Implementation of a Global Pediatric Trauma Course in an Upper Middle-Income Country: A Pilot Study.

INTRODUCTION: Over 90% of pediatric trauma deaths occur in low- and middle-income countries (LMICs), yet pediatric trauma-focused training remains unstandardized and inaccessible, especially in LMICs. In Brazil, where trauma is the leading cause of death for children over age 1, we piloted the first global adaptation of the Trauma Resuscitation in Kids (TRIK) course and assessed its feasibility. METHODS: A 2-day simulation-based global TRIK course was hosted in Belo Horizonte in October 2022, led by one Brazilian and four Canadian instructors. The enrollment fee was $200 USD, and course registration sold out in 4 d. We administered a knowledge test before and after the course and a postcourse self-evaluation. We recorded each simulation to assess participants' performance, reflected in a team performance score. Groups received numerical scores for these three areas, which were equally weighted to calculate a final performance score. The scores given by the two evaluators were then averaged. As groups performed the specific simulations in varying orders, the simulations were grouped into four time blocks for analysis of performance over time. Statistical analysis utilized a combination of descriptive analysis, Wilcoxon signed-rank tests, Kruskal-Wallis tests, and Wilcoxon rank-sum tests. RESULTS: Twenty-one surgeons (19 pediatric, one trauma, one general) representing four of five regions in Brazil consented to study participation. Women comprised 76% (16/21) of participants. Overall, participants scored higher on the knowledge assessment after the course (68% versus 76%; z = 3.046, P < 0.001). Participants reported improved knowledge for all tested components of trauma management (P < 0.001). The average simulation performance score increased from 66% on day 1% to 73% on day 2, although this increase was not statistically significant. All participants reported they were more confident managing pediatric trauma after the course and would recommend the course to others. CONCLUSIONS: Completion of global TRIK improved surgeons' confidence, knowledge, and clinical decision-making skills in managing pediatric trauma, suggesting a standardized course may improve pediatric trauma care and outcomes in LMICs. We plan to more closely address cost, language, and resource barriers to implementing protocolized trauma training in LMICs with the aim to improve patient outcomes and equity in trauma care globally.

Perceived Impact of Coronavirus Disease 2019 on Surgical Training: A Brazilian Survey.

INTRODUCTION: Recent studies revealed that coronavirus disease 2019 (COVID-19) negatively impacted residency programs worldwide, particularly procedure-based programs. However, most studies are from high-income countries, with scarce data from low- and middle-income countries. Pandemic effects on surgical training were likely worse in strictly apprenticeship models relying heavily on surgical volume as opposed to competency-based programs. Notably, training programs in Brazil and other low- and middle-income countries follow these strict apprenticeship style frameworks. In this study, we aimed to evaluate the trainees' perceptions of the impact of COVID-19 on their Brazilian surgical programs. METHODS: A cross-sectional study was performed using an anonymous survey in Portuguese, distributed via social media platforms to surgical residents enrolled in Brazilian surgery programs. Data collection took place from August 2021 to May 2022. The survey contained 30 questions on the perception of the impact of COVID-19 on surgical training. RESULTS: One-hundred sixty-two residents from 17 different surgical specialties and all five regions of Brazil responded to the survey. Of 162 residents, 145 (89%) believed the pandemic negatively impacted their surgical training. Furthermore, of 162 residents, 153 (94%) reported that elective surgical volume decreased during the pandemic and 91 (56%) were redeployed to assist with COVID-19 management. As a result, 102 of 162 (63%) residents believed their surgical skills were negatively impacted by COVID-19. Yet, 95 of 162 (59%) residents reported their residency programs did not offer resources to mitigate the pandemic's impact on training. Of 162 residents, 57 (35%) reported they did not feel on track for graduation, with no statistical difference between responses by year of residency (P = 0.083). Additionally, 124 of 162 (77%) residents reported that the pandemic negatively affected their mental health, most commonly related to stress at work, stress about transmitting COVID-19, and loss in surgical training. CONCLUSIONS: Most of the surveyed Brazilian surgical residents felt the COVID-19 pandemic negatively impacted their training. This leads to believe that the detrimental impacts of the pandemic exposed preexisting weaknesses in the Brazilian surgical training model's dependence on a strict apprenticeship model. Our findings suggest a crucial need to redesign surgical education programs to make residency programs more prepared for changes in surgical volume, evolve the apprenticeship model to competency-based approaches, and unify surgical training standards in low- and middle-income countries.

