Current perspectives of oncoplastic breast surgery in Pakistan

Oncoplastic breast surgery is based on the concept of tumour-specific immediate reconstruction. It combines both local and distant techniques to maintain breast texture, symmetry and cosmesis without compromising oncological outcome. The current narrative review was planned to highlight the current state and future of oncoplastic breast surgery in low- and middle-income
countries where its utilisation in surgical practice remains insubstantial because majority of the surgeons who are treating breast cancer are either general surgeons or breast surgeons who do not have expertise in oncoplastic breast surgery or reconstructive surgery. Moreover, scarcity of financial resources, ignorance about oncoplastic breast surgery techniques, disfigurement
distress and cultural taboos coerce women to hide in the shadows with their breast disease. Oncoplastic breast surgery needs more exposure in a developing country like Pakistan.

Global Hospital Infrastructure and Pediatric Burns

Low income regions carry the highest mortality burden of pediatric burns and attention to remedy these inequities has shifted from isolated mission trips towards building infrastructure for lasting improvements in surgical care. This study aims to investigate disparities in pediatric burn care infrastructure and their impact on mortality outcomes. The multinational Global Burn Registry was queried for all burn cases between January 2018 and August 2021. Burn cases and mortality rates were analyzed by Chi-Square and multinomial regression. There were a total of 8537 cases of which 3492 (40.9%) were pediatric. Significantly lower mortality rates were found in facilities with sophisticated nutritional supplementation (p<0.001), permanent internet connectivity (p<0.001), critical care access (p<0.001), burn OR access (p=0.003), dedicated burn unit (p<0.001), and advanced plastic and reconstructive skills (p=0.003). Significant disparities were found in the availability of these resources between high- and low-income countries, as well granular information within low income regions. In a multinomial logistic regression controlling for TBSA, the most significant predictive factors for mortality were limited critical care availability (OR 15.18, p<0.001) and sophisticated nutritional access (OR 0.40, p=0.024). This is the first quantitative analysis of disparities in global burn infrastructure. The identification of nutritional support as an independent and significant protective factor suggests that low-cost interventions in hospital nutrition infrastructure may realize significant gains in global burn care. Granular information in the variability of regional needs will begin to direct targeted infrastructure initiatives rather than a one-size-fits-all approach in developing nations.

Magnitude of mortality and its associated factors among Burn victim children admitted to South Gondar zone government hospitals, Ethiopia, from 2015 to 2019

Background
Burn is one of the leading causes of preventable death and disability every year in low and middle-income countries, which mainly affects those aged less than 15 years. Death from burn injuries carries the most significant losses, which often have grave consequences for the countries. Even though data from different settings are necessary to tackle it, pieces of evidence in this area are limited. Thus, this study was aimed to answer the question, what is the Magnitude of Mortality? And what are the factors associated with mortality among burn victim children admitted to South Gondar Zone Government Hospitals, Ethiopia, from 2015 to 2019?

Methods
Institutional-based cross-sectional study design was used to study 348 hospitalized burn victim pediatrics’, from 2015 to 2019. A simple random sampling method was used. Data were exported from Epidata to SPSS version 23 for analysis. Significant of the variables were declared when a p-value is < 0.05.

Result
The mortality rate of burn victim children in this study was 8.5% (95% CI = 5.5–11.4). Medical insurance none users burn victim children were more likely (AOR 3.700; 95% CI =1.2–11.5) to die as compared with medical insurance users, burn victim children with malnutrition were more risk (AOR 3.9; 95% CI = 1.3–12.2) of mortality as compared with well-nourished child. Moreover, electrical (AOR 7.7; 95% CI = 1.8–32.5.2) and flame burn (AOR 3.3; 95% CI = 1.2–9.0), total body surface area greater than 20% of burn were more likely (AOR 4.6; 95% CI 1.8–11.8) to die compared to less than 20% burn area and burn victim children admitted with poor clinical condition at admission were four times (AOR 4.1, 95% CI = 1.3–12.0) of mortality compared to a good clinical condition.

Conclusion
The mortality among burn victim children was higher than most of the studies conducted all over the world. Medical insurance none users, being malnourished, burned by electrical and flame burn, having total body surface area burnt greater than 20%, and having poor clinical condition at addition were significantly associated with mortality of burn victim pediatrics. Therefore, timely identification and monitoring of burn injury should be necessary to prevent mortality of burn victim pediatrics.

Management of Soft-Tissue Coverage of Open Tibia Fractures in Latin America: Techniques, Timing, and Resources

Purpose
This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America.

Methods
A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs).

