The Efficacy of Honey Compared to Silver Sulfadiazine for Burn Wound Dressing in Superficial and Partial Thickness Burns—A Systematic Review and Meta-Analysis

Burn dressings play a vital role in protecting the patient from infection and aiding in the wound healing process. At present, the best burn wound dressing remains unknown. This study aimed to assess the efficacy of honey versus silver sulfadiazine dressing (SSD) for the treatment of superficial and partial thickness burns. We performed a systematic review and meta-analysis using the PubMed, MEDLINE and Embase databases to find relevant randomised control trials (RCTs) for inclusion. The outcomes measures included complete burn wound healing time, the proportion of wounds rendered sterile and subjective pain relief associated with the respective dressing type. This review was completed in line with PRISMA guidelines and has been registered with PROSPERO (Study ID: CRD42022337433). All studies in the English language that assessed honey versus SSD for patients with superficial or partial thickness burns were included. Quality and risk of bias assessments were performed using the Cochrane RoB2 tool. Seven studies were identified: totalling a population of 582 patients. From three studies, meta-analysis showed no significant difference in complete wound healing time (p = 0.06). Meta-analysis from five studies highlighted an overall significant difference favouring honey dressing in the proportion of wounds rendered sterile at day 7 post-injury (OR 10.80; 95% CI [5.76, 20.26]; p < 0.00001; I2 = 88%). We conclude that honey dressings may be as or more effective than SSD in the treatment of superficial and partial thickness burn injuries. However, due to the low quality of available studies in this field, further research is necessary to establish the optimum burn dressing. Ideally, this should be conducted in the form of prospective three-arm RCTs in accordance with the CONSORT statement.

Prevalence and Severity of Burn Scars in Rural Mozambique

Background
Burn injuries are common in low- and middle-income countries (LMICs) and their associated disability is tragic. This study is the first to explore burn scars in rural communities in Mozambique. This work also validated an innovate burn assessment tool, the Morphological African Scar Contractures Classification (MASCC), used to determine surgical need.

Methods
Using a stratified, population-weighted survey, the team interviewed randomly selected households from September 2012 to June 2013. Three rural districts (Chókwè, Nhamatanda, and Ribáuè) were selected to represent the southern, central and northern regions of the country. Injuries were recorded, documented with photographs, and approach to care was gathered. A panel of residents and surgeons reviewed the burn scar images using both the Vancouver Scar Scale and the MASCC, a validated visual scale that categorizes patients into four categories corresponding to levels of surgical intervention.

Results
Of the 6104 survey participants, 6% (n = 370) reported one or more burn injuries. Burn injuries were more common in females (57%) and most often occurred on the extremities. Individuals less than 25 years old had a significantly higher odds of reporting a burn scar compared to people older than 45 years. Based on the MASCC, 12% (n = 42) would benefit from surgery to treat contractures.

Conclusion
Untreated burn injuries are prevalent in rural Mozambique. Our study reveals a lack of access to surgical care in rural communities and demonstrates how the MASCC scale can be used to extend the reach of surgical assessment beyond the hospital through community health workers.

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings

Background:
Argentina is a country with varying access to orthopedic surgical care. The Argentine Association of Trauma and Orthopedics (AATO) “Interior Committee” was developed to address potential regional differences and promote standardization of orthopedic trauma care. The paper assesses the level of national standardization of the management of open tibia fractures across 9 provinces in Argentina.

Methods:
Utilizing a matched-comparison group design, management of these injuries were assessed and compared between 3 groups: an “AATO Exterior Committee” consisting of surgeons that practice in Buenos Aires, and 2 “Interior Committees,” comprising surgeons that practice in outlying provinces, 1 of which is affiliated with the AATO, and 1 that is not affiliated with the AATO. The study was conducted in 2 phases: phase 1 assessed open tibia fracture management characteristics, and phase 2 evaluated the management of soft-tissue wound coverage following open fractures.

Results:
Soft-tissue coverage procedures for Gustilo Anderson Type IIIB fractures were more commonly performed by orthopedic surgeons in Interior Committees than the AATO Exterior Committee. Greater rates of definitive wound coverage within 7 days post-injury were reported in both Interior Committees compared to the Exterior Committee. Plastic surgeons were reported as more available to those in the AATO Exterior Committee group than in the AATO Interior Committees.

Conclusion:
While treatment patterns were evident among groups, differences were identified in the management and timing of soft-tissue coverage in Gustilo Anderson Type IIIB fractures between the Exterior Committee and both Interior Committees. Future targeted educational and surgical hands-on training opportunities that emphasize challenges faced in resource-limited settings may improve the management of open tibia fractures in Argentina.

