Impact of COVID-19 on Elective Cleft Surgery in Low- and Middle-income Countries.

BACKGROUND: The COVID-19 pandemic disrupted health systems worldwide, including in low- and middle-income countries (LMICs). Many countries limited the delivery of elective surgery. To date, COVID-19's impact on elective surgery in LMICs has been unquantified. We use operative data from a large international non-government cleft organization to compare case volume for 2019 and 2020 to quantify the impact of COVID-19. METHODS: Smile Train supports a partner network of over 1100 partners globally to deliver treatment to children with cleft lip and cleft palate (CLP). Treatment data is documented into a proprietary digital platform, Smile Train Express. We compared monthly treatment data for 2019 to 2020, by country, and by World Bank Income group to describe the effect that the COVID-19 pandemic has had on CLP surgery in LMICs. RESULTS: Our analysis shows 25,444 (31.4%) fewer primary operations performed between January and December 2020 than in the same period in 2019 with the most significant decline in procedures observed in April 2020. Many countries resumed elective surgery for CLP procedures from May onward and volume approximated that of pre-pandemic baseline by November of 2020. CONCLUSIONS: The emergence of the COVID-19 pandemic had a large impact on health systems and service delivery across the world. We find that this is evident in the delivery of CLP surgery in LMICs. The impact is characterized by a dramatic decrease in surgery rates in April of 2020 with a recovery of surgical volume from July 2020 onwards. The rate of surgical rate recovery is consistent across World Bank Income groups.

The "Safdarjung Method" of Estimation of Total Body Surface Area (TBSA) Burns in Major Amputees.

Accurate estimation of total body surface area (TBSA) burns is the cornerstone of initiating correct fluid therapy in burns. The current formulae are designed for patients with intact body. However, the authors having worked at a high-volume burns center (Safdarjung Hospital, New Delhi, India) have encountered patients with major amputations presenting with burns. The existing formulae are inaccurate for estimating TBSA in major amputees, leading to inaccurate fluid estimation in such cases. The authors have designed a novel method to estimate TBSA burns in patients with major amputations that involves a "correction factor" to account for the amputated parts.

Nasendoscopic Findings of Velopharyngeal Sphincter in Operated Cleft Palate Patients: Is It Different than Normal Population.

Objective This study was aimed for nasendoscopic assessment of velopharyngeal sphinteric closure in patients with operated cleft palate and to compare it with normal population. Design A cross-sectional study was done in a tertiary cleft care center in 30 patients with operated cleft palate after a minimum of 6 months of their surgery and 30 randomly selected volunteers with normal speech. Both groups were one-time evaluated by three observers using 70 degree rigid nasendoscope and/or pediatric fiber optic endoscope. Velopharyngeal sphincter closure characteristics in terms of pattern of closure, dominant element involved in the closure, degree of palatal movement, and completeness of the closure were evaluated, recorded, and compared between the groups. Results In both groups, the most common pattern of closure is coronal and soft palate is the dominant mobile element in velopharyngeal closure. All normal subjects showed complete closure of the sphincter with good soft palate movement. But only 50% of the operated patients with cleft showed complete closure and even less than them had good movements of the soft palate. Conclusions Although the pattern of the closure in the operated patients is similar to the normal subjects, the movement of the soft palate and completeness of the velopharyngeal sphincter closure still remain the problem in the operated palate patients.

New fluid therapy protocol in acute burn from a tertiary burn care centre.

