Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study.

OBJECTIVE: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. METHODS: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. RESULTS: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. CONCLUSION: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

Personality, Success, and Beyond: The Layperson's Perception of Patients With Facial Transplantation.

BACKGROUND: While the goal of facial vascularized composite allotransplantation (FVCA) is to provide patients with improved physical and social function, no study has evaluated layperson perception of social acceptance and perceived career success of patients with FVCA. The purpose of this study was to determine how FVCA changes social acceptance and perceived career success of patients with facial disfiguration. METHODS: Eight hundred fifteen laypersons were surveyed through Mechanical Turk to evaluate their perceptions of patients with FVCA. Respondents were shown facial photographs of patients pre-FVCA, post-FVCA, and matched controls and evaluated these photos on 26 items of perceived social acceptance and career success. Responses were analyzed using descriptive statistics and the Wilcoxon signed-rank test. RESULTS: Both male and female post-FVCA photos were perceived as significantly more socially accepted and professionally successful than their pre-FVCA photos in at least 21 out of 26 items (P < 0.001 for all), but the posttransplant patients scored lower than their control in at least 25 out of 26 items (P < 0.001 for all). Additionally, there were discrepancies in findings based on patient gender. CONCLUSIONS: This study suggests that while FVCA has a significantly positive impact on social acceptance and perceived professional success, it does not fully reinstate these qualities. Furthermore, varying surgical outcomes and/or cognitive biases (such as gender) may impact perceptions of the individual by the public. Our findings suggest a need to standardize practices to better predict and improve outcomes and encourage surgeons to consider patient factors such as gender when planning these procedures.

Surgical capacity assessment in the state of Amazonas using the surgical assessment tool. Cross-sectional study / Avaliação da capacidade cirúrgica do estado do Amazonas utilizando uma ferramenta de avaliação cirúrgica. Estudo transversal

ABSTRACT Objective: Brazil is a country with universal health coverage, yet access to surgery among remote rural populations remains understudied. This study assesses surgical care capacity among hospitals providing care for the rural populations in the Amazonas state of Brazil through in-depth facility assessments. Methods: a stratified randomized cross-sectional evaluation of hospitals that self-report providing surgical care in Amazonas was conducted from July 2016 to March 2017. The Surgical Assessment Tool (SAT) developed by the World Health Organization and the Program in Global Surgery and Social Change at Harvard Medical School was administered at remote hospitals, including a retrospective review of medical records and operative logbooks. Results: 18 hospitals were surveyed. Three hospitals (16.6%) had no operating rooms and 12 (66%) had 1-2 operating rooms. 14 hospitals (77.8%) reported monitoring by pulse oximetry was always present and six hospitals (33%) never have a professional anesthesiologist available. Inhaled general anesthesia was available in 12 hospitals (66.7%), but 77.8% did not have any mechanical ventilation device. An average of 257 procedures per 100,000 were performed. 10 hospitals (55.6%) do not have a specific post-anesthesia care unit. For the regions covered by the 18 hospitals, with a population of 497,492 inhabitants, the average surgeon, anesthetist, obstetric workforce density was 6.4. Conclusion: populations living in rural areas in Brazil face significant disparities in access to surgical care, despite the presence of universal health coverage. Development of a state plan for the implementation of surgery is necessary to ensure access to surgical care for rural populations.

RESUMO Objetivo: o Brasil é um país com cobertura universal de saúde, mas o acesso à cirurgia entre populações remotas permanece pouco estudado. Este estudo avalia a capacidade cirúrgica em hospitais que servem populações rurais no estado do Amazonas, Brasil, por meio de avaliações aprofundadas das instalações. Métodos: foi realizada avaliação estratificada randomizada transversal de hospitais que relataram prestar assistência cirúrgica de julho de 2016 a março de 2017. A Ferramenta de Avaliação Cirúrgica desenvolvida pela Organização Mundial da Saúde e o Programa de Cirurgia Global e Mudança Social da Harvard Medical School foi administrada em hospitais remotos, incluindo uma revisão retrospectiva de registros médicos e livros cirúrgicos. Resultados: 18 hospitais foram pesquisados. Três hospitais (16,6%) não tinham salas cirúrgicas e 12 (66%) tinham 1-2. 14 hospitais (77,8%) relataram que a oximetria de pulso estava "sempre presente" e seis hospitais (33%) nunca têm um anestesiologista disponível. A anestesia inalatória estava disponível em 12 hospitais (66,7%), 77,8% não possuíam dispositivo de ventilação mecânica. Em média, 257 procedimentos por 100.000 foram realizados. 10 hospitais (55,6%) não possuem unidade de recuperação anestésica. Para as regiões de abrangência dos 18 hospitais, com população de 497.492 habitantes, a densidade média de força de trabalho cirúrgica, anestesista e obstétrica foi de 6,4. Conclusão: as populações que vivem em áreas rurais no Brasil enfrentam disparidades significativas no acesso à assistência cirúrgica, apesar da presença de cobertura universal de saúde. O desenvolvimento de um plano estadual de cirurgia é necessário para garantir acesso à assistência cirúrgica às populações rurais.

