Trauma is often viewed as an individual or interpersonal issue. This paper expands the definition of trauma to include the impact collective and structural elements on health and well-being. The need for a trauma-informed response is demonstrated, with instruction as to how to implement this type of care in order to resist re-traumatization. Three examples from healthcare settings across the nation are provided, to demonstrate the ways in which organizations are bringing forward this patient-centered, trauma-informed approach to care.

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Introduction: HIV-associated inflammation contributes to higher CVD risk among persons living with HIV (PLWH). Heart failure (HF) is a prominent CVD manifestation in sub-Saharan Africa where HIV prevalence is high. Systolic dysfunction is a well-known complication of untreated, advanced HIV disease, but it is unknown if ongoing inflammation contributes to myocardial dysfunction during antiretroviral therapy (ART). We evaluated myocardial function via cardiac magnetic resonance (CMR) and studied associations with inflammatory biomarkers among ART-treated PLWH residing in Khayelitsha township near Cape Town, South Africa. Methods: CMR images were ascertained via a large bore 3T Siemens Skyra MRI scanner using standardized protocols. Biomarkers were measured from stored plasma using immunoassays and were log 2 -transformed for analyses. Linear regression was used to evaluate cross-sectional associations between CMR parameters and biomarker concentrations, adjusted for age, sex, current smoking, and hypertension. Results: Among 133 ART-treated PLWH without known CVD, 64% (85) were female, 99% (132) were Black African, 29% (39) were smokers, 92% (123) had undetectable HIV viral load, mean (SD) age was 50 (9) years, and current and nadir CD4+ count were 535 (270) and 271 (213) cells/μL, respectively. Higher TNFR1, TNF-α, and IFN-γ were associated with lower left ventricular ejection fraction (p=0.03, 0.05, and 0.03, respectively) and systolic global circumferential strain (p=0.01, 0.04, and 0.02) ( Table ). Higher TNFR1 was also associated with lower diastolic strain rate in circumferential (p=0.02), longitudinal (p=0.05), and radial (p=0.01) planes. Conclusion: These data suggest inflammation may contribute to lower myocardial function among ART-treated PLWH prior to development of clinical HF. The magnitude of this effect was modest, but potential long-term effects on myocardial tissue remodeling and subsequent HF risk warrant further investigation among a growing ART-treated population in South Africa.

Aims Efforts to improve access to antiretroviral therapy (ART) have shifted morbidity and mortality among persons living with HIV (PLWH) from AIDS to non-communicable diseases, such as cardiovascular disease (CVD). However, contemporary data on CVD among PLWH in sub-Saharan Africa in the current ART era are lacking. The aim of this study was to assess the burden of cardiac stress among PLWH in South Africa via measurement of N-terminal prohormone of brain natriuretic peptide (NT-proBNP). Methods and results NT-proBNP was measured at baseline in 224 PLWH enrolled in a sub-study of a tuberculosis vaccine trial in Khayelitsha township near Cape Town, South Africa. Thresholds were applied at the assay's limit of detection (≥137 pg/mL) and a level indicative of symptomatic heart failure in the acute setting (>300 pg/mL). Mean (SD) age of participants was 39 (6) years, 86% were female, and 19% were hypertensive. Mean (SD) duration of HIV diagnosis was 8.3 (3.9) years and CD4 + count was 673 (267) with 79% prescribed ART for a duration of 5.6 (2.7) years. Thirty-one percent of participants had NT-proBNP > 300 pg/mL. Elevated vs. undetectable NT-proBNP level was associated with older age (P = 0.04), no ART (P = 0.03), and higher plasma tumour necrosis factor-α (P = 0.01). Conclusions Among South African PLWH largely free of known CVD and on ART with high CD4 + counts and few comorbidities, we observed a high proportion with elevated NT-proBNP levels, suggesting the burden of cardiac stress in this population may be high. This observation underscores the need for more in-depth research, including the current effect of HIV on heart failure risk among a growing ART-treated population in sub-Saharan Africa.

Pediatric Emergency Department Thoracotomy systematic review reveals a scarcity of quality data. Experts from PTS, EAST and WTA, have developed practice management guidelines with GRADE methodology to provide guidance for trauma surgeons.