Results
The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p<0.01) and plastic surgeons were more available (<24 hours of patient presentation to the hospital) in HICs than MICs (63% vs. 26%, p=0.05), demonstrating statistically significant differences. In addition, respondents in HICs performed free flaps more commonly than in MICs for proximal third (55% vs. 18%, p<0.01), middle third (36% vs. 9%, p=0.02), and distal third (55% vs. 10%, p<0.01) lower extremity wounds. Negative Pressure Wound Therapy (NPWT or Wound VAC) was the only resource available to more than half of the respondents. Though not statistically significant, surgeons reported having more access to plastic surgeons at their institutions in HICs than MICs (91% vs. 62%, p=0.12) and performed microsurgical flaps more commonly at their respective institutions (73% vs. 42%, p=0.06).

Conclusions
The study demonstrated that most orthopaedic surgeons in Latin America have received no soft-tissue training; that HICs and MICs have different access to plastic surgeons and different expectations for flap type and definitive coverage timing; and that most respondents had limited access to necessary soft-tissue coverage surgical resources. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.

Adapting Elements of Cleft Care Protocols in Low- and Middle-income Countries During and After COVID-19: A Process-driven Review With Recommendations

Objective
A consortium of global cleft professionals, predominantly from low- and middle-income countries, identified adaptations to cleft care protocols during and after COVID-19 as a priority learning area of need.

Design
A multidisciplinary international working group met on a videoconferencing platform in a multi-staged process to make consensus recommendations for adaptations to cleft protocols within resource-constrained settings. Feedback was sought from a roundtable discussion forum and global organizations involved in comprehensive cleft care.

Results
Foundational principles were agreed to enable recommendations to be globally relevant and two areas of focus within the specified topic were identified. First the safety aspects of cleft surgery protocols were scrutinized and COVID-19 adaptations, specifically in the pre- and perioperative periods, were highlighted. Second, surgical procedures and cleft care services were prioritized according to their relationship to functional outcomes and time-sensitivity. The surgical procedures assigned the highest priority were emergent interventions for breathing and nutritional requirements and primary palatoplasty. The cleft care services assigned the highest priority were new-born assessments, pediatric support for children with syndromes, management of acute dental or auditory infections and speech pathology intervention.

Conclusions
A collaborative, interdisciplinary and international working group delivered consensus recommendations to assist with the provision of cleft care in low- and middle-income countries. At a time of global cleft care delays due to COVID-19, a united approach amongst global cleft care providers will be advantageous to advocate for children born with cleft lip and palate in resource-constrained settings.

Burn injury prevention in low- and middle- income countries: scoping systematic review

Background
Burn injuries are a leading cause of morbidity and disability, with the burden of disease being disproportionately higher in low- and middle-income countries (LMIC). Burn prevention programmes have led to significant reductions in the incidence of burns in high-income countries. However, a previous systematic review published in 2015 highlighted that implementation and evaluation of similar programmes has been limited in LMIC. The objective of this scoping review and narrative synthesis was to summarise and understand the initiatives that have been carried out to reduce burn injuries in LMIC and their effectiveness.

Methods
We aimed to identify publications that described studies of effectiveness of burn prevention interventions applied to any population within a LMIC and measured burn incidence or burns-related outcomes. Suitable publications were identified from three sources. Firstly, data was extracted from manuscripts identified in the systematic review published by Rybarczyk et al. We then performed a search for manuscripts on burn prevention interventions published between January 2015 and September 2020. Finally, we extracted data from two systematic reviews where burn evidence was not the primary outcome, which were identified by senior authors. A quality assessment and narrative synthesis of included manuscripts were performed.

Results
In total, 24 manuscripts were identified and categorized according to intervention type. The majority of manuscripts (n = 16) described education-based interventions. Four manuscripts focused on environmental modification interventions and four adopted a mixed-methods approach. All of the education-based initiatives demonstrated improvements in knowledge relating to burn safety or first aid, however few measured the impact of their intervention on burn incidence. Four manuscripts described population-based educational interventions and noted reductions in burn incidence. Only one of the four manuscripts describing environmental modification interventions reported burns as a primary outcome measure, noting a reduction in burn incidence. All mixed-method interventions demonstrated some positive improvements in either burn incidence or burns-related safety practices.

Conclusion
There is a lack of published literature describing large-scale burn prevention programmes in LMIC that can demonstrate sustained reductions in burn incidence. Population-level, collaborative projects are necessary to drive forward burn prevention through specific environmental or legislative changes and supplementary educational programmes.

Impact of COVID-19 pandemic on global burn care

Background
Worldwide, different strategies have been chosen to face the COVID-19-patient surge, often affecting access to health care for other patients. This observational study aimed to investigate whether the standard of burn care changed globally during the pandemic, and whether country´s income, geographical location, COVID-19-transmission pattern, and levels of specialization of the burn units affected reallocation of resources and access to burn care.

