Benjamin B. Massenburg

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.

Risk Factors for Readmission and Adverse Outcomes in Abdominoplasty.

Background: In an era of outcomes-driven medicine, being able to benchmark complication rates of various procedures is of utmost importance. The rates of readmission, reoperation, and adverse outcomes in abdominoplasty have been previously reported, although risk factors for these adverse outcomes have not been thoroughly elucidated. This study aims to identify specific independent risk factors for readmission and other adverse outcomes of abdominoplasty. Methods: This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program and identified all abdominoplasties performed in 2011 and 2012. Univariate logistic regression analysis was used to identify significant associations between preoperative risk factors and adverse outcomes. Multivariate logistic regression analysis was then used to identify independent risk factors and causes of readmission and other adverse outcomes. Results: Of the 2946 abdominoplasties identified, there were 251 readmissions (8.5 percent), 146 reoperations (5.0 percent), and 574 patients (19.5 percent) who experienced a general complication. The most common adverse outcomes were wound complications in 281 patients (9.5 percent), pulmonary complications in 67 patients (2.3 percent), and thromboembolic complications in 34 patients (1.2 percent). Multivariate regression analysis demonstrated that American Society of Anesthesiologists class above 3, preoperative cardiac comorbidities, pulmonary comorbidities, wounds or wound infections, postoperative thromboembolic complications, wound complications, and having returned to the operating room on the primary admission were independent risk factors for readmission. Conclusions: This study provides the first critical analysis of risk factors for 30-day readmission in abdominoplasty. These risk factors can aid in patient selection, surgical planning, and postoperative allocation of resources for patients undergoing abdominoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The Impact of Resident Participation in Outpatient Plastic Surgical Procedures

IntroductionEnsuring patient safety along with a complete surgical experience for residents is of utmost importance in plastic surgical training. The effect of resident participation on the outcomes of outpatient plastic surgery procedures remains largely unknown. We assess the impact of resident participation on surgical outcomes using a prospective, validated, national database.MethodsWe identified all outpatient procedures performed by plastic surgeons between 2007 and 2012 in the American College of Surgeons National Surgical Quality Improvement Program database. Multivariate regression models assessed the impact of resident participation when compared to attendings alone on 30-day wound complications, overall complications, and return to the operating room (OR).ResultsA total of 18,641 patients were identified: 12,414 patients with an attending alone and 6227 with residents participating. The incidence of overall complications, wound complications, and return to OR was increased with resident participation. When confounding variables were controlled for in multivariate analysis, resident participation was no longer associated with increased risk of wound complications. When stratified by year, incidence of overall complications, wound complications, and return to OR in the resident participation group are trending down and fail to be significantly different in 2011 and 2012. Multivariate analysis shows a similar trend.ConclusionsResident participation is no longer independently associated with increased complications in outpatient plastic surgery in recent years, suggesting that plastic surgical training is successfully continuing to improve in both outcomes and safety. Additional prospective studies that characterize patient outcomes with resident seniority and the degree of resident participation are warranted.Level of Evidence IIThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

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 Brazils 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 Brazils 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 state of the surgical workforce in Brazil

BACKGROUND A critical insufficiency of surgeons, anesthesiologists, and obstetricians exists around the world, leaving billions of people without access to safe operative care. The distribution of the surgical workforce in Brazil, however, is poorly described and rarely assessed. Though the surgical workforce is only one element in the surgical system, this study aimed to map and characterize the distribution of the surgical workforce in Brazil in order to stimulate discussion on future surgical policy reforms. METHODS The distribution of the surgical workforce was extracted from the Brazilian Federal Medical Board registry as of July 2014. Included in the surgical workforce were surgeons, anesthesiologists, and obstetricians. RESULTS There are 95,169 surgeons, anesthesiologists, and obstetricians in the surgical workforce of Brazil, creating a surgical workforce density of 46.55/100,000 population. This varies from 20.21/100,000 population in the North Region up to 60.32/100,000 population in the South Region. A total of 75.2% of the surgical workforce is located in the 100 biggest cities in Brazil, where only 40.4% of the population lives. The average age of a physician in the surgical workforce is 46.6 years. Women make up 30.0% of the surgical workforce, 15.8% of surgeons, 36.6% of anesthesiologists, and 53.8% of obstetricians and gynecologists. CONCLUSION Brazil has a substantial surgical workforce, but inequalities in its distribution are concerning. There is an urgent need for increased surgeons, anesthesiologists, and obstetricians in states like Pará, Amapá, and Maranhão. Female surgeons and anesthesiologists are particularly lacking in the surgical workforce, and incentives to recruit these physicians are necessary. Government policies and leadership from health organizations are required to ensure that the surgical workforce will be more evenly distributed in the future.