The Impact of Payment Reform on Pediatric Craniofacial Fracture Care in Maryland.

STUDY DESIGN: Retrospective, quasi-experimental difference-in-differences investigation. OBJECTIVE: Pediatric craniofacial fractures are often associated with substantial morbidity and consumption of healthcare resources. Maryland's All Payer Model (APM) represents a unique case study of the health economics surrounding pediatric craniofacial fractures. The APM implemented global hospital budgets to disincentivize low-value care and encourage preventive, community-based efforts. The objective of this study was to investigate how this reform has impacted pediatric craniofacial fracture care in Maryland. METHODS: Children (≤18 years) receiving inpatient craniofacial fracture-related care in Maryland between January, 2009 through December, 2016 were investigated. New Jersey was used for comparison. Data were abstracted from the Kid's Inpatient Database (Healthcare Cost and Utilization Project). RESULTS: Between 2009-2016, 3,655 pediatric patients received inpatient care for craniofacial fractures in Maryland and New Jersey. Prior to APM implementation, around 20% of Maryland patients received care outside of urban teaching hospitals. After APM implementation, less than 6% of patients received care outside of urban teaching hospitals (p = 0.003). Implementation of the APM in Maryland also resulted in fewer pediatric craniofacial fracture admissions than New Jersey, though this only reached borderline significance (adjusted difference-in-differences estimate: -1.1 fewer admissions, 95% confidence interval: -2.1 to 0.0, p = 0.05). Inpatient costs for pediatric craniofacial care and mean did not change post-APM. CONCLUSIONS: Maryland's APM consolidated pediatric craniofacial fracture inpatient care at urban, teaching hospitals. Inpatient costs and lengths of stay did not change after policy implementation, but overall admission rates decreased. Such considerations are important when considering national expansion of global hospital budgeting.

Public Perceptions of Physician Attire and Professionalism in the US.

Importance: In recent years, casual physician attire (fleece jackets and softshell jackets) has become increasingly popular, but to our knowledge, public perceptions of these garments have not been studied. Furthermore, gender biases may result in differing expectations and perceptions of female and male physicians and may be associated with patient rapport and trust building. Objective: To characterize public perceptions of casual physician attire and implicit gender biases in public assessment of physicians' professional attire. Design, Setting, and Participants: This survey study used a population-based survey administered via Amazon Mechanical Turk from May to June 2020 among individuals aged 18 years or older who were US residents and for whom English was the primary language. Intervention: Survey featuring photographs of a male or female model wearing various types of physician attire (white coat, business attire, and scrubs). Main Outcomes and Measures: Respondents' ratings of professionalism, experience, and friendliness of the male and female models in various attire and perceptions of the models' most likely health care profession. Preference scores for various outfits were calculated as the difference between the preference score for an outfit and the mean preference score for the outfit-role pairing. Results: Of 522 surveys completed, 487 were included for analysis; the mean (SD) age of respondents was 36.2 (12.4) years, 260 (53.4%) were female, and 372 (76.4%) were White individuals. Respondents perceived models of health care professionals wearing white coats vs those wearing fleece or softshell jackets as significantly more experienced (mean [SD] experience score: white coat, 4.9 [1.5]; fleece, 3.1 [1.5]; softshell, 3.1 [1.5]; P < .001) and professional (mean [SD] professionalism score: white coat, 4.9 [1.6]; fleece, 3.2 [1.5]; softshell, 3.3 [1.5]; P < .001). A white coat with scrubs attire was most preferred for surgeons (mean [SD] preference index: 1.3 [2.3]), whereas a white coat with business attire was preferred for family physicians and dermatologists (mean [SD] preference indexes, 1.6 [2.3] and 1.2 [2.3], respectively; P < .001). Regardless of outerwear, female models in business attire as inner wear were rated as less professional than male counterparts (mean [SD] professionalism score: male, 65.8 [25.4]; female, 56.2 [20.2]; P < .001). Both the male and the female model were identified by the greater number of respondents as a physician or surgeon; however, the female model vs the male model was mistaken by more respondents as a medical technician (39 [8.0] vs 16 [3.3%]; P < .005), physician assistant (56 [11.5%] vs 11 [2.3%]; P < .001), or nurse (161 [33.1%] vs 133 [27.3%]; P = .050). Conclusions and Relevance: In this survey study, survey respondents rated physicians wearing casual attire as less professional and experienced than those wearing a white coat. Gender biases were found in impressions of professionalism, with female physicians' roles being more frequently misidentified. Understanding disparate public perceptions of physician apparel may inform interventions to address professional role confusion and cumulative career disadvantages for women in medicine.

