Factors predicting burn surgery operative time in a middle income country regional burn service.

Access to theatre is essential for surgical management of deep burns. This is a scarce resource in low-middle income countries. It underpins the importance of optimizing theatre time. We sought to look at specific factors and their influence on operative time in minor to moderate burn surgery. This knowledge can assist teams where theatre planning and optimization may be beneficial in resource limited settings . Operative records between January and December 2018 at the Regional Hospital , were analysed. Data fields included age, gender, total body surface area of burn, surface area burn operated on, intra-operative position change, seniority of surgeon, presence of an assistant, inclusion of special areas, predicted operative time and actual operative time. Operative records for 265 patients were analysed, with a median operative time of 40 minutes (IQR 25 - 64). Overall factors that predict longer operating time are larger total body surface area burn, larger surface area burn operated on, an operation involving at least one special area, number of special areas operated on, position change, presence of an assistant and longer predicted operative time. Total percentage burn, operated percentage, special areas to be operated and position change are overall factors to be considered when planning a burns list for the non-specialist burn surgeon. This knowledge may be useful for an inexperienced surgeon to understand, and aid in the effective utilisation of limited operative time available for the surgical management of deep burns in resource limited settings.

Graphic medicine meets human anatomy: The potential role of comics in raising whole body donation awareness in Italy and beyond. A pilot study.

Cadaver dissection has always played a fundamental role in medical education. However, especially in Italy, the topic of body donation has remained partially unknown for years. The current study analyses graphic medicine as a new possible communication tool, evaluating and reflecting, with second-year students enrolled in the International School of Medicine and Surgery at the University of Bologna, about its potentialities for body donation awareness-raising in both the scientific community and the general population. For the first time in an Italian University, two graphic medicine workshops were organized focusing on human anatomy and body donation. Seminars were positively evaluated by students using a four items Likert-scale question: mean 3.54 (± SD 0.73) for the Likert question about the experiences of the workshops; 3.88 (± 0.33) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the general population; 3.59 (± 0.65) for the Likert question regarding the use of graphic medicine in body donation awareness campaigns among the scientific community. Furthermore, the open-ended questions included in the anonymous questionnaire were analyzed using the constructivist grounded qualitative analysis, whence various themes emerged. Finally, five graphic medicine projects about body donation were created by students, proving their interest in testing this method to promote body donation, focusing the attention on different communicative aspects. Considering the results of this pilot study, the co-creative collaborative use of graphic medicine could be evaluated as an additional strategy to increase body donation awareness-raising in Italy and beyond, especially in the non-experts' community.

Burning Questions: What Should the Pharmacist Know about Managing Minor Burns?

Burn injuries are an endemic health concern in developing countries. Globally, Africa has the highest incidence of burn injuries per capita. A total of 2.3% of the South African population suffer burn injuries annually and may present at community pharmacies and primary healthcare (PHC) facilities. Pharmacists and PHC nurses must, therefore, remain abreast with the latest treatments for burn care. This commentary presents the most recent information for assessing burn wounds, first aid, referral guidelines, and identifying toxic shock syndrome in more severe burns cases. The successful management of patients with burns in an outpatient setting is contingent on patient selection. It is important for pharmacists and PHC nurses to know when to treat or refer a patient. Therefore, a set of guidelines for their use in PHC and community pharmacy settings is presented. Appropriate training on the use of these guidelines, would ensure a better assessment of burn wounds, leading to more positive patient outcomes. This commentary is a useful update to continuing professional development and can be utilised in community pharmacies and PHC settings in South Africa and across the African continent in the absence of formalised treatment guidelines for minor burns.

Reaching consensus on an analgesia protocol for paediatric burn patients in a resource-scarce South African community.