Evolution of Gender Disparities Among Brazilian Surgical, Anesthesia, and Obstetric Providers.

INTRODUCTION: Since 2010, most graduating physicians in Brazil have been female, nevertheless gender disparities among surgical specialties still exist. This study aims to explore whether the increase in female physicians has translated to increased female representation among surgical specialties in Brazil. METHODS: Data on gender, years of practice, and specialty was extracted from Demografia Médica do Brasil, from 2015 to 2020. The percentage of women across 18 surgical, anesthesia, and obstetric (SAO) specialties and the relative increases in female representation during the study period were calculated. RESULTS: Of the 18 SAO specialties studied, 16 (88%) were predominantly male (>50%). Only obstetrics/gynecology and breast surgery showed a female predominance, with 58% and 52%, respectively. Urology, neurosurgery, and orthopedic surgery and traumatology were the three specialties with the largest presence of men - and the lowest absolute growth in the female workforce from 2015 to 2020. CONCLUSIONS: In Brazil, where significant gender disparities persist, women are still underrepresented in surgical specialties. Female presence is predominant in surgical specialties dedicated to the care of female patients, while it remains poor in those with male patient dominance. Over the last 5 y, the proportion of women working in SAO specialties has grown, but not as much as in nonsurgical specialties. Future studies should focus on investigating the causes of gender disparities in Brazil to understand and tackle the barriers to pursuing surgical specialties.

Teaching Trauma in Resource-Limited Settings: A Scoping Review of Pediatric Trauma Courses.

PURPOSE: Injury remains an important cause of death and disability globally, with 95% of all childhood injury deaths occurring in low- and lower-middle-income countries (LMICs). Pediatric trauma training, tailored to the resources in LMICs, represents an opportunity to improve such outcomes. We explored the nature of course offerings in pediatric trauma in resource-limited settings. METHODS: Seven databases were interrogated up to June 12, 2020, to retrieve articles examining pediatric trauma training in LMICs, as defined by the World Bank, without language restrictions. Independent authors reviewed and selected abstracts based on set criteria. Data from included studies was extracted and analyzed. An adapted Critical Appraisal Skills Programme checklist designed for cohort studies was used to assess the risk of bias. RESULTS: After screening 3960 articles for eligibility, 16 were included for final analysis. Course delivery methods included didactic modules, simulations, clinical mentorship, small group discussion, audits, assessments, and feedback. Knowledge acquisition was primarily assessed through pre/post-tests, clinical skills assessments, and self-assessment questionnaires. Twelve studies detailed course content, nine of which were based on the WHO Emergency Triage, Assessment and Treatment model, which is not specific to trauma. The other three studies involved locally developed pediatric trauma-focused training courses, including airway management, head trauma and cervical spine management, thoracic and abdominal trauma, orthopedic trauma, burn and wound management, and shock. CONCLUSION: Despite being essential to decreasing pediatric trauma morbidity and mortality worldwide, educational programs in pediatric trauma are not a widespread reality in low-and-middle-income countries. The development of accessible and efficient pediatric trauma education programs is critical for improving pediatric trauma quality of care.

Potentially Avertable Child Mortality Associated with Surgical Workforce Scale-up in Low- and Middle-Income Countries: A Global Study.

