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.

The Plastic Surgery Workforce and Its Role in Low-income Countries.

BACKGROUND: Plastic surgery varies in scope, especially in different settings. This study aimed to quantify the plastic surgery workforce in low-income countries (LICs), understand commonly treated conditions by plastic surgeons working in these settings, and assess the impact on reducing global disease burden. METHODS: We queried national and international surgery societies, plastic surgery societies, and non-governmental organizations to identify surgeons living and working in LICs who provide plastic surgical care using a cross-sectional survey. Respondents reported practice setting, training experience, income sources, and perceived barriers to care. Surgeons ranked commonly treated conditions and reported which of the Disease Control Priorities-3 essential surgery procedures they perform. RESULTS: An estimated 63 surgeons who consider themselves plastic surgeons were identified from 15 LICs, with no surgeons identified in the remaining 16 LICs. Responses were obtained from 43 surgeons (70.5%). The 3 most commonly reported conditions treated were burns, trauma, and cleft deformities. Of the 44 "Essential Surgical Package'' procedures, 37 were performed by respondents, with the most common being skin graft (73% of surgeons performing), cleft lip/palate repair (66%), and amputations/escharotomy (61%). The most commonly cited barrier to care was insufficient equipment. Only 9% and 5% of surgeons believed that there are enough plastic surgeons to handle the burden in their local region and country, respectively. CONCLUSIONS: Plastic surgery plays a significant role in the coverage of essential surgical conditions in LICs. Continued expansion of the plastic surgical workforce and accompanying infrastructure is critical to meet unmet surgical burden in low- and middle-income countries.

Palatal Fistula Risk after Primary Palatoplasty: A Retrospective Comparison of a Humanitarian Organization and Tertiary Hospitals.

BACKGROUND: Humanitarian surgical organizations provide palatoplasties for patients without access to surgical care. Few organizations have evaluated the outcomes of these trips. This study evaluates the palatal fistula rate in patients from two cohorts in rural China and one in the United States. METHODS: This study compared the odds of fistula formation among three cohorts whose palates were repaired between 2005 and 2009. One cohort included 97 Chinese patients operated on by teams from the United States and Canada under the auspices of Resurge International. They were compared to cohorts at Huaxi Stomatology Hospital and the University of California San Francisco (UCSF). Age, fistula presence, and Veau class were compared among cohorts using Chi-square tests. Logistic regression was used to analyze predictors of fistula formation. RESULTS: The fistula risk was 35.4% in patients treated by humanitarian teams, 12.8% at Huaxi University Hospital and 2.5% at UCSF ( P < 0.001). Age and Veau class were associated with fistula formation (Age P = 0.0015; Veau P < 0.001). ReSurge and Huaxi patients had 20.2 and 5.6 times the odds of developing a fistula, respectively, compared to UCSF patients ( P < 0.01, both). A multivariable model controlling for surgical group, age, and gender showed an association between Veau class and the odds of fistula formation. CONCLUSIONS: Chinese children undergoing palatoplasty by international teams had higher odds of palatal fistula than children treated by Chinese surgeons in established institutions and children treated in the United States. More research is required to identify factors affecting complication rates in low-resource environments.

Economic modeling of surgical disease: a measure of public health interventions.

The measurement of the burden of disease and the interventions that address that burden can be done in various units. Reducing these measures to the common denominator of economic units (i.e., currency) enables comparison with other health entities, interventions, and even other fields. Economic assessment is complex, however, because of the multifactorial components of what constitutes health and what constitutes health interventions, as well as the coupling of those data to economic means. To perform economic modeling in a meaningful manner, it is necessary to: (1) define the health problem to be addressed; (2) define the intervention to be assessed; (3) define a measure of the effect of the health entity with and without the intervention (which includes defining the counterfactual); and (4) determine the appropriate method of converting the health effect to economics. This paper discusses technical aspects of how economic modeling can be done both of disease entities and of interventions. Two examples of economic modeling applied to surgical problems are then given.

