(s): Andrew William Makkink, Helen SlabberAbstractIntroductionSimulation-based learning affords participants the opportunity to practice high-acuity, low-incidence situations without risk to the patient. The realism of a simulated scenario is often referred to as fidelity. High levels of fidelity imply high levels of realism. One method of enhancing fidelity is the use of moulage. Commercially available moulage kits and professionally applied moulage are often expensive and therefore not practical in the resource-constrained environment. Cost-effective alternatives are required for the resource-constrained environment.MethodsStudents at a South African university used readily available, low cost materials to apply self-constructed, low cost moulage for a bandaging practical. A cross sectional design used a purpose-designed, validated questionnaire to gather data related to face and content validity of the self-constructed moulage. Frequency analysis formed the cornerstone of Likert-type quantitative data analysis. An open-ended question afforded participants the opportunity to express their own opinions related to the moulage experience.ResultsThe results revealed that there was both high face validity and high content validity of the self-constructed moulage. Participants found the activity enjoyable and a generally positive learning experience. The self-constructed moulage was realistic and added to the fidelity of the scenario. Participant confidence was improved and their engagement in the learning activity was enhanced. Participants found the self-constructed, low-cost moulage more realistic that commercial products that they had been exposed to.ConclusionThe use of low-cost, self-constructed moulage is a feasible and economically viable means of enhancing fidelity within the resource-constrained simulation setting. This technique is not necessarily limited to emergency medical care and can be used in other areas of healthcare simulation.
       
  • Cross-sectional survey on occupational needle stick injuries amongst
           prehospital emergency medical service personnel in Johannesburg

    • Abstract: Publication date: Available online 23 October 2019Source: African Journal of Emergency MedicineAuthor(s): Jared McDowall, Abdullah E. LaherAbstractIntroductionPrehospital personnel are exposed to challenging situations that place them at increased risk of sustaining a needle stick injury (NSI). Blood borne infections such as HIV and Hepatitis B or C may be transmitted from a NSI. Sub-Saharan Africa has the largest number of people living with HIV globally. There is no data pertaining to NSI among Emergency Medical Service (EMS) personnel in South Africa. This study aimed to investigate the cumulative incidence, knowledge, attitudes and practices pertaining to NSIs amongst a select group of prehospital personnel in Johannesburg.MethodsThis was a prospective, questionnaire based, cross-sectional survey of personnel employed at three EMS service providers in Johannesburg.ResultsOf the 240 subjects that participated in the study, there was a total of 93 NSIs amongst 63 (26.3%) subjects. Of these, 41 (65.1%) had sustained one previous NSI, 16 (25.4%) had two NSIs, 5 (7.9%) had three NSIs and one (1.6%) had five NSIs. Almost two-thirds (n = 60; 64.5%) of NSIs were sustained during intravenous line insertion. Most of the study subjects were male (n = 145, 60.4%), between the age of 25–29 years (n = 67, 27.9%), had a BLS qualification as the highest level of training (n = 89, 37.1%), had>10 years of EMS experience (n = 69; 28.8%) and were up to date with their Hepatitis B vaccination at the time of the study. HIV post exposure prophylaxis (PEP) was initiated in 82 (88.2%) out of the 93 NSI incidents. However, the recommended 28-day course of therapy was only completed in 68 (82.9%) out of the 82 cases where PEP was initiated.ConclusionPrehospital personnel are at risk of sustaining a NSI. There is a need to promote awareness with regards to the risks, preventive measures, awareness of PEP protocols and the timely initiation and completion of HIV PEP amongst EMS personnel in Johannesburg.
       
  • The preventability of trauma-related death at a tertiary hospital in
           Ghana: a multidisciplinary panel review approach

    • Abstract: Publication date: Available online 18 October 2019Source: African Journal of Emergency MedicineAuthor(s): Rockefeller A. Oteng, Daniel Osei-Kwame, Maysel Stella E. Forson-Adae, Kwame Ekremet, Hussein Yakubu, Bernard Arhin, Ronald F. MaioAbstractIntroductionThe purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residencyMethodThis was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP).Results1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%–66.3%)ConclusionFifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review.
       