Safety of Irradiated Homologous Costal Cartilage Graft in Cleft Rhinoplasty.

BACKGROUND: Autologous cartilage grafts have a low risk of infection and extrusion in cleft rhinoplasty. However, harvesting autologous cartilage involves donor-site morbidity and increased time under anesthesia. Irradiated homologous costal cartilage grafts may be an effective alternative. METHODS: A retrospective study was performed on patients with a history of cleft lip who underwent rhinoplasty for cleft nasal deformity at Johns Hopkins Hospital from 2009 to 2018. Patients were excluded if their rhinoplasty did not involve a cartilage graft. RESULTS: One hundred sixty-five cleft rhinoplasties (patient age, 2 to 72 years; 52 percent female) were performed. Median follow-up time was 256 days; 30 percent were revision operations. Ninety-six procedures (58 percent) used irradiated homologous costal cartilage grafts, with the remaining using autologous cartilage. Complications resulted from 18 procedures (11 percent), seven (10 percent) involving autologous cartilage and 11 (12 percent) involving irradiated homologous costal cartilage. Most autologous cartilage complications (86 percent) required operative intervention, versus seven of 11 (64 percent) for irradiated homologous costal cartilage. Complications associated with irradiated homologous costal cartilage included infection (n = 5), warping (n = 2), and extrusion (n = 1), while two patients with autologous cartilage experienced collapse and one each experienced resorption, warping, and hypertrophic donor-site scarring. There was no difference between groups regarding complication rate or complications requiring operative intervention (p = 0.3 and p = 0.5, respectively). CONCLUSIONS: Irradiated homologous costal cartilage grafts are equally safe and effective as autologous cartilage for use in cleft rhinoplasty. These grafts are readily available and eliminate donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

National Trends in Pediatric Facial Fractures: The Impact of Health Care Policy.

BACKGROUND: Traumatic injuries are significant sources of morbidity and mortality in the pediatric population. Using a national database, this study aims to characterize pediatric facial fracture management and the effect of health care policy changes on populations receiving treatment. METHODS: A retrospective cohort study was performed using Healthcare Cost and Utilization Project Kids' Inpatient Database databases from 2000 to 2016. Pediatric patients admitted with a facial fracture diagnosis were included. Clinical outcomes include mortality, reduction of fracture during hospital stay, and open fracture reduction. The impact of the Affordable Care Act on patient demographics and management was assessed. RESULTS: Between 2000 and 2016, 82,414 patients were managed for facial fractures, 8.3 percent of whom were managed after implementation of the Affordable Care Act (n = 6841). Mean age was 15.2 years, and the male-to-female ratio was 2.9:1. Significant racial disparities were identified before the Affordable Care Act: African American and Native American patients had decreased odds of having facial fracture reduction during the initial hospital stay (OR, 0.84 and 0.86, respectively), and identifying as either Hispanic or Native American was associated with higher odds of mortality (OR, 1.4 or 2.4, respectively). Race was not contributory to patient mortality after the Affordable Care Act. Before Affordable Care Act implementation, patients receiving care with no charge (including charity care/charity research) had lower odds of having an open reduction or any reduction; insurance status was not contributory to management after the Affordable Care Act. CONCLUSION: Although the Affordable Care Act may have increased access to care for certain populations, race- and sex-associated differences in mortality rate and fracture management should be further investigated to ensure a national standard of equitable patient care.

Data-Driven Insights on the Effects of COVID-19 on Public Interest in Medical Aesthetics: Part II (Active Analysis).