BACKGROUND: Expansion of access to surgical care can improve health outcomes, although the impact that scale-up of the surgical workforce will have on child mortality is poorly defined. In this study, we estimate the number of child deaths potentially avertable by increasing the surgical workforce globally to meet targets proposed by the Lancet Commission on Global Surgery. METHODS: To estimate the number of deaths potentially avertable through increases in the surgical workforce, we used log-linear regression to model the association between surgeon, anesthetist and obstetrician workforce (SAO) density and surgically amenable under-5 mortality rate (U5MR), infant mortality rate (IMR), and neonatal mortality rate (NMR) for 192 countries adjusting for potential confounders of childhood mortality, including the non-surgical workforce (physicians, nurses/midwives, community health workers), gross national income per capita, poverty rate, female literacy rate, health expenditure per capita, percentage of urban population, number of surgical operations, and hospital bed density. Surgically amenable mortality was determined using mortality estimates from the UN Inter-agency Group for Child Mortality Estimation adjusted by the proportion of deaths in each country due to communicable causes unlikely to be amenable to surgical care. Estimates of mortality reduction due to upscaling surgical care to support the Lancet Commission on Global Surgery (LCoGS) minimum target of 20-40 SAO/100,000 were calculated accounting for potential increases in surgical volume associated with surgical workforce expansion. RESULTS: Increasing SAO workforce density was independently associated with lower surgically amenable U5MR as well as NMR (p < 0.01 for each model). When accounting for concomitant increases in surgical volume, scale-up of the surgical workforce to 20-40 SAO/100,000 could potentially prevent between 262,709 (95% CI 229,643-295,434) and 519,629 (465,046-573,919) under 5 deaths annually. The majority (61%) of deaths averted would be neonatal deaths. CONCLUSION: Scale up of surgical workforce may substantially decrease childhood mortality rates around the world. Our analysis suggests that scale-up of surgical delivery through increase in the SAO workforce could prevent over 500,000 children from dying before the age of 5 annually. This would represent significant progress toward meeting global child mortality reduction targets.

Implementation of a checklist to improve pediatric trauma assessment quality in a Brazilian hospital.

BACKGROUND: Trauma is the leading cause of death among children and adolescents in Brazil. Measurement of quality of care is important, as well as interventions that will help optimize treatment. We aimed to evaluate adherence to standardized trauma care following the introduction of a checklist in one of the busiest Latin American trauma centers. MATERIAL AND METHODS: A prospective, non-randomized interventional trial was conducted. Assessment of children younger than age 15 was performed before and after the introduction of a checklist for trauma primary survey assessment. Over the study period, each trauma primary survey was observed and adherence to each step of a standardized primary assessment protocol was recorded. Clinical outcomes including mortality, admission to pediatric intensive-care units, use of blood products, mechanical ventilation, and number of CT scans in the first 24 h were also assessed. RESULTS: A total of 80 patients were observed (39 pre-intervention and 41 post-intervention). No statistically significant differences were observed between the pre- and post-intervention groups in regard to adherence to checklist by specialty (57.7% versus 50.5%, p = 0.115) and outcomes. No mortality was observed. CONCLUSION: In our trauma center, the quality of the adherence to standardized trauma assessment protocols is poor among both surgical and non-surgical providers. The quality of this assessment did not improve after the introduction of a checklist. Further work aimed at organizing the approach to pediatric trauma including triage and trauma education specifically for pediatric providers is needed.

Online action planning forums to develop a roadmap to mitigate the impact of COVID-19 on the delivery of global children's surgical care.

PURPOSE: We aimed to understand the challenges facing children's surgical care providers globally and realistic interventions to mitigate the catastrophic impact of COVID-19 on children's surgery. METHODS: Two online Action Planning Forums (APFs) were organized by the Global Initiative for Children's Surgery (GICS) with a geographically diverse panel representing four children's surgical, anesthesia, and nursing subspecialties. Qualitative analysis was performed to identify codes, themes, and subthemes. RESULTS: The most frequently reported challenges were delayed access to care for children; fear among the public and patients; unavailability of appropriate personal protective equipment (PPE); diversion of resources toward COVID-19 care; and interruption in student and trainee hands-on education. To address these challenges, panelists recommended human resource and funding support to minimize backlog; setting up international, multi-center studies for systematic data collection specifically for children; providing online educational opportunities for trainees and students in the form of large and small group discussions; developing best practice guidelines; and, most importantly, adapting solutions to local needs. CONCLUSION: Identification of key challenges and interventions to mitigate the impact of the COVID-19 pandemic on global children's surgery via an objective, targeted needs assessment serves as an essential first step. Key interventions in these areas are underway.