Burn Admissions Across Low- and Middle-income Countries: A Repeated Cross-sectional Survey

Burn injuries have decreased markedly in high-income countries while the incidence of burns remains high in Low- and Middle-Income Countries (LMICs) where more than 90% of burns are thought to occur. However, the cause of burns in LMIC is poorly documented. The aim was to document the causes of severe burns and the changes over time. A cross-sectional survey was completed for 2014 and 2019 in eight burn centers across Africa, Asia, and Latin America: Cairo, Nairobi, Ibadan, Johannesburg, Dhaka, Kathmandu, Sao Paulo, and Guadalajara. The information summarised included demographics of burn patients, location, cause, and outcomes of burns. In total, 15,344 patients were admitted across all centers, 37% of burns were women and 36% of burns were children. Burns occurred mostly in household settings (43–79%). In Dhaka and Kathmandu, occupational burns were also common (32 and 43%, respectively). Hot liquid and flame burns were most common while electric burns were also common in Dhaka and Sao Paulo. The type of flame burns varies by center and year, in Dhaka, 77% resulted from solid fuel in 2014 while 74% of burns resulted from Liquefied Petroleum Gas in 2019. In Nairobi, a large proportion (32%) of burns were intentional self-harm or assault. The average length of stay in hospitals decreased from 2014 to 2019. The percentage of deaths ranged from 5% to 24%. Our data provide important information on the causes of severe burns which can provide guidance in how to approach the development of burn injury prevention programs in LMIC.

A Systematic Review of the Cost-Effectiveness of Cleft Care in Low- and Middle-Income Countries: What is Needed?

Objective
The objective of this paper is to conduct a systematic review that summarizes the cost-effectiveness of cleft lip and/or palate (CL/P) care in low- and middle-income countries (LMICs) based on existing literature.

Design
We searched eleven electronic databases for articles from January 1, 2000 to December 29, 2020. This study is registered in PROSPERO (CRD42020148402). Two reviewers independently conducted primary and secondary screening, and data extraction.

Setting
All CL/P cost-effectiveness analyses in LMIC settings.

Patients, Participants
In total, 2883 citations were screened. Eleven articles encompassing 1,001,675 patients from 86 LMICs were included.

Main Outcome Measures
We used cost-effectiveness thresholds of 1% to 51% of a country’s gross domestic product per capita (GDP/capita), a conservative threshold recommended for LMICs. Quality appraisal was conducted using the Joanna Briggs Institute (JBI) checklist.

Results
Primary CL/P repair was cost-effective at the threshold of 51% of a country’s GDP/capita across all studies. However, only 1 study met at least 70% of the JBI criteria. There is a need for context-specific cost and health outcome data for primary CL/P repair, complications, and existing multidisciplinary management in LMICs.

Conclusions
Existing economic evaluations suggest primary CL/P repair is cost-effective, however context-specific local data will make future cost-effectiveness analyses more relevant to local decision-makers and lead to better-informed resource allocation decisions in LMICs.

A plastic and reconstructive surgery landscape assessment of Malawi: a scoping review of Malawian literature

Background
Plastic and reconstructive surgery (PRS) remains highly relevant to the unmet need for surgery in Malawi. Better understanding the current PRS landscape and its barriers may help address some of these challenges. This scoping review aimed to describe: (1) the scope and focus of the PRS literature being produced in Malawi and (2) the challenges, deficits, and barriers to providing accessible, high-quality PRS in Malawi.

Methods
This scoping review was conducted on four databases (SCOPUS, PubMed, Web of Science, EMBASE) from inception through September 1, 2020 following the PRISMA-ScR guidelines.

Results
The database search retrieved 3852 articles, of which 31 were included that examined the burden of PRS-related conditions in Malawi. Of these 31 articles, 25 primarily discussed burn-related care. Burns injuries have a high mortality rate; between 27 and 75% in the studies. The literature revealed that there are only two burn units nationally with one PRS specialist in each unit, compounded by a lack of interest in PRS specialization by Malawian medical students. Congenital anomalies were the only other PRS-related condition examined and reported in the literature, accounting for 23% of all pediatric surgeries in tertiary facilities.

Conclusions
There is a need to increase the country’s capacity to handle burn reconstruction and other PRS-related conditions to reduce overall morbidity and mortality. Additional publicly funded research at the district and community level is warranted to determine the true burden of PRS disease in Malawi to derive health system strengthening and workforce capacity building strategies.

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.