BACKGROUND: The COVID-19 pandemic significantly affected financial and psychosocial factors that influence plastic surgery demand. OBJECTIVES: The authors sought to actively assess public interest changes and the reasons underlying these shifts. METHODS: Using Amazons' Mechanical Turk, we crowdsourced public opinions regarding aesthetic interventions from April 30 to May 3, 2020. The survey assessed prior experience with and interest in 6 aesthetic interventions before and during the pandemic and reasons for changing interest. United States residents aged 18 years and over who passed the attention check were included. RESULTS: We included 704 of 838 total responses. One-half of respondents were female; the median age group was 25 to 34 years. During the pandemic, 21% of respondents had increased and 33% decreased interest in at least one intervention. Non-invasive procedures (7.3%), facial aesthetic surgery (6.6%), and medical-grade skincare (5.9%) elicited the greatest interest increase. Seeing themselves in the mirror more often (43.2%), desire to look better after the crisis (41.8%), and increased time on social media (40.4%) were the top reasons for increased interest. The most common reasons for decreased interest were changing spending priorities (58%), focusing on other health aspects (49.8%), and worrying about infection in medical facilities (46.3%). Almost one-half of respondents considered virtual consultations for interventions of increased interest. CONCLUSIONS: The COVID-19 pandemic significantly affected interest in medical aesthetics. Offering telemedicine and discussing detailed COVID-19 infection control policies with patients will be critical to address patient needs and concerns. These findings can be used to improve patient outreach, advertisement, and counseling as practices focus on reopening.

Efficacy of Facilitated Capacity Building in Providing Cleft Lip and Palate Care in Low- and Middle-Income Countries.

Providing surgical repair for congenital anomalies such as cleft lip and palate (CLP) can be challenging in low- and middle-income countries. One nonprofit organization seeks to address this need through a partnership model. This model provides long-term aid on multiple levels: surgeon and healthcare provider education, community outreach, and funding. The authors examined the effectiveness of this partnership model in providing CLP care and increasing cleft care capacity over time. This organization maintains data on each partner and procedure and collected data on hospital and patient characteristics through voluntary partner surveys from 2010 to 2014. Effectiveness of care provision outcomes included number of surgeries/partner hospital and patient demographics. Cleft surgical system strengthening was measured by the complexity of repair, waitlist length, and patient follow-up. From 2001 to 2014, the number of procedures/hospital/year grew from 15 to 109, and frequency of alveolar bone grafts increased from 1% to 3.4%. In addition, 97.9% of partners reported that half to most patients come from rural areas. Waitlists decreased, with 9.2% of partners reporting a waitlist of ≥50 in 2011 versus 2.7% in 2014 (P < 0.001). Patient follow-up also improved: 35% of partners in 2011 estimated a follow-up rate of ≥75%, compared with 51% of partners in 2014 (P < 0.001). The increased number of procedures/hospital/year supports the partnership model's effectiveness in providing CLP care. In addition, data supports cleft surgical system strengthening-more repairs use alveolar bone grafts, waitlists decreased, and follow-up improved. These findings demonstrate that the partnership model may be effective in providing cleft care and increasing cleft surgical capacity.

Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study.

BACKGROUND: Brazil boasts a health scheme that aspires to provide universal coverage, but its surgical system has rarely been analysed. In an effort to strengthen surgical systems worldwide, the Lancet Commission on Global Surgery proposed a collection of 6 standardised indicators: 2-hour access to surgery, surgical workforce density, surgical volume, perioperative mortality rate (POMR) and protection against impoverishing and catastrophic expenditure. This study aims to characterise the Brazilian surgical health system with these newly devised indicators while gaining understanding on the complexity of the indicators themselves. METHODS: Using Brazil's national healthcare database, commonly reported healthcare variables were used to calculate or simulate the 6 surgical indicators. Access to surgery was calculated using hospital locations, surgical workforce density was calculated using locations of surgeons, anaesthesiologists and obstetricians (SAO), and surgical volume and POMR were identified with surgical procedure codes. The rates of protection against impoverishing and catastrophic expenditure were modelled using cost of surgical inpatient hospitalisations and a γ distribution of incomes based on Gini and gross domestic product/capita. FINDINGS: In 2014, SAO density was 34.7/100 000 population, surgical volume was 4433 procedures/100 000 people and POMR was 1.71%. 79.4% of surgical patients were protected against impoverishing expenditure and 84.6% were protected against catastrophic expenditure due to surgery each year. 2-hour access to surgery was not able to be calculated from national health data, but a proxy measure suggested that 97.2% of the population has 2-hour access to a hospital that may be able to provide surgery. Geographic disparities were seen in all indicators. INTERPRETATION: Brazil's public surgical system meets several key benchmarks. Geographic disparities, however, are substantial and raise concerns of equity. Policies should focus on stimulating appropriate geographic allocation of the surgical workforce and better distribution of surgical volume. In some cases, where benchmarks for each indicator are met, supplemental analysis can further inform our understanding of health systems. This measured and systematic evaluation should be encouraged for all nations seeking to better understand their surgical systems.