Bellwether Procedures for Monitoring Subnational Variation of All-cause Perioperative Mortality in Brazil.

BACKGROUND: All-cause perioperative mortality rate (POMR) is a commonly reported metric to assess surgical quality. Benchmarking POMR remains difficult due to differences in surgical volume and case mix combined with the burden of reporting and leveraging this complex and high-volume data. We seek to determine whether the pooled and individual procedure POMR of each bellwether (cesarean section, laparotomy, management of open fracture) correlate with state-level all-cause POMR in the interest of identifying benchmark procedures that can be used to make standardized regional comparisons of surgical quality. METHODS: The Brazilian National Healthcare Database (DATASUS) was queried to identify unadjusted all-cause POMR for all patient admissions among public hospitals in Brazil in 2018. Bellwether procedures were identified as any procedure involving laparotomy, cesarean section, or treatment of open long bone fracture and then classified as emergent or elective. The pooled POMR of all bellwether procedures as well as for each individual bellwether procedure was compared with the all-cause POMR in each of the 26 states, and one federal district and correlations were calculated. Funnel plots were used to compare surgical volume to perioperative mortality for each bellwether procedure. RESULTS: 4,756,642 surgical procedures were reported to DATASUS in 2018: 237,727 emergent procedures requiring laparotomy, 852,821 emergent cesarean sections, and 210,657 open, long bone fracture repairs. Pooled perioperative mortality for all of the bellwether procedures was correlated with all-procedure POMR among states (r = 0.77, p < 0.001). POMR for emergency procedures (2.4%) correlated with the all-procedure (emergent and elective) POMR (1.6%, r = 0.93, p < .001), while POMR for elective procedures (0.4%) did not (p = .247). POMR for emergency laparotomy (4.4%) correlated with all-procedure POMR (1.6%, r = 0.52, p = .005), as did the POMR for open, long bone fractures (0.8%, r = 0.61, p < .001). POMR for emergency cesarean section (0.05%) did not correlate with all-procedure POMR (p = 0.400). There was a correlation between surgical volume and emergency laparotomy POMR (r = - 0.53, p = .004), but not for emergency cesarean section or open, long bone fractures POMR. CONCLUSION: Procedure-specific POMR for laparotomy and open long bone fracture correlates modestly with all-procedure POMR among Brazilian states which is primarily driven by emergency procedure POMR. Selective reporting of emergency laparotomy and open fracture POMR may be a useful surrogate to guide subnational surgical policy decisions.

Improving Pediatric Trauma Education by Teaching Non-technical Skills: A Randomized Controlled Trial.

BACKGROUND: Pediatric trauma is a significant cause of child mortality, and the absence of non-technical skills (NTS) among health providers is linked with errors in patients' care. In this study, we evaluate the effectiveness of a structured debriefing protocol in enhancing NTS during pediatric trauma simulation. METHODS: A total of 45 medical students were successfully recruited from two medical schools, one in Brazil and one in Canada. Medical students were assigned to a control (N = 20) or intervention group (N = 25) in a randomized control trial. Following simulated scenarios, participants in the intervention group underwent NTS debriefing, while the control received standard debriefing based on the Advanced Trauma Life Support (ATLS) protocol. Students' confidence, NTS level, and performance were measured through self-assessment surveys, the Non-Technical Skills for Surgeons (NOTSS) score, and adherence to the trauma protocol, respectively. Baseline characteristics and outcomes were compared using t-tests, Mann-Whitney, Wilcoxon signed-rank Kruskal-Wallis, ANOVA, and a repeated-measures ANCOVA. A significance level was set at p < 0.05. RESULTS: The workshop increased students' confidence in leading trauma resuscitation regardless of their assignment to condition. While controlling for covariates, students in the intervention group significantly improved their overall NOTSS compared to those in the control and in all categories: situational awareness, decision-making, communication and teamwork, and leadership. The intervention teams also demonstrated a significant increase in completing trauma protocol steps. CONCLUSION: Implementing structured debriefing focusing on NTS enhanced these skills and improved adherence to protocol among medical students managing pediatric trauma-simulated scenarios. These findings support integrating NTS training in pediatric trauma education. LEVEL OF EVIDENCE: I.

