Protecting pregnant women from climate disasters: Strategies in the aftermath of Pakistan's devastating flood

Sudden‐onset climate events can have a significant impact on maternal health care systems, particularly in low‐ and middle‐income countries where resources are limited. We outline strategic policies that can help anticipate and plan for such disasters and help minimize negative maternal outcomes.

Geospatial mapping of surgical systems for earthquake emergency planning in Guerrero, Mexico: an ecological study

Background

Accessibility to surgical services can impact earthquake preparedness and response. We aimed to estimate the population with timely access to surgical care in Guerrero, a Mexican state with high tectonic activity, and identify populations at risk in the event of an earthquake.

Methods

We conducted an ecological study using open government data. We extracted data from Guerrero municipalities regarding their earthquake risk, social vulnerability, social inequality, marginalisation, and resilience indices. The latest combines municipalities' resistance to unexpected events and capacity to maintain optimal functionality without immediate federal or international support. Geographical coordinates of active public and private surgical facilities in Guerrero were combined with ancillary spatial data on roads and municipalities' population density to estimate population coverage within 30-min and 1-h driving time to surgical facilities in Redivis. We built an ordered beta regression model for each driving time estimate.

Findings

We identified 25 public and 16 private facilities capable of providing surgical care in Guerrero. The population with access to facilities with surgical capacity within 30 min and 1-h driving times were 48.4% and 69.1%, respectively. We found that municipalities with very high levels of earthquake risk, social vulnerability, social inequality, and marginalisation, and very low levels of resilience had decreased coverage. In the multivariable analysis, the resilience index was statistically significant only for the 30-min model, with an effect size of 0.524 (95% CI 0.082, 1.089).

Interpretation

Access to surgical care remains unequally distributed in Guerrero municipalities at the highest risk for earthquakes. Municipalities' resilience was the most significant predictor of higher surgical care coverage in 30-min driving time. Our study provides insights on how surgical system strengthening can enhance earthquake emergency disaster planning.

Funding

No funding.

Availability of laparoscopic surgery in Mexico's public health system: a nationwide retrospective analysis

Background

Laparoscopic surgery remains limited in low-resource settings. We aimed to examine its use in Mexico and determine associated factors.

Methods

By querying open-source databases, we conducted a nationwide retrospective analysis of three common surgical procedures (i.e., cholecystectomies, appendectomies, and inguinal hernia repairs) performed in Mexican public hospitals in 2021. Procedures were classified as laparoscopic based on ICD-9 codes. We extracted patient (e.g., insurance status), clinical (e.g., anaesthesia technique), and geographic data (e.g., region) from procedures performed in hospitals and ambulatories. Multivariable analysis with random forest modelling was performed to identify associated factors and their importance in adopting laparoscopic approach.

Findings

We included 97,234 surgical procedures across 676 public hospitals. In total, 16,061 (16.5%) were performed using laparoscopic approaches, which were less common across all procedure categories. The proportion of laparoscopic procedures per 100,000 inhabitants was highest in the northwest (22.2%, 16/72) while the southeast had the lowest (8.3%, 13/155). Significant factors associated with a laparoscopic approach were female sex, number of municipality inhabitants, region, anaesthesia technique, and type of procedure. The number of municipality inhabitants had the highest contribution to the multivariable model.

Interpretation

Laparoscopic procedures were more commonly performed in highly populated, urban, and wealthy northern areas. Access to laparoscopic techniques was mostly influenced by the conditions of the settings where procedures are performed, rather than patients' non-modifiable characteristics. These findings call for tailored interventions to sustainably address equitable access to minimally invasive surgery in Mexico.

Funding

None.

High-resolution gridded population datasets for Latin America and the Caribbean using official statistics

"Leaving no one behind" is the fundamental objective of the 2030 Agenda for Sustainable Development. Latin America and the Caribbean is marked by social inequalities, whilst its total population is projected to increase to almost 760 million by 2050. In this context, contemporary and spatially detailed datasets that accurately capture the distribution of residential population are critical to appropriately inform and support environmental, health, and developmental applications at subnational levels. Existing datasets are under-utilised by governments due to the non-alignment with their own statistics. Therefore, official statistics at the finest level of administrative units available have been implemented to construct an open-access repository of high-resolution gridded population datasets for 40 countries in Latin American and the Caribbean. These datasets are detailed here, alongside the 'top-down' approach and methods to generate and validate them. Population distribution datasets for each country were created at a resolution of 3 arc-seconds (approximately 100 m at the equator), and are all available from the WorldPop Data Repository.