BACKGROUND: Ringer lactate is the main fluid for resuscitation of acute burns. However it is not a complete fluid alone, as it does not take care of sugar and electrolyte balance adequately. This study has been carried out to compare the use of Ringer lactate (RL) alone and combination of RL with Dextrose Normal Saline (DNS) as fluid replacement therapy in acute burn. OBJECTIVE: To assess the biochemical parameters with the use of DNS as maintenance fluid in combination with Ringer lactate as resuscitation fluid in acute burns resuscitation. METHOD: A prospective randomized control study has been carried out by enrolling 200 patients into 2 groups, treated in ICU and resuscitated by using Modification of Brooke's formula (2mL/kg/% TBSA for resuscitation plus 2500mL maintenance). Group A received RL for resuscitation and DNS as maintenance in 1st 72h of burns. Group B received RL only for 1st 72h. The effects of this on various blood parameters were studied. RESULTS: Mean value of sodium at 24h was 137.79±3.89 in group A and was 133.2±4.57 (p<.0001) in group B. The sodium levels remained in range of 137-138 (p<.0001) in group A with only 22% patients showing lower range of sodium levels, whereas, there was a falling trend (p<.0001) of sodium levels in group B on subsequent days with 54.00% (p<.0001) showing hyponatremia on 1st day which increased to 76% on 3rd day. Mean values of early morning random blood sugar (RBS) levels in group A remained between 165.5±65.51mg/dL-115.82±32.52mg/dL on all 3days but in group B there was a falling trend from 127.49±46.11mg/dL to 102.84±22.92mg/dL by 3rd day. Thus, there was significant difference in levels of sodium and RBS in patients receiving DNS as maintenance fluid in addition to RL in acute phase. CONCLUSION: RL is not an ideal fluid for maintenance as it is low in sodium (130mEq/L) as well as potassium (4mEq/L) in view of daily electrolyte requirement. There is no glucose content in it to provide calories. Therefore, DNS should be added as daily maintenance fluid with RL as replacement for evaporative losses following burns.

Comparative evaluation of three methods of skin graft fixation for split thickness skin graft after release of post burn contracture of the neck.

OBJECTIVES: Split thickness skin graft is an essential component of release of post burn contracture of neck. There are many methods of fixation of skin grafts; however, there is lack of objective comparison between different techniques. This study has been designed to compare three commonly used techniques of split thickness skin graft fixation methods. Surgical time, advantages, cost factor and post-operative outcome have been compared amongst three techniques. METHODS: A randomized interventional comparative study was conducted to compare three methods of skin graft fixation in patients of 10-50 years age group, with contracture of more than 3 month duration having more than 100cm2 skin defects after contracture release. Resurfacing of the defects after contracture release was carried out in all the groups using autologous split skin grafts. Patients were included in three groups; Group 1: tie over method, Group 2: skin stapler fixation and Group 3: Cyanoacrylate glue fixation. RESULTS: Mean duration of fixation procedure was 34min in tie over group, in skin stapler group 7min and in cyanoacrylate group 12min. Mean cost of fixation material was 10.23 USD in tie-over group, 11.23 USD in stapler group and 40.06 USD in cyanoacrylate group. Mean score of pain/discomfort (visual analog score) on dressing removal in tie-over group was 3, for skin stapler group was 2.9 and that for cyanoacrylate glue group was 1.8. mean graft take was found to be 90.1% in tie-over group, 94.1% in skin stapler group & 93.8% in cyanoacrylate glue group. On logistic regression analysis, keeping all the variables constant in the groups the complications as the outcome variable, three groups are comparable. The need for regrafting remains inconclusive. CONCLUSIONS: Skin stapler method for skin graft fixation was least time consuming, affordable and highly reliable when graft take success was considered. Cyanoacrylate glue fixation method was least painful and reliable in terms of graft take success though costlier than other two.

Impact of burn contractures of chest wall and their surgical release on pulmonary function.

BACKGROUND: Extensive burn scars and contractures are likely to restrict the movements of the chest wall which may affect the pulmonary ventilation by restricting its expansion during inspiration. We designed this study to evaluate the effect of burn contractures of chest wall on pulmonary function and to estimate the effect of contracture release on pulmonary functions in patients with compromised PFT. METHODS: Pulmonary function tests (PFT) of 20 patients having chest wall contractures involving more than 50% of the chest circumference were studied. Restrictive lung disease was defined as forced vital capacity (FVC) value less than 80% of predicted normal for the age, weight, and height of that patient. Patients with a restrictive pattern on PFT were subjected to the surgical release of the contracture. PFT was repeated one month after the surgery which was compared with the initial report. RESULTS: Of the 20 patients included in the study, 5 (25%) patients had a restriction pattern on PFT. 1 patient had a mild restriction, 2 patients had moderate restriction and 2 patients had a severe restriction of pulmonary function. The mean duration of contracture was 58.2±15.75months in patients with a pulmonary restriction as compared to 29.87±6.21months in patients with a normal PFT (p=0.001). All patients having a restrictive pattern on PFT had contracture involvement of >75% of the chest wall circumference (p=0.0036). The mean forced vital capacity (FVC) increased from 1.94L preoperatively to 2.11L after surgical release of the contracture (p=0.047). However, the restriction pattern in PFT did remain. CONCLUSION: Long standing chest wall contractures and contractures involving >75% of the chest circumference are likely to cause a restrictive pattern on PFT. Any significant improvement of pulmonary function after surgical release of the contracture is unlikely.