The State of Artificial Intelligence in Pediatric Surgery: A Systematic Review.

BACKGROUND: Artificial intelligence (AI) has been recently shown to improve clinical workflows and outcomes - yet its potential in pediatric surgery remains largely unexplored. This systematic review details the use of AI in pediatric surgery. METHODS: Nine medical databases were searched from inception until January 2023, identifying articles focused on AI in pediatric surgery. Two authors reviewed full texts of eligible articles. Studies were included if they were original investigations on the development, validation, or clinical application of AI models for pediatric health conditions primarily managed surgically. Studies were excluded if they were not peer-reviewed, were review articles, editorials, commentaries, or case reports, did not focus on pediatric surgical conditions, or did not employ at least one AI model. Extracted data included study characteristics, clinical specialty, AI method and algorithm type, AI model (algorithm) role and performance metrics, key results, interpretability, validation, and risk of bias using PROBAST and QUADAS-2. RESULTS: Authors screened 8178 articles and included 112. Half of the studies (50%) reported predictive models (for adverse events [25%], surgical outcomes [16%] and survival [9%]), followed by diagnostic (29%) and decision support models (21%). Neural networks (44%) and ensemble learners (36%) were the most commonly used AI methods across application domains. The main pediatric surgical subspecialties represented across all models were general surgery (31%) and neurosurgery (25%). Forty-four percent of models were interpretable, and 6% were both interpretable and externally validated. Forty percent of models had a high risk of bias, and concerns over applicability were identified in 7%. CONCLUSIONS: While AI has wide potential clinical applications in pediatric surgery, very few published AI algorithms were externally validated, interpretable, and unbiased. Future research needs to focus on developing AI models which are prospectively validated and ultimately integrated into clinical workflows. LEVEL OF EVIDENCE: 2A.

The Impact of Educational Materials on Parental Anxiety and Productivity: A Clinical Trial in Pediatric Appendicitis.

OBJECTIVES: There is limited literature on how acute appendicitis, the most common acute children's surgical illness, affects the family. We conducted a prospective study to assess the impact of educational materials on parents' anxiety and productivity during the child's illness. METHODS: A quasi-experimental clinical trial was conducted among parents of children undergoing laparoscopic appendectomy. In Phase I, parents received the standard explanations at diagnosis and throughout the postoperative period. In Phase II, parents also received a comprehensive educational brochure on pediatric appendicitis at diagnosis. The primary outcome, parental preoperative anxiety, was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The secondary outcome, parental productivity, was evaluated through a post-recovery online questionnaire based on the Productivity and Disease Questionnaire (PRODISQ). Baseline characteristics and outcomes were compared between the two cohorts using t-tests, Mann-Whitney, chi-square, or Fischer's exact test as appropriate. RESULTS: Phases I and II included 67 and 66 families, respectively. Patient demographics and disease severity were similar between both groups. Of the 53 parents (80.3%) in Phase II who answered the postoperative questionnaire, most recommended the booklet (96.2%), as it decreased their stress (78.0%) and enhanced their understanding of appendicitis (94.1%). However, the two groups showed similar preoperative anxiety levels and postoperative productivity loss. CONCLUSIONS: Educational materials increased satisfaction with surgical care but did not mitigate the high parental preoperative anxiety levels and postoperative productivity loss. Additional research is required to elucidate interventions that may improve these important patient and family-centered outcomes. TYPE OF STUDY: Non-Randomized Clinical Trial. LEVEL OF EVIDENCE: II.

Social determinants of gastrointestinal malformation mortality in Brazil: a national study.

