Building an ecosystem of safe surgery and anesthesia through cleft care

Cleft lip and/or palate (CLP) is among the world’s most common congenital anomalies, affecting an estimated 1 in 700 live births. CLP can lead to a wide range of health problems, including feeding difficulties that contribute to malnutrition, oral health challenges, delays in speech and language development, and long-term emotional and physical health issues. Receiving timely high-quality cleft surgical and anesthesia care, in addition to a range of interdisciplinary health services, is critical to the health and development of children impacted by CLP.

Too often, however, whether a baby receives this essential treatment is dependent upon the city, country, or region in which they are born. The global burden of surgical disease is a significant and long-neglected area within global health that disproportionately affects low-and middle-income countries (LMICs) compared to high-income countries (HICs). The estimated 1.7 billion children who live without access to surgical care around the globe, including many with CLP, live with a greater risk of life-long disability and a higher risk of mortality.

Barriers to surgical care in LMICs include a lack of trained health-care providers, inadequate infrastructure, high out-of-pocket costs, and lack of political prioritization. Historically, short-term missions have sought to address the burden of surgical conditions such as CLP, but this short-term, siloed approach fails to address – and in many cases has only perpetuated – the systemic causes of global surgical inequity, which cuts across sectors, disciplines, and borders. As momentum for the prioritization of surgical care grows, it is also clear that outdated models must be replaced by approaches that strengthen the entire ecosystem of safe surgery and anesthesia car

Quality improvement training for burn care in low-and middle-income countries: A pilot course for nurses

Background
There is an urgent need to empower practitioners to undertake quality improvement (QI) projects in burn services in low-middle income countries (LMICs). We piloted a course aimed to equip nurses working in these environments with the knowledge and skills to undertake such projects.

Methods
Eight nurses from five burns services across Malawi and Ethiopia took part in this pilot course, which was evaluated using a range of methods, including interviews and focus group discussions.

Results
Course evaluations reported that interactive activities were successful in supporting participants to devise QI projects. Appropriate online platforms were integral to creating a community of practice and maintaining engagement. Facilitators to a successful QI project were active individuals, supportive leadership, collaboration, effective knowledge sharing and demonstrable advantages of any proposed change. Barriers included: staff attitudes, poor leadership, negative culture towards training, resource limitations, staff rotation and poor access to information to guide practice.

Conclusions
The course demonstrated that by bringing nurses together, through interactive teaching and online forums, a supportive community of practice can be created. Future work will include investigating ways to scale up access to the course so staff can be supported to initiate and lead quality improvement in LMIC burn services.

The treatment challenges and limitation in high-voltage pediatric electrical burn at rural area: A case report

Introduction
Although rare, electrical injury in pediatrics is potentially life threatening and has significant and long-term impact in life. It is challenging to manage such cases in rural areas.

Presentation of case
A fully conscious 13-year-old boy was admitted to the emergency room after being electrocuted by high-voltage power cable, with superficial partial thickness burn over right arm, trunk, and left leg (26 % of total body surface area). Tachycardia and non-specific ST depression was found on ECG examination and was diagnosed with high-voltage electrical injury. Treatments were based on ANZBA algorithm with several modifications, i.e., administering lower concentration of oxygen with nasal cannula instead of non-rebreathing mask as well as Ketorolac and Antrain® for analgesic instead of morphine.

Discussion
Different choices of treatments were given due to limited resources. Despite possible cardiac and renal complication, further tests could not be done. Fortunately, after strict monitoring, no signs of abnormality were found. We used silver sulfadiazine, Sofratulle® and dry sterile gauze as a dressing of choice following immediate surgical debridement. The patient was observed daily through 7 days of hospitalization and followed-up for 1 year, achieving normal physiologic function of the affected area but unsatisfactory esthetic result.

Conclusion
Lack of infrastructure, drugs, and trained personnel are some of the challenges that still exist in most rural areas. Thus, implementation of available standardized guidelines such as ANZBA, and giving similar training to personnel as well as providing feasible equipment followed by strict monitoring for the patient are needed to achieve maximum results.

Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Peri‐operative SARS‐CoV‐2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS‐CoV‐2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre‐operative SARS‐CoV‐2 infection were compared with those without previous SARS‐CoV‐2 infection. The primary outcome measure was 30‐day postoperative mortality. Logistic regression models were used to calculate adjusted 30‐day mortality rates stratified by time from diagnosis of SARS‐CoV‐2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre‐operative SARS‐CoV‐2 diagnosis. Adjusted 30‐day mortality in patients without SARS‐CoV‐2 infection was 1.5% (95%CI 1.4–1.5). In patients with a pre‐operative SARS‐CoV‐2 diagnosis, mortality was increased in patients having surgery within 0–2 weeks, 3–4 weeks and 5–6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3–4.8), 3.9 (2.6–5.1) and 3.6 (2.0–5.2), respectively). Surgery performed ≥ 7 weeks after SARS‐CoV‐2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9–2.1)). After a ≥ 7 week delay in undertaking surgery following SARS‐CoV‐2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2–8.7) vs. 2.4% (95%CI 1.4–3.4) vs. 1.3% (95%CI 0.6–2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS‐CoV‐2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay

Pregnancy Associated Breast Cancer (PABC): Report from a gestational cancer registry from a tertiary cancer care centre, India

Background
Pregnancy associated breast cancer (PABC) is a rare entity and defined as breast cancer diagnosed during pregnancy or one-year post-partum. There is sparse data especially from low and middle-income countries (LMIC) and merits exploration.