Premenarchal labia minora hypertrophy.

Labia minora hypertrophy is a relatively uncommon surgical entity being popularised in the realm of vulvovaginal plastic surgeries. Apart from the unaesthetic appearance of the hypertrophied minora, these cases are also associated with itching, hygiene problem, pain while sitting down, sports activities, difficulty in wearing tight clothing, bleeding and discomfort while or after sexual intercourse, social embarrassment, insecurity and psychological diminution of confidence and self-esteem. In a country like India, due to sociocultural reasons, patients hesitate to consult a doctor for such deformities. Most of the patients suffer in silence for years. Although common in the west, very few surgeons in the country perform this simple and rewarding surgery. Here, we are presenting a case of premenarchal juvenile labia minora hypertrophy (JLMH) in an 8-year-old child. Labial hypertrophy in this age group is uncommon. We were unable to find hypertrophy of labia minora in the eight-year-old child on English literature search.

Scald burn, a preventable injury: Analysis of 4306 patients from a major tertiary care center.

BACKGROUND: Scalds have distinct epidemiological and predisposing risk factors amongst all types of burns. Though scald affects all age groups, the brunt falls on the minor age groups. It may result in major physical disabilities and significant loss of school years. Apart from the economic burden on family, major scald burn may compromise overall development of the affected children. Most of the scald injuries occur in domestic settings and are preventable. Despite improvement in living conditions, the incidence of scald burn has failed to decline. Our aim was to study the detailed epidemiology and severity of scald burn amongst all age groups. METHODS: A retrospective study was carried out from the records of all burn patients who attended a tertiary burn care center from January 2013 and December 2014. Data of the patients with scald injury was segregated and analyzed using Microsoft excel spreadsheet. RESULT: 10,175 burn patients attended the burn casualty during the study period, of which 42.3% had sustained scald. 56.85% of patients were under 15 years of age with preschool children (36.4%) being the prime victims of scald. The % TBSA involved is also relatively larger in children. Scald follows definite seasonal variation peaking in winters. 36.8% patients arrived to the hospital without any first aid. 74.2% of patients reported to casualty with in 24hours after sustaining scald injury. The median time interval between injury and reporting to casualty was 3hours 30minutes. CONCLUSION: This study concludes that the scald is injury of all age groups, though majority of them are children. The first aid is not given to large number of patients and late reporting is quite common. These are the factors which may affect the course of scald burn. Spreading public awareness regarding safe household practises and educating them for proper first aid management after scald may have significant impact on the burden of care and outcome.

Cryptic Bacteria of Lower Limb Deep Tissues as a Possible Cause of Inflammatory and Necrotic Changes in Ischemia, Venous Stasis and Varices, and Lymphedema.

BACKGROUND: Infections and inflammation of the lower limb skin, soft tissues, and vessels are more common than in other body regions. The aim was to determine whether cryptic bacteria dwelling in deep tissues are the cause. METHODS: We performed bacteriologic studies of specimens harvested from arteries of amputated ischemic legs, leg varices, and tissue fluid/lymph and lymphatics in lymphedema. RESULTS: Calf arteries contained isolates in 61% and femoral arteries in 36%, whereas normal cadaveric organ donors' arteries in 11%. Bacterial deoxyribonucleic acid (DNA) was detected in 70%. The majority of isolates belonged to the coagulase-negative staphylococci and Staphylococcus aureus; however, highly pathogenic bacteria were also detected. All were sensitive to all antibiotics except penicillin. Saphenous vein varices contained bacterial cells in 40% and controls 4%; bacterial DNA was found in 69%. The majority of bacteria were S. epidermidis and S. aureus susceptible to all antibiotics except penicillin, Lymph and epifascial lymphatics limb contained bacteria in 60% and 33% samples, respectively and controls in 7%. Most were S. epidermidis susceptible to all antibiotics except penicillin. CONCLUSION: Cryptic bacteria are present in lower limb tissues and may play a pathologic role in surgical site infections. Proper antibacterial prophylaxis should be considered when planning surgical interventions.