Introduction: In Brazil, approximately 5% are born with a congenital disorder, potentially fatal without surgery. This study aims to evaluate the relationship between gastrointestinal congenital malformation (GICM) mortality, health indicators, and socioeconomic factors in Brazil. Methods: GICM admissions (Q39-Q45) between 2012 and 2019 were collected using national databases. Patient demographics, socioeconomic factors, clinical management, outcomes, and the healthcare workforce density were also accounted for. Pediatric Surgical Workforce density and the number of neonatal intensive care units in a region were extracted from national datasets and combined to create a clinical index termed 'NeoSurg'. Socioeconomic variables were combined to create a socioeconomic index termed 'SocEcon'. Simple linear regression was used to investigate if the temporal changes of both indexes were significant. The correlation between mortality and the different indicators in Brazil was evaluated using Pearson's correlation coefficient. Results: Over 8 years, Brazil recorded 12804 GICM admissions. The Southeast led with 6147 cases, followed by the Northeast (2660), South (1727), North (1427), and Midwest (843). The North and Northeast reported the highest mortality, lowest NeoSurg, and SocEcon Index rates. Nevertheless, mortality rates declined across regions from 7.7% (2012) to 3.9% (2019), a 51.7% drop. The North and Midwest experienced the most substantial reductions, at 63% and 75%, respectively. Mortality significantly correlated with the indexes in nearly all regions (p<0.05). Conclusion: Our study highlights the correlation between social determinants of health and GICM mortality in Brazil, using two novel indexes in the pediatric population. These findings provide an opportunity to rethink and discuss new indicators that could enhance our understanding of our country and could lead to the development of necessary solutions to tackle existing challenges in Brazil and globally.

Expansion of national surgical, obstetric, and anaesthesia plans in Latin America: can Brazil be next?

On the sidelines of the 75th Session of the Regional Committee of the World Health Organization for the Americas, the Republic of Ecuador hosted an event to expand on National Surgical, Obstetric, and Anaesthesia Plans (NSOAPs). NSOAPs are policy frameworks that offer governments a pathway to incorporate surgical planning into their overall health strategies. In Latin America, Ecuador became the first country to lead the development of an NSOAP and is fostering regional efforts for other Latin American countries to have sustainable surgical strengthening plans. Brazil is a prominent candidate for enrolling in an NSOAP process to enhance its public health system's functionality. An NSOAP in Brazil can help mitigate social disparities, promote greater efficiency in allocating existing resources, and optimise public health system financing. This process can also encourage the creation of resources and distinct NSOAP vocabulary in Portuguese to facilitate the development of NSOAPs in other Portuguese-speaking and low- and middle-income countries. In this viewpoint, we explore why an NSOAP can benefit Brazil's surgical system, national features that enable surgical policymaking, and how multiple stakeholder engagement can contribute to the country's planning, validation, and implementation of an NSOAP.

Technology-enhanced trauma training in low-resource settings: A scoping review and feasibility analysis of educational technologies.

BACKGROUND: Lack of training contributes to the burden of trauma-related mortality and morbidity in low- and lower-middle-income countries (LMICs). Educational technologies present a unique opportunity to enhance the quality of trauma training. Therefore, this study reviews current technologies used in trauma courses and evaluates their feasibility for LMICs. METHODS: We conducted a scoping review evaluating the learning outcomes of technology-enhanced training in general trauma assessment, team skills or any procedures covered in the 2020 Advanced Trauma Life Support® program. Based on the Technology-Enhanced Learning criteria, we created and applied a feasibility analysis tool to evaluate the technologies for use in LMICs. RESULTS: We screened 6471 articles and included 64. Thirty-four (45%) articles explored training in general trauma assessment, 28 (37%) in team skills, and 24 (32%) in procedures. The most common technologies were high-fidelity mannequins (60%), video-assisted debriefing (19%), and low-fidelity mannequins (13%). Despite their effectiveness, high-fidelity mannequins ranked poorly in production, maintenance, cost, and reusability categories, therefore being poorly suited for LMICs. Virtual simulation and digital courses had the best feasibility scores, but still represented a minority of articles in our review. CONCLUSION: To our knowledge, this is the first study to perform a feasibility analysis of trauma training technologies in the LMIC context. We identified that the majority of trauma courses in the literature use technologies which are less suitable for LMICs. Given the urgent need for pediatric trauma training, educators must use technologies that optimize learning outcomes and remain feasible for low-resource settings. LEVEL OF EVIDENCE: IV.