  • Identifying quality indicators for prehospital emergency care services in
           the low to middle income setting: The South African perspective

    • Abstract: Publication date: Available online 6 August 2019Source: African Journal of Emergency MedicineAuthor(s): Ian Howard, Peter Cameron, Lee Wallis, Maaret Castrén, Veronica LindströmAbstractIntroductionHistorically, performance within the Prehospital Emergency Care (PEC) setting has been assessed primarily based on response times. While easy to measure and valued by the public, overall, response time targets are a poor predictor of quality of care and clinical outcomes. Over the last two decades however, significant progress has been made towards improving the assessment of PEC performance, largely in the form of the development of PEC-specific quality indicators (QIs). Despite this progress, there has been little to no development of similar systems within the low- to middle-income country setting. As a result, the aim of this study was to identify a set of QIs appropriate for use in the South African PEC setting.MethodsA three-round modified online Delphi study design was conducted to identify, refine and review a list of QIs for potential use in the South African PEC setting. Operational definitions, data components and criteria for use were developed for 210 QIs for inclusion into the study.ResultsIn total, 104 QIs reached consensus agreement including, 90 clinical QIs, across 15 subcategories, and 14 non-clinical QIs across two subcategories. Amongst the clinical category, airway management (n = 13 QIs; 14%); out-of-hospital cardiac arrest (n = 13 QIs; 14%); and acute coronary syndromes (n = 11 QIs; 12%) made up the majority. Within the non-clinical category, adverse events made up the significant majority with nine QIs (64%).ConclusionWithin the South Africa setting, there are a multitude of QIs that are relevant and appropriate for use in PEC. This was evident in the number, variety and type of QIs reaching consensus agreement in our study. Furthermore, both the methodology employed, and findings of this study may be used to inform the development of PEC specific QIs within other LMIC settings.
       
  • Rapid, remote education for point-of-care ultrasound among non-physician
           emergency care providers in a resource limited setting

    • Abstract: Publication date: Available online 8 July 2019Source: African Journal of Emergency MedicineAuthor(s): Benjamin Terry, David L. Polan, Rashidah Nambaziira, Julius Mugisha, Mark Bisanzo, Romolo GaspariAbstractIntroductionAccess to high-quality emergency care in low- and middle-income countries (LMIC) is lacking. Many countries utilise a strategy known as “task-shifting” where skills and responsibilities are distributed in novel ways among healthcare personnel. Point-of-care ultrasound (POCUS) has the potential to significantly improve emergency care in LMICs.MethodsPOCUS was incorporated into a training program for a ten-person cohort of non-physician Emergency Care Providers (ECPs) in rural Uganda. We performed a prospective observational evaluation on the impact of a remote, rapid review of POCUS studies on the primary objective of ECP ultrasound quality and secondary objective of ultrasound utilisation. The study was divided into four phases over 11 months: an initial in-person training month, two middle month blocks where ECPs performed ultrasounds independently without remote electronic feedback, and the final months when ECPs performed ultrasounds independently with remote electronic feedback. Quality was assessed on a previously published eight-point ordinal scale by a U.S.-based expert sonographer and rapid standardised feedback was given to ECPs by local staff. Sensitivity and specificity of ultrasound exam findings for the Focused Assessment with Sonography for Trauma (FAST) was calculated.ResultsOver the study duration, 1153 ultrasound studies were reviewed. Average imaging frequency per ECP dropped 61% after the initial in-person training month (p = 0.01) when ECPs performed ultrasound independently, but rebounded once electronic feedback was initiated (p = 0.001), with an improvement in quality from 3.82 (95% CI, 3.32–4.32) to 4.68 (95% CI, 4.35–5.01) on an eight-point scale. The sensitivity and specificity of FAST exam during the initial training period was 77.8 (95% CI, 59.2–83.0) and 98.5 (95% CI, 93.3–99.9), respectively. Sensitivity improved 88% compared to independent, non-feedback months whereas specificity was unchanged.ConclusionsRemotely delivered quality assurance feedback is an effective educational tool to enhance provider skill and foster continued and sustainable use of ultrasound in LMICs.
       