Bovine Cartilage: A Near Perfect Training Tool for Carving Ear Cartilage Framework.

OBJECTIVE: To develop a training module for carving ear cartilage. SETTING: Designing the ear framework is one of the most challenging surgical steps during ear reconstruction in microtia and acquired deformities of the ear. Trainees do not get an opportunity to carve ear cartilage during their training period. MATERIAL: Ox scapular cartilage was retrieved from a manual slaughterhouse. It was transported in a 4°C ice chamber. This was used as a training material for carving the ear framework. Each scapular cartilage was adequate for two to three ear frameworks. RESULTS: Twenty-two trainees used the bovine cartilage in a wet lab. All had positive feedback on their ear framework carving experience. In their opinion, the consistency, flexibility, and cutting experience almost matched that of human costal cartilage. CONCLUSION: The ox scapular cartilage has been found to be a near perfect material for training and practicing carving of the ear cartilage.

Congenital trilobe tongue associated with cleft palate: a rare anomaly.

Cleft of the palate and congenital anomaly of the tongue is a rare occurrence. A child with the tongue in three segments is being presented for the first time in the literature. This child also had partial cleft palate. The cleft palate was repaired at 7 months of age, and the tongue was reconstructed at 15 months. The tongue reconstruction was done utilizing the three segments of the tongue by an innovative method. This child has been followed up for 6 months with satisfactory results. Congenital abnormalities of the tongue associated with cleft palate may be considered as evidence of close interrelation of embryogenesis of the tongue and palate.

Unfavourable results in hypospadias.

Hypospadias urethroplasty is considered difficult as the complications and unfavourable results are not uncommon. At the turn of the century, due to a better understanding of applied anatomy of hypospadias, new techniques were developed which significantly brought down the complication rate. However unfavourable results are still disturbing. An algorithm for selection of surgery has been presented. Forty three secondary surgeries were performed over 3 years for correction of unfavourable results. The urethrocutaneous fistula was the most common (21%) followed by meatal stenosis (14%) and narrow neourethra (14%). Common unfavourable results have been discussed. On the basis of experience with a large number of hypospadias urethroplasty 'tips to avoid or minimise unfavourable results' have been presented. However, one should assess the final outcome of urethroplasty using hypospadias objective scoring evaluation.

Granular cell ameloblastoma mimicking oncocytoma.

Granular cell ameloblastoma is a variant of ameloblastoma where cells located in the central portion of the follicles have granular eosinophilic cytoplasm and the peripheral cells resemble ameloblasts. A case of granular cell ameloblastoma of the mandible having very similar histopathological features of oncocytoma (oxyphilic adenoma) is reported where tumor cells were arranged in cords, sheets and follicles and their cytoplasm was full of eosinophilic granules.

Pressure ulcers: Back to the basics.

Pressure ulcer in an otherwise sick patient is a matter of concern for the care givers as well as the medical personnel. A lot has been done to understand the disease process. So much so that USA and European countries have established advisory panels in their respective continents. Since the establishment of these organizations, the understanding of the pressure ulcer has improved significantly. The authors feel that the well documented and well publicized definition of pressure ulcer is somewhat lacking in the correct description of the disease process. Hence, a modified definition has been presented. This disease is here to stay. In the process of managing these ulcers the basic pathology needs to be understood well. Pressure ischemia is the main reason behind the occurrence of ulceration. Different extrinsic and intrinsic factors have been described in detail with review of literature. There are a large number of risk factors causing ulceration. The risk assessment scales have eluded the surgical literature and mostly remained in nursing books and websites. These scales have been reproduced for completion of the basics on decubitus ulcer. The classification of the pressure sores has been given in a comparative form to elucidate that most of the classifications are the same except for minor variations. The management of these ulcers is ever evolving but the age old saying of "prevention is better than cure" suits this condition the most.