The Association of Accessory Auricular Tissue With Solid Organ Abnormalities and Its Effect on Auditory and Vestibular Function.

BACKGROUND: Accessory auricular tissue is a common congenital anomaly ranging from an accessory skin appendage to a separate pinna. The association between auditory or vestibular dysfunction and accessory auricular tissue is debated, and little is known about related solid organ abnormalities. We examine the prevalence of accessory auricular tissue, its association between solid organ abnormalities and auditory/vestibular dysfunction, and its management. METHODS: A retrospective cohort study was performed using the 2000 to 2012 HCUP kids' inpatient database. Live newborns with a diagnosis of accessory auricle were included. RESULTS: Of the 19,638,453 births recorded between 2000 and 2012, 0.13% had accessory auricular tissue (n = 25,802); 11.8% underwent excision or destruction of the tissue during birth admission. Newborns with this diagnosis were more likely to receive auditory and vestibular testing (5% vs 4.2%, P < 0.001; 5.5% vs 5%, P < 0.001) and to be diagnosed with abnormal auditory function (1.2% vs 0.5%, P < 0.001) and hearing loss (0.09% vs 0.02%, P < 0.001). Diagnosis of auditory impairment had a 3-fold higher odds of surgical management during birth stay (odds ratio, 3.12; 95% confidence interval, 1.826-5.339). Although none were diagnosed with vestibular dysfunction, patients with accessory auricular tissue were 1.5-fold to 3-fold more likely to have cardiac malformations and 4-fold more likely to have renal anomalies. CONCLUSIONS: Newborns with accessory auricular tissue more frequently undergo auditory and vestibular testing during birth stay. Auditory dysfunction, cardiac malformations, and renal anomalies are more frequently diagnosed in patients with accessory auricular tissue. However, none were diagnosed with vestibular impairment, bringing into question the necessity of vestibular testing.

Neonatal Micrognathia: National Trends in Early Mandibular Surgery.

BACKGROUND: Micrognathia is a congenital anomaly that may pose breathing and feeding limitations in newborns, sometimes necessitating invasive management. The present study aims to identify the complications associated with receiving mandibular surgery during the birth stay in order to better predict which patients may benefit from early surgical intervention. METHODS: A retrospective cohort study was performed using the 2000 to 2012 kids' inpatient databases. We included all live newborn infants born in the hospital through vaginal delivery or caesarean section. We used multivariate logistic regression to investigate the demographic and clinical factors associated with receiving mandibular surgery for micrognathia during the birth stay. RESULTS: Of 19,638,453 births, 999 were diagnosed with micrognathia (0.005%). Forty (4%) patients with micrognathia underwent mandibular surgery during the initial admission. On univariate analysis in newborns with micrognathia, mandibular surgery during birth stay was associated with cleft palate, apnea, intubation, tracheostomy, obstructive sleep apnea (OSA), and long mechanical ventilation. Multivariate analysis supported the association between mandibular surgery during the initial admission and long mechanical ventilation (odds ratio [OR], 24.6; 95% confidence interval [CI], 7.7-78.5), OSA (OR, 24.9; 95% CI, 2.5-261.8), apnea (OR, 4.2; 95% CI, 1.5-11.3), and cleft palate (OR, 4.6; 95% CI, 2.0-10.6). However, intubation and tracheostomy were not found to be associated with early mandibular surgery during the birth stay. CONCLUSIONS: The present study identified long mechanical ventilation, apnea, cleft palate, and OSA as factors indicating patients who may benefit from early mandibular surgery, such as mandibular distraction osteogenesis. These findings may bring the clinician closer to standardizing the indications for early mandibular distraction osteogenesis.

Access to safe blood in low-income and middle-income countries: lessons from India.

