Convolutional Neural Network Models for Automatic Preoperative Severity Assessment in Unilateral Cleft Lip.

BACKGROUND: Despite the wide range of cleft lip morphology, consistent scales to categorize preoperative severity do not exist. Machine learning has been used to increase accuracy and efficiency in detection and rating of multiple conditions, yet it has not been applied to cleft disease. The authors tested a machine learning approach to automatically detect and measure facial landmarks and assign severity grades using preoperative photographs. METHODS: Preoperative images were collected from 800 unilateral cleft lip patients, manually annotated for cleft-specific landmarks, and rated using a previously validated severity scale by eight expert reviewers. Five convolutional neural network models were trained for landmark detection and severity grade assignment. Mean squared error loss and Pearson correlation coefficient for cleft width ratio, nostril width ratio, and severity grade assignment were calculated. RESULTS: All five models performed well in landmark detection and severity grade assignment, with the largest and most complex model, Residual Network, performing best (mean squared error, 24.41; cleft width ratio correlation, 0.943; nostril width ratio correlation, 0.879; severity correlation, 0.892). The mobile device-compatible network, MobileNet, also showed a high degree of accuracy (mean squared error, 36.66; cleft width ratio correlation, 0.901; nostril width ratio correlation, 0.705; severity correlation, 0.860). CONCLUSIONS: Machine learning models demonstrate the ability to accurately measure facial features and assign severity grades according to validated scales. Such models hold promise for the creation of a simple, automated approach to classifying cleft lip morphology. Further potential exists for a mobile telephone-based application to provide real-time feedback to improve clinical decision making and patient counseling.

The cost of electric-scooter related orthopaedic surgery.

AIM: To highlight the growing cost of electric-scooter (e-scooter) related injuries necessitating surgical intervention by the Auckland City Hospital Orthopaedic Department. METHODS: Retrospective audit of operations by the Auckland City Hospital Orthopaedic Department from 15 October 2018 up to and inclusive of 22 February 2019. Inclusion criteria was that the direct cause of injury necessitating surgery was secondary to an e-scooter accident. Further demographic data was collected including injury sustained and operation details. The surgical costs were calculated, including anaesthetic time, surgical time, staffing, implants used and inpatient stay as well as clinic follow-up. RESULTS: Over the 19-week period of this study there were 21 patients requiring 23 operations as a direct result of e-scooters. The summative anaesthetic, theatre suite and staffing costs of these operations was $162,901. Implants required to fix the fractures totalled $39,898. Ninety-three inpatient nights and 61 follow-up clinic appointments were required incurring an additional expense of $141,639 and $16,119 respectively. Overall, these 23 cases cost a total of $360,557. The extrapolated loss of income was $44,368 secondary to these injuries. This represents a total economic cost of $404,925, or $19,282 per person. CONCLUSION: This study highlights that there can be serious consequences of e-scooter travel. High energy trauma not previously associated with scooter injuries is becoming increasingly prevalent as a result of readily available e-scooters. Many of the injuries identified represent significant morbidity to patients in terms of pain, lengthy rehabilitation and loss of income. Furthermore, the socioeconomic costs for DHBs continues to climb and adds to the acute surgical burden in an already busy healthcare system. The hazards of e-scooters should not be underestimated by both the general public and policy-makers.

The Medical Mission and Modern Core Competency Training: A 10-Year Follow-Up of Resident Experiences in Global Plastic Surgery.

BACKGROUND: The emphasis on cultural competency for physicians and surgeons is increasingly important, as communication with both patients and other providers significantly affects individual and system-wide outcomes. International surgical training has been shown to improve leadership skills, cultural competency, and technical proficiency of participants in short-term follow-up. This study explores the long-term impact of international surgical mission experiences on developing participants' core competencies, professional outcomes, and commitment to global health. METHODS: All 208 plastic and reconstructive surgeons who completed the Operation Smile Regan/Stryker fellowship programs between 2006 and 2015 were surveyed electronically. RESULTS: One hundred sixty-five surveys were returned, for an overall response rate of 79.3 percent. The majority of participants reported that the fellowship positively impacted all six Accreditation Council for Graduate Medical Education core competencies. Most participants who were attending physicians at the time of the survey were practicing general plastic surgery, with 42 percent in an academic/teaching environment, 32 percent in assistant/associate professor positions, and 6 percent in either a program director or department chairman position. The majority currently volunteer on local or international missions, and all respondents would consider volunteering again. CONCLUSIONS: Carefully structured and rigorously proctored programs such as the Regan/Stryker Fellowship offer plastic surgery residents the opportunity to gain valuable professional and personal experiences that benefit them long after their service experience. Programs of this nature can not only effectively improve cultural competency of physicians, but also positively influence their attitudes toward leadership and direct that potential to meet the growing need for surgical care in low- and middle-income countries.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part I: challenge and commitment.