BACKGROUND: Despite the exceptional burden of burns in low- and middle-income countries (LMIC) and the importance of adequate analgesia in burn care, there is a lack of analgesia protocol developed in resource-scarce settings. This necessitates the development of an analgesia protocol applicable to the resource-scarce setting. This study presents the findings of a modified Delphi study aimed at achieving consensus by a panel of experts in the management of burn injuries from low- and middle-income settings across Africa. METHODS: A two-round Delphi survey was conducted to achieve consensus on an analgesia protocol for paediatric burn patients for a resource-limited setting. The Delphi panel consisted of nine experts with experience in management of burn injuries in low-income settings. RESULTS: Consensus was determined by an a priori threshold of 80% of agreement for a drug to be included in the analgesia protocol. There was a largely overarching agreement with regard to the background analgesia protocol and strong agreement regarding the use of an initial dose of ketamine and midazolam for procedural sedation. CONCLUSION: A modified Delphi method was used to obtain expert consensus for a recently adopted analgesia protocol for burn-injured children in a resource-limited setting, with experts in the management of burn injuries in low- and middle-income settings. The expert consensus leads to the rigour and robustness of the protocol. Delphi methods are exceptionally valuable in healthcare research and the aim of such studies is to find converging expert opinions.

Factors impacting time to surgery and the effect on in-hospital mortality.

OBJECTIVES: Early surgery improves outcomes after burn injuries but is often not available in limited resource settings (LRS), where a more conservative approach is widespread. This study aimed to analyze factors associated with delay in surgical treatment, and the impact on in-hospital mortality. METHODS: All patients with burns treated with surgery between 2016 and 2019 at the Pietermaritzburg Burn Service, in South Africa, were included in this retrospective study. Early surgery was defined as patients who underwent surgery within 7 days from injury. The population was analyzed descriptively and differences between groups were tested using t-test, and χ2 test or Fisher's exact test, as appropriate. Multivariable logistic regression was used to analyze the effect of delay in surgical treatment on in-hospital mortality, after adjustment for confounders. RESULTS: During the study period, 620 patients with burns underwent surgery. Of them, 16% had early surgery. The early surgery group had a median age and TBSA of 11 years (3-35) and 12.0% (5-22) compared to 7 years (2-32) and 6.0% (3-13) in the late surgery group (p=0.45, p<0.001). In logistic regression, female sex [aOR: 3.30 (95% CI: 1.47-7.41)], TBSA% [aOR: 1.09 (95% CI: 1.05-1.12)], and FTB [aOR: 3.21 (95% CI: 1.43-7.18)] were associated with in-hospital mortality, whereas having early surgery was not [aOR: 1.74 (95% CI: 0.76-3.98)]. CONCLUSION: This study found that early surgery was not associated with in-hospital mortality. Independent predictors of in-hospital mortality were female sex, presence of full thickness burn, and larger burn size. Future studies should investigate if burn care capacity in LRS may influence the association between early excision and outcome.

Impact of gender bias on women surgeons: a South African perspective.

A recent article in this journal by Katrina Hutchison exposes and addresses the cumulative effects of implicit bias on women in surgery. We doubt that there is a single woman in any surgical field who has not experienced both implicit and explicit bias. Many of the issues facing women in surgery seem to be mirrored in both the developed and developing countries. There is little literature describing the exact situation in Africa. South African government institutions have made a concerted effort to improve the representation of minorities in business, education and the health sector. In the hospital setting, hiring is done by means of a quota system based on demographics within that particular sector. This has also resulted in a number of unforeseen epistemic biases. This policy-driven 'forced' hiring of female candidates also led to feelings of doubt in the candidates themselves about their merits and competence and capabilities. This epistemic bias can then filter down, feeding the already prevalent imposter syndrome and confidence issues felt by many female surgical trainees. Not only do we need to aim to change the culture in surgical departments by changing the image of the 'stereotypical surgeon', we need to extend this message out into our training institutions, communities and peoples' homes. We believe that this is the only way to change a culture steeped in implicit bias, to be more inclusive of women and other minority groups and shed the assumption that they are lesser.

Narrative Training as a Method to Promote Nursing Empathy Within a Pediatric Rehabilitation Setting.

