Epidemiological Predictors of Financial Toxicity in Surgical Burn Injuries: A Multicenter, Longitudinal, Cohort Study.

BACKGROUND: Burns constitute a major global health challenge, causing over 11 million injuries and 300,000 deaths annually and surpassing the economic burden of cervical cancer and HIV combined. Despite this, patient-level financial consequences of burn injuries remain poorly quantified, with a significant gap in data from low- and middle-income countries. In this study, we evaluate financial toxicity in burn patients. METHODS: A prospective, multicenter cohort study was conducted across two tertiary care hospitals in India, assessing 123 adult surgical in-patients undergoing operative interventions for burn injuries. Patient sociodemographic, clinical, and financial data were collected through surveys and electronic records during hospitalization and at 1, 3, and 6 months postoperatively. Out-of-pocket costs (OOPCs) for surgical burn treatment were evaluated during hospitalization. Longitudinal changes in income, employment status, and affordability of basic subsistence needs were assessed at the 1-, 3-, and 6-month postoperative time point. Degree of financial toxicity was calculated using a combination of the metrics catastrophic health expenditure and financial hardship. Development of financial toxicity was compared by sociodemographic and clinical characteristics using logistic regression models. RESULTS: Of the cohort, 60% experienced financial toxicity. Median OOPCs was US$555.32 with the majority of OOPCs stemming from direct nonmedical costs (US$318.45). Cost of initial hospitalization exceeded monthly annual income by 80%. Following surgical burn care, income decreased by US$318.18 within 6 months, accompanied by a 53% increase in unemployment rates. At least 40% of the cohort consistently reported inability to afford basic subsistence needs within the 6-month perioperative period. Significant predictors of developing financial toxicity included male gender (odds ratio, 4.17; 95% confidence interval, 1.25-14.29; P = 0.02) and hospital stays exceeding 20 days (odds ratio, 11.17; 95% confidence interval, 2.11-59.22; P ≤ 0.01). CONCLUSIONS: Surgical treatment for burn injuries is associated with substantial financial toxicity. National and local policies must expand their scope beyond direct medical costs to address direct nonmedical and indirect costs. These include burn care insurance, teleconsultation follow-ups, hospital-affiliated subsidized lodging, and resources for occupational support and rehabilitation. These measures are crucial to alleviate the financial burden of burn care, particularly during the perioperative period.

Distichiasis: An Unusual Complication of the Preseptal Transconjunctival Approach and Its Management.

ABSTRACT: Distichiasis is a rare condition where the accessory row of eyelashes exit from the posterior lid margin apparently from the opening of the meibomian glands, causing corneal irritation and ulceration. The authors report a rare clinical presentation of acquired distichiasis, as a complication of a preseptal transconjunctival approach. The patient presented with complaints of discomfort over the right eyelid after the management of zygomaticomaxillary complex fracture. On evaluation, the diagnosis of acquired distichiasis was made and was surgically managed by direct tarsal strip excision. During the follow up the complete resolution of symptoms without lid margin deformity was noted. Acquired distichiasis as a complication of the preseptal transconjunctival approach was rarely reported. Hence the understanding of the condition and its management is necessary to avoid the sequela.

Traditional Versus Virtual Surgery Planning of the Fronto-Orbital Unit in Anterior Cranial Vault Remodeling Surgery.

BACKGROUND: Craniosynostosis correction surgery is a complex procedure, which involves complete dismantling and reassembly of the cranial vault components. The traditional planning method for these surgeries results in increased intra-operative time owing to its highly subjective nature. The advent of virtual surgical planning (VSP) platform has lead to a greater pre-operative insight and precision outcome in calvarial remodeling surgeries. The purpose of this paper is to evaluate intra-operative time and blood loss difference as a measure of surgical efficiency between VSP based template guided Anterior Cranial Vault Reconstruction (ACVR) with Fronto-Orbital Unit Advancement (FOUA) and the traditional surgeries. METHODS: Data were collected from patients who underwent ACVR with FOUA in our unit. Patients were divided into 2 groups, Template Fronto-Orbital Unit (TFOU) group and Non-template Fronto-Orbital Unit (NFOU) group. In TFOU group, Virtual planning along with fabrication of Template guide was carried out. Patients undergoing ACVR using traditional techniques were categorized as NFOU group. A comparative prospective analysis was carried out in terms of Intra-operative time duration and blood loss. Student 't' test was used to compare the means of the 2 groups. RESULTS: A total of 10 patients were included in the present study. There were 5 control (NFOU) and 5 TFOU cases. There was a significant decrease in the operating time in TFOU group compared to the NFOU group. TFOU group also showed reduced intra-operative bleed compared to the NFOU group. CONCLUSION: Virtual surgical planning (VSP) and 3D modeling with prefabricated template guide augurs reliable outcomes and portends the possibility of lesser intra-operative time. It is a valuable tool, which offers enormous benefits in terms of precise pre-surgical planning with predictive results.