BACKGROUND: With an estimated backlog of 4,000,000 patients worldwide, cleft lip and cleft palate remain a stark example of the global burden of surgical disease. The need for a new paradigm in global surgery has been increasingly recognized by governments, funding agencies, and professionals to exponentially expand care while emphasizing safety and quality. This three-part article examines the evolution of the Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) as an innovative model for sustainable cleft care in the developing world. METHODS: The GCCCC is the result of a unique public-private partnership between government, charity, and private enterprise. In 2009, Operation Smile, the Government of Assam, the National Rural Health Mission, and the Tata Group joined together to work towards the common goal of creating a center of excellence in cleft care for the region. RESULTS: This partnership combined expertise in medical care and training, organizational structure and management, local health care infrastructure, and finance. A state-of-the-art surgical facility was constructed in Guwahati, Assam which includes a modern integrated operating suite with an open layout, advanced surgical equipment, sophisticated anesthesia and monitoring capabilities, central medical gases, and sterilization facilities. CONCLUSION: The combination of established leaders and dreamers from different arenas combined to create a synergy of ambitions, resources, and compassion that became the backbone of success in Guwahati.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part II: program development and quality care.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) is committed to free medical and surgical care to patients afflicted with facial deformities in Assam, India. A needs-based approach was utilized to assemble numerous teams, processes of care, and systems aimed at providing world-class care to the most needy of patients, and to assist them with breaking through the barriers that prohibit them from obtaining services. METHODS: A team of international professionals from various disciplines served in Guwahati full time to implement and oversee patient care and training of local counterparts. Recruitment of local professionals in all disciplines began early in the scheme of the program and led to gradual expansion of all medical teams. Emphasis was placed on achieving optimal outcome for each patient treated, as opposed to treating the maximum number of patients. RESULTS: The center is open year round to offer full-time services and follow-up care. Along with surgery, GCCCC provides speech therapy, child life counseling, dental care, otolaryngology, orthodontics, and nutrition services for the cleft patients under one roof. Local medical providers participated in a model of graded responsibility commiserate with individualized skill and progress, and gradually assumed all leadership positions and now account for 92% of the workforce. Institutional infrastructure improvements positioned and empowered teams of skilled local providers while implementing systemized perioperative processes. CONCLUSION: This needs-based approach to program development in Guwahati was successful in optimization of quality and safety in all clinical divisions.

Scalable, sustainable cost-effective surgical care: a model for safety and quality in the developing world, part III: impact and sustainability.

BACKGROUND: The Guwahati Comprehensive Cleft Care Center (GCCCC) utilizes a high-volume, subspecialized institution to provide safe, quality, and comprehensive and cost-effective surgical care to a highly vulnerable patient population. METHODS: The GCCCC utilized a diagonal model of surgical care delivery, with vertical inputs of mission-based care transitioning to investments in infrastructure and human capital to create a sustainable, local care delivery system. Over the first 2.5 years of service (May 2011-November 2013), the GCCCC made significant advances in numerous areas. Progress was meticulously documented to evaluate performance and provide transparency to stakeholders including donors, government officials, medical oversight bodies, employees, and patients. RESULTS: During this time period, the GCCCC provided free operations to 7,034 patients, with improved safety, outcomes, and multidisciplinary services while dramatically decreasing costs and increasing investments in the local community. The center has become a regional referral cleft center, and governments of surrounding states have contracted the GCCCC to provide care for their citizens with cleft lip and cleft palate. Additional regional and global impact is anticipated through continued investments into education and training, comprehensive services, and research and outcomes. CONCLUSION: The success of this public private partnership demonstrates the value of this model of surgical care in the developing world, and offers a blueprint for reproduction. The GCCCC experience has been consistent with previous studies demonstrating a positive volume-outcomes relationship, and provides evidence for the value of the specialty hospital model for surgical delivery in the developing world.

Improving patient follow-up in developing regions.

BACKGROUND: Cleft surgery follow-up in developing regions is challenging. This study evaluated rates, costs, and satisfaction of 2 follow-up programs at the Guwahati Comprehensive Cleft Care Centre (GC4) in Assam, India. METHODS: For this study, 10,582 postoperative visits were analyzed from May 2011 to November 2013. A questionnaire was administered to subsets of follow-up patients at both locations. Costs were calculated. RESULTS: Eighty-five percent of patients had follow-up at GC4, and 15% were seen in the patients' local districts. One hundred ninety-five questionnaires were completed (122 at GC4, 73 in local districts). Patients with local follow-up had fewer accompanying family members (mean, 1.95 vs 0.99; P = 0.00), fewer days off work (mean, 1.84 vs 1.15; P = 0.19), less lost income (Indian rupees 367 vs 143, P = 0.00), and lower direct costs (mean Rs, 911 vs 299; P = 0.00). The financial burden of local follow-up was significantly lower (P = 0.003). No significant differences were seen for convenience, likelihood of attending follow-up, or satisfaction. Follow-ups increased after revising programs from a mean of 139 monthly visits (follow-up to surgery ratio of 0.722) to a mean of 363 visits (ratio of 1.57). The center's mean cost for local follow-up was Rs 303 per patient, whereas the estimated costs would have been Rs 1100 for follow-up at the center. CONCLUSIONS: This study demonstrates potential improvements in costs and outcomes by changing the model of care. Despite significant follow-up challenges, much progress can be achieved through process changes and outreach follow-up programs. The results have important applications across the developing world.