Methods
The Burn Care Survey is a questionnaire developed to collect information on the capacity to provide burn care by burn units around the world, before and during the pandemic. The survey was distributed between September and October 2020. McNemar`s test analyzed differences between services provided before and during the pandemic, χ2 or Fisher’s exact test differences between groups. Multivariable logistic regression analyzed the independent effect of different factors on keeping the burn units open during the pandemic.

Results
The survey was completed by 234 burn units in 43 countries. During the pandemic, presence of burn surgeons did not change (p=0.06), while that of anesthetists and dedicated nursing staff was reduced (<0.01), and so did the capacity to manage patients in all age groups (p=0.04). Use of telemedicine was implemented (p<0.01), collaboration between burn centers was not. Burn units in LMICs and LICs were more likely to be closed, after adjustment for other factors.

Conclusions
During the pandemic, most burn units were open, although availability of standard resources diminished worldwide. The use of telemedicine increased, suggesting the implementation of new strategies to manage burns. Low income was independently associated with reduced access to burn care.

Access to burn care in low-and middle-income countries: An assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

This study investigates patients’ access to surgical care for burns in a low-and-middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50 percent reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within three weeks for 74 percent in this group. Of contracture patients, seventy four percent, had sought healthcare after the acute burn injury. Of the same group, only 4 percent had been treated with skin grafts beforehand, and 70 percent never received surgical care or a referral. Combined, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively impacting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socio-economic factors that determine patient mortality and disability.

Think global, act local: Burn care in a resource-limited setting

The burden of burn injuries remains a major global health issue.1,2 Worldwide,millions of people suffer from burns and burn-related disabilities and deformities. Every year over 8 million people require medical attention due to burns. Burns cause an estimated loss of 8.5 million disability-adjusted life years (DALYs) each year due to premature death and disability.3 Five per cent of all injury-related deaths are caused by burns, which amounts to an estimated 120,000 deaths annually.4 Non-fatal burns are a leading cause of disability, which cause long-term physical and psychological problems.5,6 There are large differences in burn care worldwide.1 In high-income countries (HICs) major progress has been made in acute burn care over the past decades. With advancements made in the prevention of burns and treatments of wounds, the incidence of burns has decreased and the survival rate of patients has increased. The current mortality reported by HICs is 1.5%.7 This is in stark contrast to low- and middle-income countries (LMICs). In these countries the burden of burn incidence, mortality and morbidity remains high.1,8,9 The vast majority of all burns globally occur in LMICs. This is because people use open fires in daily life, for example for cooking, heating and agriculture. The incidence of burns in these countries is estimated to be 1.3 per 100,000 people, compared to 0.14 per 100,000 people in HICs.8,10 The few existing studies from LMICs show that poor populations are most at risk of sustaining burns, and that the majority of patients are children.1,2,9,11,12 The higher morbidity and mortality is a consequence of the fact that geographically isolated and economically disadvantaged populations have limited access to safe and timely burn care.2 Due to this lack of care, 95% of all fatal fire-related cases of mortality due to burns occurs in LMICs. Studies have estimated that the risk of child mortality due to burns is currently over seven times
higher in LMICs compared to HICs

The impact of the COVID-19 pandemic on international reconstructive collaborations in Africa

Background
The SARS-CoV-2 (COVID-19) pandemic has catalysed a widespread humanitarian crisis in many low- and middle-income countries around the world, with many African nations significantly impacted. The aim of this study was to quantify the impact of the COVID-19 pandemic on the planning and provision of international reconstructive collaborations in Africa.

Methods
An anonymous, 14-question, multiple choice questionnaire was sent to 27 non-governmental organisations who regularly perform reconstructive surgery in Africa. The survey was open to responses for four weeks, closing on the 7th of March 2021. A single reminder was sent out at 2 weeks. The survey covered four key domains: (1) NGO demographics; (2) the impact of COVID-19 on patient follow-up; (3) barriers to the safe provision of international surgical collaborations during COVID-19; (4) the impact of COVID-19 on NGO funding.

Results
A total of ten reconstructive NGOs completed the survey (response rate, 37%). Ethiopia (n = 5) and Tanzania (n = 4) were the countries where most collaborations took place. Plastic, reconstructive and burns surgery was the most common sub-speciality (n = 7). For NGOs that did not have a year-round presence in country (n = 8), only one NGO was able to perform reconstructive surgery in Africa during the pandemic. The most common barrier identified was travel restrictions (within country, n = 8 or country entry-exit, n = 7). Pre-pandemic, 1547 to ≥ 1800 patients received reconstructive surgery on international surgical collaborations. After the outbreak, 70% of NGOs surveyed had treated no patients, with approximately 1405 to ≥ 1640 patients left untreated over the last year.

Conclusions
The COVID-19 pandemic has placed huge pressures on health services and their delivery across the globe. This theme has extended into international surgical collaborations leading to increased unmet surgical needs in low- and middle-income countries.