PURPOSE: Empathy is deemed essential to nursing, yet interventions that promote and sustain empathy in practicing nurses within healthcare organizations are limited. We tested the feasibility and perceived impact of an arts-based narrative training intervention involving pediatric rehabilitation nurses for the purpose of promoting nursing empathy. DESIGN AND METHODS: One-group qualitative repeated-measures design at an urban Canadian pediatric rehabilitation hospital. Eight nurse participants attended six 90-minute weekly group narrative training sessions and two in-depth interviews pre- and post-intervention. RESULTS: The intervention positively impacted participants in three primary domains: Empathy for Patients and Families, Empathy Within Nursing Team, and Empathy for the Self. Major findings included: increased value placed on patients' and families' backstory, identification of "moral empathic distress" (MED), enhanced sense of collaborative nursing community, and renewal of professional purpose. CONCLUSIONS: This study is the first of its kind conducted in the pediatric rehabilitation nursing context. Results indicate that arts-based narrative training enhances nursing empathy and contributes to a supportive nursing culture. PRACTICE IMPLICATIONS: In addition to enhancing empathy in clinical domains, nurses who participated in narrative training reported improved team collaboration, self-care practices, and renewed professional purpose. The results from the intervention are encouraging and future research needs to explore its utility in other settings with larger and more diverse sample.

Ethics of Burn Wound Care in a Low-Middle Income Country.

This review focuses on burn care in low- and middle-income countries (LMICs). It attempts to put the burden of disease in perspective by showing that burn care is under-resourced across the spectrum of LMICs and by interrogating the ethical dilemmas and challenges that staff face in caring for burn patients in this environment, with a focus on South Africa. More specifically, it will attempt to address the following issues: the threshold for utilizing the intensive care unit (ICU), how to balance treatment against cost, the percentage burn considered survivable and how it should be determined, the use of skin from both cadavers and living related donors, and the appropriate ethical guidelines for LMICs.

The hermunculus: what is known about the representation of the female body in the brain?

The representation of the body in the brain, the homunculus, was posited by Wilder Penfield based on his studies of patients with intractable epilepsy. While he mapped both male and female patients, Penfield reports little about the females. The now iconic illustration of the map is clearly male with testicles, penis, and no breasts. In order to bring attention to this omission and to stimulate studies of female somatosensory cortex (SS), we discuss what is known about the map of the female body in the brain, including Penfield's findings in his female patients and subsequent work by others exploring the human female SS. We reveal that there is much we do not know about how the entire female body is represented in the brain or how it might change with different reproductive life stages, hormones, and experiences. Understanding what is and is not currently known about the female SS is a first step toward fully understanding neurological and physiological sex differences, as well as producing better-informed treatments for pain conditions related to mastectomy, hysterectomy, vulvodynia, and fibromyalgia. We suggest that the time is ripe for a full mapping of the female brain with the production of a hermunculus.

Mid-twentieth-century anatomical transparencies and the depiction of three-dimensional form.

Before the advent of digital visualization, the "anatomical transparency"--layered images of organ systems, printed on a transparent medium--flourished in the mid-twentieth century as an interactive means to represent complex anatomical relationships to medical professionals and lay audiences. This article introduces the transparency work of medical illustrators Gladys McHugh and Ernest W. Beck, situating it in the historical context of strategies to represent three-dimensional anatomical relationships using print media.

Humane images: visual rhetoric in depictions of atypical genital anatomy and sex differentiation.

Visual images are widely used in medical and patient education to enhance spoken or written explanations. This paper considers the role of such illustrations in shaping conceptions of the body; specifically, it addresses depictions of variant sexual anatomy and their part in the discursive production of intersex bodies. Visual language--even didactic, 'factual' visual language--carries latent as well as manifest content, and influences self-perceptions and social attitudes. In the case of illustrations about atypical sex development, where the need for non-stigmatising communication is crucial, it is especially important to consider the implicit messages conveyed by imagery and compositional strategies.

Using the principles of interactive cartography to communicate the mechanisms of migraine pain.

The program entitled 'Mapping Migraine Pain' was created based on the principles of interactive cartography to communicate the complexity of the mechanisms of migraine pain. An innovative zoom slider was developed to enhance spatial orientation and comprehension of multiple scales of information from the anatomical to the cellular and molecular levels. Think-aloud protocols were conducted with ten undergraduate first-year medical students to evaluate the significance and usability of the program. The zoom slider, based on interactive cartography, proved to be an effective and intuitive navigational element.