Methods
The study (2013 -2020) evaluated demographics, treatment patterns and outcomes of PABC.

Results
There were 104 patients, median age of 31 years; 43 (41%) had triple-negative disease, 31(29.8%) had hormone-receptor (HR) positive and HER2 negative, 14 (13.5%) had HER2-positive and HR negative and 16(15.4%) had triple positive disease. 101(97%) had IDC grade III tumors and 74% had delayed diagnosis. 72% presented with early stage (24, EBC) or locally advanced breast cancer (53, LABC) and received either neoadjuvant (n=49) or adjuvant (n=26) chemotherapy and surgery. Trastuzumab, tamoxifen, and radiotherapy were administered post-delivery. At a median follow up of 27 (IQR:19-35) months, the estimated 3-year event-free survival (EFS) for EBC and LABC was 82% (95% CI: 65.2 – 100) and 56% (95% CI: 42 – 75.6%) and for metastatic 24% (95% CI: 10.1% – 58.5%) respectively.

Of the 104 patients, 34 were diagnosed antepartum (AP) and 15 had termination, 2 had preterm and 16 had full-term deliveries(FTDs). Among postpartum cohort (n=70), 2 had termination, 1 had preterm, 67 had FTDs. 83(including 17 from AP) children from both cohorts were experiencing normal milestones.

Conclusion
Data from the first Indian PABC registry showed that the majority had delayed diagnosis and aggressive features(TNBC, higher grade). Treatment was feasible in majority and stage matched outcomes were comparable to non-PABCs.

Telementoring, Surgery training, Rural surgery, Breast cancer

Abstract
Telementorship allows an expert surgeon to mentor another surgeon through an advanced procedure from a remote location via 2-way audio-visual communication. The current article was planned to review the existing literature and evaluate the utility of telementorship regarding educating rural surgeons in Pakistan about multidisciplinary breast cancer care. Publications from 2016 to 2020 were searched on PubMed and GoogleScholar and 10 most recent publications were selected. Review of literature revealed that even though telementorship in this context might be comparable to onsite mentorship, multiple concerns need to be addressed before its implementation. These include lack of concrete evidence regarding its effectiveness, legal, security and financial issues. Thus, a pilot project evaluating the efficacy of telementorship needs to be conducted for rural breast surgeons working in Pakistan. If these studies show promise and an affordable, convenient and effective method of telementorship is devised, then it may become the future of breast surgery training in far-flung regions of Pakistan.

Health System Factors That Influence Treatment Delay in Women With Breast Cancer in Sub-saharan Africa: A Systematic Review

Abstract
Background
Breast cancer patients in sub-Saharan Africa experience long delays between their first presentation to a health care facility and the start of cancer treatment. The role of the health system in the increasing delay in treatment has not been widely investigated. This review aimed to identify existing information on health system factors that influence treatment delays in women with breast cancer in sub-Saharan Africa to contribute to the reorientation of health policies in the region.
Methods
PubMed, ScienceDirect, African Journals Online, Mendeley, ResearchGate and Google Scholar were searched to identify relevant studies published between 2010 and July 2020. We performed a qualitative synthesis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyse (PRISMA) statement. Related health system factors were extracted and classified according to the World Health Organization’s six health system building blocks. The quality of qualitative and quantitative studies was assessed by using the Critical Appraisal Skills Program quality-assessment tool and the National Institute of Health Quality Assessment Tool, respectively. In addition, we used the Confidence in the Evidence from Reviews of Qualitative Research tool to assess the evidence for each qualitative finding.
Results
From 14,184 identified studies, this systematic review included 28 articles. We identified a total of 36 barriers and 8 facilitators that may influence treatment delay in women with breast cancer. The principal health system factors identified were mainly related to human resources and service delivery, particularly difficulty accessing health care, diagnostic errors, poor management, and treatment cost.
Conclusion
The present review shows that treatment delay among women with breast cancer in sub-Saharan Africa is influenced by many related health system factors. Policymakers in sub-Saharan Africa need to tackle the financial accessibility to breast cancer treatment by adequate universal health coverage policies and reinforce the clinical competencies for health workers to ensure timely diagnosis and appropriate care for women with breast cancer in this region

The cost of inpatient burn management in Nepal

Abstract
Introduction
The management of burns is costly and complex with inpatient burns accounting for a high proportion of the costs associated with burn care. We conducted a study to estimate the cost of inpatient burn management in Nepal. Our objectives were to identify the resource and cost components of the inpatient burn care pathways and to estimate direct and overhead costs in two specialist burn units in tertiary hospitals in Nepal.