Providing more than health care: the dynamics of humanitarian surgery efforts on the local microeconomy.

Humanitarian cleft surgery has long been provided by teams from resource-rich countries traveling for short-term missions to resource-poor countries. After identifying an area of durable unmet need through surgical missions, Operation Smile constructed a permanent center for cleft care in Northeast India. The Operation Smile Guwahati Comprehensive Cleft Care Center (GCCCC) uses a high-volume subspecialized institution to provide safe, quality, comprehensive, and cost-effective cleft care to a highly vulnerable patient population in Assam, India. The purpose of this study was to profile the expenses of several cleft missions carried out in Assam and to compare these to the expenditures of the permanent comprehensive cleft care center. We reviewed financial data from 4 Operation Smile missions in Assam between December 2009 and February 2011 and from the GCCCC for the 2012-2013 fiscal year. Expenses from the 2 models were categorized and compared. In the studied period, 33% of the mission expenses were spent locally compared to 94% of those of the center. The largest expenses in the mission model were air travel (48.8%) and hotel expenses (21.6%) for the team, whereas salaries (46.3%) and infrastructure costs (19.8%) made up the largest fractions of expenses in the center model. The evolution from mission-based care to a specialty hospital model in Guwahati incorporated a transition from vertical inputs to investments in infrastructure and human capital to create a sustainable local care delivery system.

Long-term survival in patients with refractory angina.

AIMS: An increasing number of patients with severe coronary artery disease (CAD) are not candidates for traditional revascularization and experience angina in spite of excellent medical therapy. Despite limited data regarding the natural history and predictors of adverse outcome, these patients have been considered at high risk for early mortality. METHODS AND RESULTS: The OPtions In Myocardial Ischemic Syndrome Therapy (OPTIMIST) program at the Minneapolis Heart Institute offers traditional and investigational therapies for patients with refractory angina. A prospective clinical database includes detailed baseline and yearly follow-up information. Death status and cause were determined using the Social Security Death Index, clinical data, and death certificates. Time to death was analysed using survival analysis methods. For 1200 patients, the mean age was 63.5 years (77.5% male) with 72.4% having prior coronary artery bypass grafting, 74.4% prior percutaneous coronary intervention, 72.6% prior myocardial infarction, 78.3% 3-vessel CAD, 23.0% moderate-to-severe left-ventricular (LV) dysfunction, and 32.6% congestive heart failure (CHF). Overall, 241 patients died (20.1%: 71.8% cardiovascular) during a median follow-up 5.1 years (range 0-16, 14.7% over 9). By Kaplan-Meier analysis, mortality was 3.9% (95% CI 2.8-5.0) at 1 year and 28.4% (95% CI 24.9-32.0) at 9 years. Multivariate predictors of all-cause mortality were baseline age, diabetes, angina class, chronic kidney disease, LV dysfunction, and CHF. CONCLUSION: Long-term mortality in patients with refractory angina is lower than previously reported. Therapeutic options for this distinct and growing group of patients should focus on angina relief and improved quality of life.

The medical mission and modern cultural competency training.

BACKGROUND: Culture has increasingly appreciated clinical consequences on the patient-physician relationship, and governing bodies of medical education are widely expanding educational programs to train providers in culturally competent care. A recent study demonstrated the value an international surgical mission in modern surgical training, while fulfilling the mandate of educational growth through six core competencies. This report further examines the impact of international volunteerism on surgical residents, and demonstrates that such experiences are particularly suited to education in cultural competency. METHODS: Twenty-one resident physicians who participated in the inaugural Operation Smile Regan Fellowship were surveyed one year after their experiences. RESULTS: One hundred percent strongly agreed that participation in an international surgical mission was a quality educational experience and 94.7% deemed the experience a valuable part of their residency training. In additional to education in each of the ACGME core competencies, results demonstrate valuable training in cultural competence. CONCLUSIONS: A properly structured and proctored experience for surgical residents in international volunteerism is an effective instruction tool in the modern competency-based residency curriculum. These endeavors provide a unique understanding of the global burden of surgical disease, a deeper appreciation for global public health issues, and increased cultural sensitivity. A surgical mission experience should be widely available to surgery residents.