Comparison of fistula rates after palatoplasty for international and local surgeons on surgical missions in Ecuador with rates at a craniofacial center in the United States.

BACKGROUND: International organizations have performed palatoplasties in low- and middle-income countries for decades, often working with local providers. Few studies report long-term outcomes, especially for palatal fistulas. A fistula after palatoplasty may affect speech, socialization, and nutrition. Fistula rates on surgical missions have not been compared with rates at U.S. craniofacial centers nor have the rates of the visiting and local surgeons working on missions been compared. METHODS: Fistula rates for two Ecuadorian cohorts were compared with fistula rates for a craniofacial center in the United States. In Ecuador, North American surgeons repaired one cohort (n = 46) and Ecuadorians the other (n = 82) during 2000 through 2005. Ecuadorian patients were evaluated during 2007 and 2008. The center's clinical database (n = 189) provided U.S. cohort data. RESULTS: On missions, the fistula rates were 57 percent (95 percent CI, 46 to 68 percent) for Ecuadorian surgeons and 54 percent (95 percent CI, 39 to 69 percent) for North American surgeons. The rate was 2.6 percent (95 percent CI, 0.8 to 6.0 percent) at the U.S. craniofacial center. There was no difference between the two Ecuadorian cohorts' rates (p = 0.75), but they were significantly higher than those of the U.S. cohort (p < 0.001). Having a cleft lip together with cleft palate was associated with fistula formation, whereas surgeon nationality and older age at surgery were not. CONCLUSIONS: The fistula rate on Ecuadorian missions, regardless of the surgeon's nationality, was significantly higher than in the United States. Further investigation into the causes of this higher fistula rate in this population is needed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Plastic and reconstructive surgery in Zambia: epidemiology of 16 years of practice.

BACKGROUND: The epidemiology of surgical conditions in developing countries is not well studied, but plastic and reconstructive surgery can play a significant role in meeting the need for surgical care. Knowledge of the conditions treated by a plastic surgeon in a low-income country would inform the development of surgical services. METHODS: The surgical log of the lead author from 1993 to 2008 was reviewed. The cases were performed in 33 surgical facilities in Zambia, and name, gender, age, diagnosis, procedure, and hospital were prospectively recorded. Data were analyzed for the number and distribution of cases and for patterns related to age and gender. RESULTS: Between 1993 and 2008, 5,740 operations were performed, and complete data were available for 5,735 (99.9%) patients. There were 5,774 surgical diagnoses. Of these, 3,885 (67.2%) were acquired conditions. These included 1,985 (34.3%) burns, 514 (9.0%) keloids, 448 (7.8%) nonburn traumas, 410 (7.1%) deep tissue infections, and 343 (5.9%) tumors. The 1,889 (32.7%) congenital conditions included 1,322 (22.9%) craniofacial defects and 354 (6.1%) limb defects. Children accounted for 78.2% of burns. Trauma cases were predominantly male (273, 60.9%). Congenital conditions were repaired after 5 years of age in 355 (18.8%) cases. CONCLUSION: Based on a 16-year case log from one developing country, more than half of conditions related to plastic surgery comprised injuries and congenital anomalies. Age- and gender-related patterns were evident. These findings may inform the provision of resources for injury prevention, surgical training, and delivery of surgical services.

Volunteers in plastic surgery guidelines for providing surgical care for children in the less developed world.