Pseudoaneurysm of the internal maxillary artery: A case report of facial trauma and recurrent bleeding

INTRODUCTION Pseudoaneurysms occur when there is a partial disruption in the wall of a blood vessel, causing a hematoma that is either contained by the vessel adventitia or the perivascular soft tissue. PRESENTATION OF CASE A 32-year-old male presented to the emergency department presented with comminuted fractures in the left zygoma, ethmoids, and the right ramus of the mandible following a gunshot wound. The patient underwent open reduction of his fractures and the patient was discharged on the eighth day after the trauma. Thirteen days after the discharge and 21 days after the gunshot wound, the patient returned to the ER due to heavy nasopharyngeal bleeding that compromised the patency of the patients airways and caused hemodynamic instability. Arteriography of the facial blood vessels revealed a pseudoaneurysm of the maxillary artery. Endovascular embolization with a synthetic embolic agent resulted in adequate hemostasis, and nine days after embolization the patient was discharged. DISCUSSION The diagnosis of pseudoaneurysm is suggested by history and physical examination, and confirmed by one of several imaging methods, such as CT scan with contrast. Progressive enlargement of the lesion may lead to several complications, including rupture of the aneurysm and hemorrhage, compression of adjacent nerves, or release of embolic thrombi. CONCLUSION This case reports the long-term follow up and natural history of a patient with a post-traumatic pseudoaneurysm of the internal maxillary artery and the successful use of endovascular embolization to treat the lesion.

Resident Participation: Impact on Plastic Surgical Outcomes.

DISCUSSION: There was a tremendous rise in costs associated with skin adhesive usage in 2014, when compared to 2013. However, much of this increase occurred in the first half of the year, prior to implementation of the cost-reduction educational initiative. Data from the study period suggest that passive education at the point-of-care can shape plastic surgeon preferences. Despite increasing surgical case volume, the stability of Prineo use and relatively smaller growth of Dermabond use during the pilot period suggest that plastic surgeons may be willing to limit overall usage of surgical supplies or choose more cost-effective alternatives when aware of costs. These results also suggest that surgeons are well versed in the indications for surgical supplies, but may lack knowledge of their cost at the institutional and payer levels.

Surgical Treatment of Pediatric Craniofacial Fractures: A National Perspective.

Introduction:Head trauma is the most common cause of death because of injury in children, and trauma alone is the leading cause of morbidity and mortality in pediatrics. This study aimed to characterize the demographics and economic burden associated with the surgical and nonsurgical repair of craniofacial fractures in the pediatric inpatient population in the United States. Methods:A retrospective cohort study was performed using the 2012 Kids’ Inpatient Database which identified 20,070 patients who had a skull or facial fracture, of whom 6395 (31.9%) were treated surgically. Epidemiologic patient and hospital data were analyzed as potential determinants of surgical treatment, prolonged hospitalizations, and higher charges. Results:Pediatric craniofacial fractures are estimated to represent

Magnetic Resonance Imaging in Proximal Venous Outflow Obstruction

1.2 billion of national healthcare expenditures annually. The average patient charge for surgical treatment of a craniofacial fracture in the pediatric population is

A systematic review of quantitative research on traumatic brain injury in India

84,849 compared with