  • Retrospective review of the patient cases at a major trauma center in
           Nairobi, Kenya and implications for emergency care development

    • Abstract: Publication date: Available online 2 July 2019Source: African Journal of Emergency MedicineAuthor(s): Julie Saleeby, Justin G. Myers, Karen Ekernas, Katherine Hunold, Ali Wangara, Alice Maingi, Peyton Wilson, Vincent Mutiso, Sarah Zamamiri, Daniel Bacon, Wes Davis, John Suder, Yash Agrawal, Ogar Ogar, Ian B.K. Martin, Stephen DunlopAbstractIntroductionLow- and middle-income countries (LMICs) are continuing to experience a “triple burden” of disease - traumatic injury, non-communicable diseases (NCDs), and communicable disease with maternal and neonatal conditions (CD&Ms). The epidemiology of this triad is not well characterised and poses significant challenges to resource allocations, administration, and education of emergency care providers. The data collected in this study provide a comprehensive description of the emergency centre at Kenya's largest public tertiary care hospital.MethodsThis study is a retrospective chart review conducted at Kenyatta National Hospital of all patient encounters over a four-month period. Data were collected from financial and emergency centre triage records along with admission and mortality logbooks. Chief complaints and discharge diagnoses collected by specially trained research assistants were manually converted to standardised diagnoses using International Classification of Disease 10 (ICD-10) codes. ICD-10 codes were categorised into groups based on the ICD-10 classification system for presentation.ResultsA total of 23,941 patients presented to the emergency centre during the study period for an estimated annual census of 71,823. The majority of patients were aged 18-64 years (58%) with 50% of patients being male and only 3% of unknown sex. The majority of patients (61%) were treated in the emergency centre, observed, and discharged home. Admission was the next most common disposition (33%) followed by death (6%). Head injury was the overall most common diagnosis (11%) associated with admission.ConclusionsTrends toward NCDs and traumatic diseases have been described by this study and merit further investigation in both the urban and rural setting. Specifically, the significance of head injury on healthcare cost, utilisation, and patient death and disability points to the growing need of additional resources at Kenyatta National Hospital for acute care. It further demonstrates the mounting impact of trauma in Kenya and throughout the developing world.African relevance•This is a comprehensive description of the emergency centre at Kenya's largest public tertiary hospital•It adds to descriptions of trends of non-communicable and traumatic diseases in low- and middle-income countries•It describes epidemiology in Kenya, one of Africa's largest countries
       
  • Needs assessment for a formal emergency medicine residency program in
           southern Madagascar