Modified Medial Ramus Retractor to Facilitate Horizontal Osteotomy During Sagittal Split Ramus Osteotomy Procedure.

Introducing a horizontal osteotomy is the first and a critical step in sagittal split ramus osteotomy procedure. Identification of the lingula and medial displacement of the vital structures entering the inferior alveolar foramen are of paramount importance in ensuring a risk-free placement of the medial cut with bur or a saw. Quite often, identification of lingula and retrolingular fossa can be an arduous task owing to the thickness of the internal oblique ridge. Hence, placement of horizontal osteotomy depends on the experience of the operator.Here, the authors describe a simple, low profile instrument that aids in the identification of the lingula as well as provide a posterior stop for horizontal osteotomy during the sagittal split ramus osteotomy procedure.

Le Fort I Disassembly for the Management of Juvenile Ossifying Fibroma Extending To the Skull Base.

Ossifying fibroma is a rare benign osteogenic neoplasm arising from undifferentiated cells of the periodontal ligament. Ossifying fibroma have a well-defined border that differentiates it from fibrous dysplasia clinically; these tumors manifest as a round or ovoid, expansile, painless, slow-growing mass may displace the roots of adjacent teeth and also cause root resorption. A variety of approaches for resection of the maxilla have been described. Most involve the use of facial and lip-splitting incisions to gain wide access. Surgical approach specifically to the ossifying fibroma located in the midface includes the Le Fort I approach, Caldwell-Luc access, lateral rhinotomy with medial or total maxillectomy, external ethmoidectomy, and endoscopic surgery. The access through Le Fort I disassembly is a versatile approach not only because of the aesthetic potential in using intraoral incision but also due to its minimal invasiveness, lesser complications and gives the possibility of reconstruction in a single operation. Le Fort I disassembly followed by an excision appears to be a versatile, secure, and satisfactory option.

Virtual Surgery Planning in Orthomorphic Correction of Mandibular Dysmorphology.

Three-dimensional virtual surgery programs are widely available for orthognathic surgery. The advent of imaging software programs has proved to be useful for diagnosis, treatment planning, outcome measurement, and three-dimensional surgical simulation. Complex maxillofacial malformations continue to present challenges in analysis and correction beyond modern technology. Orthomorphic correction for mandibular dysmorphology refers to basal bone movement without any change in dental component. The purpose of this paper is to present a virtual surgery planning for surgeons to perform the orthomorphic surgery with precision and quantification. Moreover, it provides an essential educational tool for patients to foresee predicted surgical outcome.

Subdural hygroma after craniosynostosis remodeling surgery.

Craniosynostosis is defined as the premature fusion of the cranial sutures and can cause functional impairment or cosmetic deformity. Surgical techniques for the correction of craniosynostosis have changed overtime, as so have the intraoperative and postoperative complications. Extensive surgeries involving fronto-orbital unit repositioning and cranial vault remodeling are associated with various complications. Intraoperative and postoperative hemorrhage, venous infarct, air embolism, hydrocephalus, cerebrospinal fluid leak, as well as meningitis are a few complications associated with cranial vault remodeling surgery. Postoperative complications can increase the morbidity and mortality associated with these procedures. Identification of the complications and their timely management should be a part of every craniofacial reconstruction team's training program.In this article, we report a case of subdural hygroma in an infant after cranial vault remodeling procedure. Subdural hygroma is a known complication following head injuries and represents 5% to 20% of posttraumatic intracranial mass lesions. However, subdural hygroma developing after a cranial procedure is rare and has not been reported in the literature. Identification of the complication, close monitoring of the change in subdural fluid volume, and tapping of the fluid through the craniotomy site if indicated form the mainstay of management of subdural hygroma that develops after cranial vault remodeling surgery.

Fabrication of Patient Specific Titanium Implants for Correction of Cranial Defects: A Technique to Improve Anatomic Contours and Accuracy.

Hard tissue cranial defects may result from traumatic or iatrogenic etiology and warrants adequate reconstruction to provide protection to the underlying brain and cosmesis. Various techniques have been described in the literature for fabrication of patient specific titanium cranial implants. The process of fabrication of titanium patient specific implants (PSI) can be broadly classified into indirect and direct techniques. With the improvements in the medical imaging and computational modeling, direct technique of computer assisted prefabricated patient specific implants have gained popularity. However indirect method of PSI fabrication hold some specific advantage. Here we describe a technique for fabrication of titanium PSI by combining the principles of direct and indirect methods for reconstruction of cranial defects.