BACKGROUND: A significant need is met by volunteer groups who provide free reconstructive plastic surgery for underserved children in developing countries. However, at present there are no consistent guidelines for volunteer groups in plastic surgery seeking to provide high-quality and safe care. METHODS: With these quality and safety standards in mind, in 2006, the Volunteers in Plastic Surgery Committee of the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation undertook a project to develop a detailed set of guidelines for volunteer groups from developed countries seeking to provide plastic surgery services to children in developing countries. To make the guidelines include both surgical and anesthetic needs, they were developed in conjunction with the Society for Pediatric Anesthesia. RESULTS: Guidelines for the delivery of plastic surgery care by volunteer groups to developing countries have been reviewed and approved by the boards of both organizations (the American Society of Plastic Surgeons/Plastic Surgery Educational Foundation and the Society for Pediatric Anesthesia). These include guidelines for the initial site visit, site and patient selection, staff and equipment that should be available, and procedures that can be safely performed based on the site and available facilities. Guidelines for assessment of outcomes, dealing with adverse outcomes, and quality improvement are also provided. CONCLUSIONS: Any plastic surgery group undertaking an international mission trip should be able to go to one source to find a detailed discussion of the perceived needs in providing high-quality, safe care for children. The present document was created to satisfy this need.

Association between preoperative measurements and resection weight in patients undergoing reduction mammaplasty.

Current guidelines used to predict appropriate resection weight for patients undergoing reduction mammaplasty are typically based on relatively nondescript patient characteristics and are most often inaccurate. The determination of patient measurements that correlate with resection weight could enable appropriate resection weight to be predicted more precisely and on an individualized basis. To better elucidate this, data from 348 patients undergoing bilateral reduction mammaplasty (696 breasts) between October 2001 and March 2009 were reviewed retrospectively. The association between resection weight and sternal notch to nipple distance (SNN), inframammary fold to nipple distance (IMFN), and body mass index (BMI) was assessed. Regression analysis demonstrated a strong correlation between resection weight and SNN distance (r = 0.672, P < 0.001), IMFN distance (r = 0.467, P < 0.001), and BMI (r = 0.510, P < 0.001). The strongest correlation was observed after incorporating all 3 parameters (r = 0.740, P < 0.001). This enabled the calculation of a formula to predict resection weight: Predicted weight = 40.0(SNN) + 24.7(IMFN) + 17.7(BMI) - 1443 In conclusion, resection weight correlates strongly with SNN, IMFN, and BMI in patients undergoing reduction mammaplasty. When considered together, resection weight can be predicted with a strong degree of accuracy.

Estimation of impact of surgical disease through economic modeling of cleft lip and palate care.

BACKGROUND: Assessing burden of disease encompasses the prevalence of disease entities, but it is the impact that affects the populace. Similarly, optimal evaluation of intervention programs shows impact rather than simply an enumeration of services. Economic effects are a fungible measure but are difficult to assess. Modeling of economic effects was used to evaluate a cleft program in Nepal and to demonstrate impact of alleviating this subset of the surgical burden of disease. METHODS: The database of patients who underwent care at a cleft center in Katmandu in 2005 was used. Disability adjusted life years averted were calculated. Using both GNI per capita and Value of a Statistical Life, the economic value to the individuals and to society was calculated. RESULTS: The two methods yielded a conservative and a generous estimate of economic impact of treating cleft lip and palate. Using GNI per capita, cleft lip repair added between $856 and $6,598 to lifetime individual income. For cleft palate, this ranged from $2,293 to $17,278. Using Value of a Statistical Life, cleft lip repair added between $56,919 and $143,363, and cleft palate between $152,372 and $375,412. CONCLUSIONS: The immense economic gain realized by an intervention addressing a small proportion of the surgical burden of disease indicates the importance of these conditions to public health and well-being. This methodology also lends itself to broader use and to further refinement as a means of evaluation of interventions. This has implications for health policy and for funding and resource allocation for surgical conditions in the developing world.

Perspectives on plastic surgery and global health.

Of the many factors affecting the health of the human race, those amenable to correction by plastic surgical intervention comprise a significant number. The interface between the global health community and the plastic surgery community historically has been quite diminutive, but this is changing with globalization. This overview provides a primer of global health for the plastic surgeon, and a discussion of the global burden of disease as it relates to plastic surgery. The article then briefly discusses the disparity between the global plastic surgery needs and the supply of expertise, and the difficulties presented by policy, finances, and implied societal preferences for care.