    • Abstract: Publication date: Available online 2 July 2019Source: African Journal of Emergency MedicineAuthor(s): Gretchen Mockler, Rivo Andry Rakotoarivelo, Jaona Ranaivo, Rolando Valenzuela, Katherine Pierson, Dalia Calix, William MallonAbstractIntroductionWorld Health Organization data for Madagascar reveal that the nation's under age five mortality rate is 56/1000, and that its maternal mortality rate is 440/100,000. Malaria, leprosy, plague, and tuberculosis remain significant communicable disease threats. Malnutrition rates are improving but continue to impact negatively on the general health of the Malagasy population, especially in the southern region with its 1.9 million inhabitants. There are no emergency medicine (EM) training programs to serve the southern half of Madagascar, which has a large urban population in Fianarantsoa. This study aimed to assess the need for and potential feasibility of an emergency medicine training program in southern Madagascar.MethodsWe met with the institutional leadership on site at the university hospital in Fianarantsoa. A needs assessment was performed on multiple domains. Domain 1: existing hospital infrastructure and its physical plant and emergency centre (EC) space allotment. Domain 2: existing clinical and technological resources. Domain 3: educational resources and the existing curriculum for EM. Domain 4: medical student educational program and availability of prospective residency candidates. Domain 5: pre-hospital care and emergency medical services.ResultsThe size of the EC is adequate for the current census. Clinical resources are typical of many developing countries, with significant need for technological advancement and support, which we delineate in the body of our paper. There is an existing curriculum in Antananarivo and in Majanga, as well as one available through the African Federation for Emergency Medicine. The medical school in the area is relatively new, with graduating classes numbering approximately 30. There is no organised pre-hospital care system, no 9-1-1 equivalent, and no pre-hospital treatment from within metropolitan Fianarantsoa.ConclusionsWhile the needs assessment indicates substantial need for emergency medicine development in southern Madagascar, the yield (particularly for the metropolitan Fianarantsoa area) would serve the population well.
       
  • A prehospital randomised controlled trial in South Africa: Challenges and
           lessons learnt

    • Abstract: Publication date: Available online 6 March 2019Source: African Journal of Emergency MedicineAuthor(s): Willem Stassen, Lee Wallis, Maaret Castren, Craig Vincent-Lambert, Lisa KurlandAbstractThe incidence of cardiovascular disease and STEMI is on the rise in sub-Saharan Africa. Timely treatment is essential to reduce mortality. Internationally, prehospital 12 lead ECG telemetry has been proposed to reduce time to reperfusion. Its value in South Africa has not been established. The aim of this study was to determine the effect of prehospital 12 lead ECG telemetry on the PCI-times of STEMI patients in South Africa. A multicentre randomised controlled trial was attempted among adult patients with prehospital 12 lead ECG evidence of STEMI. Due to poor enrolment and small sample sizes, meaningful analyses could not be made. The challenges and lessons learnt from this attempt at Africa's first prehospital RCT are discussed. Challenges associated with conducting this RCT related to the healthcare landscape, resources, training of paramedics, rollout and randomisation, technology, consent and research culture. High quality evidence to guide prehospital emergency care practice is lacking both in Africa and the rest of the world. This is likely due to the difficulties with performing prehospital clinical trials. Every trial will be unique to the test intervention and setting of each study, but by considering some of the challenges and lessons learnt in the attempt at this trial, future studies might experience less difficulty. This may lead to a stronger evidence-base for prehospital emergency care.
       
  • A cross-sectional description of open access publication costs, policies
           and impact in emergency medicine and critical care journals

    • Abstract: Publication date: Available online 6 March 2019Source: African Journal of Emergency MedicineAuthor(s): Chante Dove, Teresa M. Chan, Brent Thoma, Damian Roland, Stevan R. BruijnsAbstractIntroductionFinding journal open access information alongside its global impact requires access to multiple databases. We describe a single, searchable database of all emergency medicine and critical care journals that include their open access policies, publication costs, and impact metrics.MethodsA list of emergency medicine and critical care journals (including citation metrics) was created using Scopus (Citescore) and the Web of Science (Impact Factor). Cost of gold/hybrid open access and article process charges (open access fees) were collected from journal websites. Self-archiving policies were collected from the Sherpa/RoMEO database. Relative cost of access in different regions were calculated using the World Bank Purchasing Power Parity index for authors from the United States, Germany, Turkey, China, Brazil, South Africa and Australia.ResultsWe identified 78 emergency medicine and 82 critical care journals. Median Citescore for emergency medicine was 0.73 (interquartile range, IQR 0.32–1.27). Median impact factor was 1.68 (IQR 1.00–2.39). Median Citescore for critical care was 0.95 (IQR 0.25–2.06). Median impact factor was 2.18 (IQR 1.73–3.50). Mean article process charge for emergency medicine was $2243.04, SD = $1136.16 and for critical care $2201.64, SD = $1174.38. Article process charges were 2.24, 1.75, 2.28 and 1.56 times more expensive for South African, Chinese, Turkish and Brazilian authors respectively than United States authors, but neutral for German and Australian authors (1.02 and 0.81 respectively). The database can be accessed here: http://www.emct.info/publication-search.html.ConclusionsWe present a single database that captures emergency medicine and critical care journal impact rankings alongside its respective open access cost and green open access policies.
       