Timely, affordable access to screened blood is essential to the provision of safe surgical care and depends on three key aspects: adequate volume of blood supply, safe protocols for blood donation and transfusion, and appropriate regulation to ensure safe, equitable and sustainable distribution. Many low-income and middle-income countries experience a deficit in these categories, particularly in rural areas. We draw on the experience of rural surgical practitioners in India and summarise the existing literature to evaluate India's blood banking system and discuss its major barriers to the safe and equitable provision of blood. Many low-income and middle-income countries struggle with accruing a sufficient voluntary, unpaid blood donation base to meet the need. Efforts to increase blood supply through mandatory family replacement donations can lead to dangerous delays in care provision. Additionally, prohibition of unbanked, directed blood transfusion restricts the options of health practitioners, particularly in rural areas. Blood safety is also a significant concern, and efforts must be taken to decrease the risk of transfusion-transmitted infections and inform and treat donors who test positive. Lastly, blood banking systems need a centralised governing body to ensure fair prices for blood, promote comprehensive transfusion reporting and increase system-wide transparency and accountability.

Barriers to Cleft Lip and Palate Repair Around the World.

BACKGROUND: Cleft lip and/or palate (CLP) is estimated to occur in 1 out of every 700 births, but for many people residing in low- and middle-income countries this deformity may be repaired late in life or not at all. This study aims to analyze worldwide provider-perceived barriers to the surgical repair of CLP in low- and middle-income countries. METHODS: From 2011 to 2014, Smile Train distributed a multiple-choice, voluntary survey to healthcare providers to identify areas of need in CLP care worldwide. Data on provider-reported barriers to care were aggregated by year, country, and larger world regions. RESULTS: A total of 1997 surveys were completed by surgeons and healthcare providers (60.7% response rate). The most commonly reported barriers were "patient travel costs" (60.7%), "lack of patient awareness" (54.1%), and "lack of financial support" (52.8%). "Patient travel costs" was the most commonly reported barrier in sub-Saharan Africa, the Middle East and North Africa, and South and Southeast Asia. "Lack of financial support" was the most commonly reported barrier in the Americas, Eastern Europe, and East Asia. CONCLUSIONS: This is the largest intercontinental study on healthcare provider-identified barriers to care, representing the limitations experienced by healthcare professionals in providing corrective surgery for CLP around the world. Financial risk protection from hidden costs, such as patient travel costs, is essential. Community health workers and nurses are critical for communication and linking CLP care to the rest of the community. Recognition of these barriers can inform future policy decisions, targeted by region, for surgical systems delivering care for patients with CLP worldwide.

The Role of Plastic Surgeons in Advancing Development Global.

In September 2015, the international community came together to agree on the 2030 Agenda for Sustainable Development, a plan of action for people, the planet, and prosperity. Ambitious and far-reaching as they are, they are built on three keystones: the elimination of extreme poverty, fighting climate change, and a commitment to fighting injustice and inequality. Critical to the achievement of the Agenda is the global realization of access to safe, affordable surgical and anesthesia care when needed. The landmark report by the Lancet Commission on Global Surgery estimated that between 28 and 32 percent of the global burden of disease is amenable to surgical treatment. However, as many as five billion people lack access to safe, timely, and affordable surgical care, a burden felt most severely in low- and middle-income countries (LMICs). Surgery, and specifically plastic surgery, should be incorporated into the international development and humanitarian agenda. As a community of care providers dedicated to the restoration of the form and function of the human body, plastics surgeons have a collective opportunity to contribute to global development, making the world more equitable and helping to reduce extreme poverty. As surgical disease comprises a significant burden of disease and surgery can be delivered in a cost-effective manner, surgery must be considered a public health priority.

Laparoscopic antrectomy: a safe and definitive treatment in managing type 1 gastric carcinoids.

BACKGROUND: Treatment for type 1 gastric carcinoid (T1GC) includes esophagogastroduodenoscopy (EGD), polypectomy, and antrectomy, but few studies compare outcomes. This study assessed risk-benefit ratio to determine the most effective treatment for T1GC. METHODS: A retrospective review of 52 T1GC patients (ages 30 to 88 years; 77% female) presenting to Mount Sinai Medical Center between 2004 and 2012 was conducted. Patient demographics, procedures, and outcomes were reviewed, and patient satisfaction was assessed using a phone-administered validated questionnaire. Data were analyzed using SPSS version 20 software. RESULTS: Average EGDs needed per follow-up year was significantly lower for antrectomy than polypectomy or EGD surveillance (.395 vs 1.038 vs 1.380, P = .002). Antrectomy patients exhibited decreased recurrence risk than polypectomy patients (11% vs 44%, P = .049), despite longer follow-up time (6.10 vs 4.39 years, P = .023). CONCLUSIONS: Antrectomy treats T1GC with lower recurrence risk and less postintervention monitoring, whereas allowing patients to avoid the discomfort of repeated EGD surveillance and anxiety over a lingering condition.