Surgathon: a new model for creating a surgical innovation ecosystem in low-resource settings.

Innovation ecosystems and emerging technologies can potentially accelerate the access to safe, affordable surgical care in low-resource settings. There is a need to develop localised innovation ecosystems that can establish an initial culture and catalyse the creation, adoption and diffusion of innovation. The surgathon model outlines one approach to seeding surgical innovation ecosystems. International academic institutions collaborated on six global surgery, innovation and ethics-themed hackathons ('surgathons') across India and Rwanda between 2016 and 2019. Over 1598 local multidisciplinary students participated, learning about challenges in the delivery of surgical care and ideating solutions that could leverage appropriate technology and resources for impact. Pursuing student ideas and evaluating their implementation past the surgathons continues to be an active effort. Surgathons have unfolded in different permutations based on local faculty, institution and health system context. The surgathon model is a novel method of priority setting challenges in global surgery and utilises locally driven expertise and innovation capacity to derive ethical solutions. The model offers a path for low-resource setting students and faculty to learn, advocate and innovate for improved surgical care.

A randomized controlled trial comparing two techniques for unilateral cleft lip and palate: Growth and speech outcomes during mixed dentition.

OBJECTIVE: To study the growth and speech outcomes in children who were operated on for unilateral cleft lip and palate (UCLP) by a single surgeon using two different treatment protocols. MATERIAL AND METHODS: A total of 200 consecutive patients with nonsyndromic UCLP were randomly allocated to two different treatment protocols. Of the 200 patients, 179 completed the protocol. However, only 85 patients presented for follow-up during the mixed dentition period (7-10 years of age). The following treatment protocol was followed. Protocol 1 consisted of the vomer flap (VF), whereby patients underwent primary lip nose repair and vomer flap for hard palate single-layer closure, followed by soft palate repair 6 months later; Protocol 2 consisted of the two-flap technique (TF), whereby the cleft palate (CP) was repaired by two-flap technique after primary lip and nose repair. GOSLON Yardstick scores for dental arch relation, and speech outcomes based on universal reporting parameters, were noted. RESULTS: A total of 40 patients in the VF group and 45 in the TF group completed the treatment protocols. The GOSLON scores showed marginally better outcomes in the VF group compared to the TF group. Statistically significant differences were found only in two speech parameters, with better outcomes in the TF group. CONCLUSIONS: Our results showed marginally better growth outcome in the VF group compared to the TF group. However, the speech outcomes were better in the TF group.

Invasive aspergillosis presenting as swelling of the buccal mucosa in an immunocompetent individual.

Fungi are ubiquitous in nature but have low virulence and cause disease usually when the host defenses are compromised. Fungal infections of the central nervous system are rare and are usually seen in immunocompromised patients. However, in recent years, there has been an increase in the number of central nervous system fungal infections in immunocompetent individuals. Intracranial fungal granulomas are rare space-occupying lesions. Among these, Aspergillus granuloma is the most common. Craniocerebral involvement by aspergillosis usually occurs via the hematogenous route or through contiguous spread from the paranasal sinuses. Predominant symptoms associated with cranial fungal granuloma include headache, vomiting, proptosis, and visual disturbances. Common signs include papilledema, cranial neuropathy, hemiparesis, and meningismus. We present a case of invasive Aspergillus granuloma in an immunocompetent individual, who presented with a palpable mass in the buccal mucosa following removal of an impacted mandibular third molar but with no other characteristic signs and symptoms of invasive fungal granuloma. To our knowledge, there is no documentation of aspergillosis presenting as a swelling in the buccal mucosa. Unexplained swellings in the buccal mucosa should be viewed with a high degree of suspicion and investigated thoroughly at the earliest.

Custom made orthotic device for maintaining skull architecture during the postoperative period in infants undergoing craniosynostosis surgery.

AIM: To fabricate a cost effective, indigenous and simple orthotics helmet for post-operative cranial molding in patients with craniosynostosis surgery. METHODS: We present a case of 15 month old infant with secondary cranial vault deformity. Cranial vault remodeling surgery involving the posterior skull was planned and executed to increase the posterior gap, so that brain growth would be facilitated towards this empty space. Materials such as thermoplastic sponge, thermoplastic ionomer resin sheet, soft sponge and Velcro straps are used to fabricate a cranial orthotics helmet. RESULTS: We have successfully used the above materials to fabricate the orthotics helmet for post-operative cranial molding. CONCLUSION: The technique described in this article is simple and cost effective. It can be custom made according to the demands of the surgical technique and the type of synostosis. It favors an individualistic prognosis, and proves worthwhile as every synostosis requires a unique treatment plan. It is an excellent adjuvant to craniosynostosis remodeling surgery.