Limitations of using the DATASUS database as a primary source of data in surgical research: a scoping review.

OBJECTIVE: DATASUS is the Brazilian Public Unified Health System (SUS) department responsible for providing health data that are used as a primary source of data in several studies on surgery and surgical specialties although its main limitations have not been previously reviewed. The objective of this work is to synthesize information from studies on surgery that used DATASUS systems as a data source and to identify the main gaps in this platform. METHODS: a scoping review was conducted according to the PRISMA-ScR method to identify papers on surgery, and other surgical specialties, that used the DATASUS platform as a primary data source. No restrictions were imposed regarding the type of study or year of publication. Grounded Theory was used to analyze the content of the articles. RESULTS: 248 works were initially analyzed and 47 were included in the final analysis of this study. The original articles included were published between 2009 and 2022 and the majority (12.76%, n=6) were published in the Journal of the Brazilian College of Surgeons. Retrospective studies (40.43%, n=19) were the most common type of study found. Content analysis of the articles identified four predominant domains in the scientific literature about the limitations of using DATASUS in surgical research: lack of data, reliability, precision and data integration. CONCLUSION: the information systems available in DATASUS are the largest source of information about the SUS, but the scientific literature on the quality of data available in these systems remains scarce and studies aimed at measuring this metric are necessary.

Online medical education: A student survey.

BACKGROUND: During COVID-19, medical schools transitioned to online learning as an emergency response to deliver their education programmes. This multi-country study compared the methods by which medical schools worldwide restructured the delivery of medical education during the pandemic. METHODS: This multi-country, cross-sectional study was performed using an internet-based survey distributed to medical students in multiple languages in November 2020. RESULTS: A total of 1,746 responses were received from 79 countries. Most respondents reported that their institution stopped in-person lectures, ranging from 74% in low-income countries (LICs) to 93% in upper-middle-income countries. While only 36% of respondents reported that their medical school used online learning before the pandemic, 93% reported using online learning after the pandemic started. Of students enrolled in clinical rotations, 89% reported that their rotations were paused during the pandemic. Online learning replaced in-person clinical rotations for 32% of respondents from LICs versus 55% from high-income countries (HICs). Forty-three per cent of students from LICs reported that their internet connection was insufficient for online learning, compared to 11% in HICs. CONCLUSIONS: The transition to online learning due to COVID-19 impacted medical education worldwide. However, this impact varied among countries of different income levels, with students from LICs and lower middle income countries facing greater challenges in accessing online medical education opportunities while in-person learning was halted. Specific policies and resources are needed to ensure equitable access to online learning for medical students in all countries, regardless of socioeconomic status.

Who gets burned in Brazil?

Burns are preventable injuries that still represent a relevant public health issue. The identification of risk factors might contribute to the development of specific preventive strategies. Data of patients admitted at the Hospital due to acute burn injuries from May 2017 to December 2019, was extracted manually from medical records. The population was analyzed descriptively, and differences between groups were tested using the appropriate statistical test. The study population consisted of 370 patients with burns admitted to the Hospital burn unit during the study period. The majority of the patients were males (257/370, 70%), median age was 33 (IQR:18-43), median TBSA% was 13 (IQR 6.35-21.5 and range 0-87.5%), and 54% of patients had full thickness burns (n=179). Children younger than 13 years old represented 17% of the study population (n=63), 60% of them were boys (n= 38), and scalds was the predominant mechanism of burn injury (n= 45). No children died, however 10% of adults did (n= 31). Self-inflicted burns were observed in 16 adults (5%), of whom 6 (38%) died during admission, however self-inflicted burns were not observed in children. Psychiatric disorders and substance misuse were frequent in this subgroup. White adults male from urban areas who had not completed primary school degree were the major risk group for burns. Smoking and alcohol misuse were the most frequent comorbidities. Accidental domestic flame burns were the predominant injuries in the adult population and scalds in the pediatric.