Methods
We conducted fieldwork at two tertiary hospitals to identify the cost of burns management in a specialist setting. Data were collected through semi-structured in-depth interviews (IDIs) and focus group discussions (FGDs) with burn experts; unit cost data was collected from hospital finance departments, laboratories and pharmacies. The study focused on acute inpatient burn cases admitted to specialist burn centres within a hospital-setting.

Results
Experts divided inpatient burn care pathways into three categories: superficial partial-thickness burns (SPT), mixed depth partial-thickness burns (MDPT) and full thickness burns (FT). These pathways were confirmed in the FGDs. A ‘typical’ burns patient was identified for each pathway. Total resource use and total direct costs along with overhead costs were estimated for acute inpatient burn patients. The average per patient pathway costs were estimated at NRs 102,194 (US$ 896.4), NRs 196,666 (US$ 1725), NRs 481,951 (US$ 4,227.6) for SPT, MDPT and FT patients respectively. The largest cost contributors were surgery, dressings and bed charges respectively.

Conclusion
This study is a first step towards a comprehensive estimate of the costs of severe burns in Nepal.

Epidemiological patterns of patients managed for cleft lip and palate during free outreach camps at a peripheral hospital in Kenya

Context: Clefts involving lip and palate are the most common craniofacial anomalies. The prevalence varies widely according to various factors. There is a paucity of epidemiological data on cleft deformities in African populations. Aims: The aim was to determine the epidemiological patterns of patients managed for cleft lip and palate during free outreach camps in Kenya and subsequently compare it with other studies done nationally, regionally, and internationally. Design: Prospective Cohort Study. Subjects and Methods: This was a prospective cohort study. Data were collected during five cleft surgery outreach camps held at Kitale County Referral Hospital in Trans-Nzoia County, Kenya, between January 2016 and January 2018. Statistical Analysis Used: The study was statistically analyzed by the Statistical Package for the Social Sciences Windows version 21 software for descriptive characteristics. Results: A total of 84 patients were reviewed, of which 74 underwent surgical management. The study population included nine different Counties in Kenya (with one patient from Uganda) and were reported to have traveled between 3 and 450 km. The age range was from 5 weeks to 35 years with patients below 2 years of age making up the majority (58.3%). There was a male preponderance (61.9%). The most common cleft deformities were cleft lip (46.4%), cleft lip and palate (34.6%), and cleft palate (15.5%). Unilateral clefts were commonly left-sided (62%). Sex distribution varied with clinical diagnosis, and familial and syndromic association was rare. Conclusions: More initiative programs are recommended to address the unmet medical and surgical needs of the cleft deformities in various parts of the region.

Protocol for a Systematic Review of Outcomes From Microsurgical Free Tissue Transfer Performed on Short-term Surgical Missions in Low-income and Middle-income Countries

Background: In many units around the world, microsurgical free tissue transfer represents the gold standard for reconstruction of significant soft tissue defects following cancer, trauma or infection. However, many reconstructive units in low-income and middle-income countries (LMICs) do not yet have access to the resources, infrastructure or training required to perform any microsurgical procedures. Long-term international collaborations have been formed with annual short-term reconstructive missions conducting microsurgery. In the first instance, these provide reconstructive surgery to those who need it. In the longer-term, they offer an opportunity for teaching and the development of sustainable local services.

Methods: A PRISMA-compliant systematic review and meta-analysis will be performed. A comprehensive, predetermined search strategy will be applied to the MEDLINE and Embase electronic databases from inception to December 2020. All clinical studies presenting sufficient data on free tissue transfer performed on short-term surgical missions (STSMs) in LMICs will be eligible for inclusion. The primary outcomes are rate of free flap failure, rate of emergency return to theatre for free flap salvage and successful salvage rate. The secondary outcomes include postoperative complications and any functional or patient reported outcome measures. Screening of studies, data extraction and assessments of study quality and bias will be conducted by two authors. Individual study quality will be assessed according to the Oxford Evidence-based Medicine Scales of Evidence 2, and risk of bias using either the ‘Revised Cochrane risk of bias tool for randomized trials’ (Rob2), or the ‘Risk of bias in non-randomized studies of interventions’ (ROBINS-I) tools. Overall strength of evidence will be assessed according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Discussion: To-date the outcomes of microsurgical procedures performed on STSMs to LMICs are largely unknown. Improved education, funding and allocation of resources are needed to support surgeons in LMICs to perform free tissue transfer. STSMs provide a vehicle for sustainable collaboration and training. Disseminating microsurgical skills could improve the care received by patients living with reconstructive pathology in LMICs, but this is poorly established. This study sets out a robust protocol for a systematic review designed to critically analyse outcomes.