  • Efficacy of nebulized fentanyl and low dose ketamine for pain control of
           patients with long bone fractures: A randomized, double-blind, clinical
           trial

    • Abstract: Publication date: Available online 3 March 2019Source: African Journal of Emergency MedicineAuthor(s): Mohammadreza Maleki Verki, Javad Mozafari, Fateme Tirandaz, Hassan Motamed, Afsane KhazaeliAbstractIntroductionFentanyl is a lipid soluble, highly potent opioid. The lipid solubility of fentanyl makes it an ideal opioid to be administrated by inhalation. The current study compared ketamine infusion and nebulized fentanyl in bone fracture pain relief.MethodsIn this double-blind, randomized clinical trial, patients aged 18 to 55 years who were admitted to the emergency department (ED) with limb fracture were recruited. A total of 127 patients were included in the study, 51.1% (65) of whom were male and 48.9% (62) of whom were female. The patients were divided equally into two groups: Group I received 100 cm3 IV infusion of normal saline and 4 μg/kg of 50 μg/ml nebulized fentanyl; Group II received 0.4 mg/kg ketamine in 10 min and 5 cm3 nebulized normal saline. Pain was assessed using a visual analog scale just before treatment and 5, 10, 15, 30, and 60 min post-treatment.ResultsBefore intervention, the pain scores of both groups showed no significant difference. However, log linear analysis in both groups showed a significantly decrement during the follow up (60 min) (p 
       
  • Utilisation of emergency blood in a cohort of South African emergency
           centres with no direct access to a blood bank

    • Abstract: Publication date: Available online 10 February 2019Source: African Journal of Emergency MedicineAuthor(s): David Morris, Daniël van Hoving, Melanie Stander, Stevan BruijnsAbstractIntroductionThe transfusion of emergency blood is an essential part of haemostatic resuscitation. Locally, where direct access to a blood bank is limited, emergency blood is stored within emergency centres. It was previously suggested that stored blood provides inadequate volumes compared to what is needed. Minimal data are available regarding indications for emergency blood usage. We aimed to describe the utilisation of emergency blood in selected Cape Town emergency centres.Materials and methodsA cross-sectional study was carried out at three secondary level emergency centres (no blood bank), and one tertiary centre (with a blood bank). Data from emergency blood recipients were recorded over a three-month study period. Indications for transfusion, number of units and location of transfusion were recorded. Indications and usage location were described in numbers and proportions.ResultsA total of 329 emergency blood units were transfused to 210 patients. Trauma accounted for 39% (n = 81) of cases and other surgical conditions for 22% (n = 47), particularly upper gastrointestinal 11% (n = 24) and perioperative bleeding 8% (n = 16). Medical conditions accounted for 15% (n = 31), with anaemia 13% (n = 27), the most prevalent indication. Gynaecological conditions accounted for 15% (n = 32), mostly ectopic pregnancy 8% (n = 17). The majority of emergency blood, 77% (n = 253) were used in the emergency centres or operating theatres, 6% (n = 21).ConclusionTrauma remains a major indication for emergency blood transfusion in this setting. This study questions the use of emergency blood for certain non-urgent diagnoses (i.e. anaemia). Given the scarcity of this resource and limitations to access, appropriate use of emergency blood needs to be better defined locally. Ongoing monitoring of the indications for which emergency blood is used, improved transfusion stewardship and better systems to access emergency blood should be a priority in this setting.
       
 
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