Exploring the distribution of risk factors for drop-out from Ponseti treatment for clubfoot across Bangladesh using geospatial cluster analysis

Clubfoot is a congenital anomaly affecting 1/1,000 live births. Ponseti casting is an effective and affordable treatment. About 75% of affected children have access to Ponseti treatment in Bangladesh, but 20% are at risk of drop-out. We aimed to identify the areas in Bangladesh where patients are at high or low risk for drop-out. This study used a cross-sectional design based on publicly available data. The nationwide clubfoot program: 'Walk for Life' identified five risk factors for drop-out from the Ponseti treatment, specific to the Bangladeshi setting: household poverty, household size, population working in agriculture, educational attainment and travel time to the clinic. We explored the spatial distribution and clustering of these five risk factors. The spatial distribution of children <5 years with clubfoot and the population density differ widely across the different sub-districts of Bangladesh. Analysis of risk factor distribution and cluster analysis showed areas at high risk for dropout in the Northeast and the Southwest, with poverty, educational attainment and working in agriculture as the most prevalent driving risk factor. Across the entire country, twenty-one multivariate high-risk clusters were identified. As the risk factors for drop-out from clubfoot care are not equally distributed across Bangladesh, there is a need in regional prioritization and diversification of treatment and enrolment policies. Local stakeholders and policy makers can identify high-risk areas and allocate resources effectively.

Mauritania’s internal migration dynamics and trends in response to rainfall variability and change1

The northwest African country of Mauritania is a vast, desert territory, which was historically been dominated by pastoral nomads. Since independence in 1960, the country has witnessed a dramatic sedentarization of its nomadic population, as well as settlements in and movements to urban centers. This vast sedentarization movement coupled with internal and interregional migration has resulted in the growth of Mauritania’s urban population from less than 10 percent of the total population in 1965 to nearly 90 percent in 2013. Factors that have caused this rapid urbanization, include the droughts that spanned the late 1960s through to the early 1980s, and the turbulent transformation of Mauritania’s political economy. The aim of this study is to determine and examine internal migration flows to analyze the relationship between long-term rainfall changes and dynamic spatial demographic shifts in terms of movements toward urban centers. In this regard, we propose an assessment approach that integrates official statistics from the decennial census and rainfall data, with available socioeconomic variables, to characterize interregional migration flows. Our result confirms that rates of interregional migration remain elevated and are expected to increase. In 2013, 702,575 individuals were documented as having participated in interregional migration, comprising 17.5 percent of the total population. In comparison, there were 477,814 individuals, which migrated inter-regionally in 2000, and 208,039 in 1988. These results demonstrate distinct interactions between climate variability and interregional migration in Mauritania throughout the past four decades.

The Development and Inclusion of Questions on Surgery in the 2018 Zambia Demographic and Health Survey

Data from household surveys serve as the backbone to sustainable development planning. For the first time, questions on surgery have been included in a nationwide Demographic and Health Survey, showing that it is feasible to integrate these questions into a large-scale survey.

Background:

While primary data on the unmet need for surgery in low- and middle-income countries is lacking, household surveys could provide an entry point to collect such data. We describe the first development and inclusion of questions on surgery in a nationally representative Demographic and Health Survey (DHS) in Zambia.

Method:

Questions regarding surgical conditions were developed through an iterative consultative process and integrated into the rollout of the DHS survey in Zambia in 2018 and administered to a nationwide sample survey of eligible women aged 15–49 years and men aged 15–59 years.

Results:

In total, 7 questions covering 4 themes of service delivery, diagnosed burden of surgical disease, access to care, and quality of care were added. The questions were administered across 12,831 households (13,683 women aged 15–49 years and 12,132 men aged 15–59 years). Results showed that approximately 5% of women and 2% of men had undergone an operation in the past 5 years. Among women, cesarean delivery was the most common surgery; circumcision was the most common procedure among men. In the past 5 years, an estimated 0.61% of the population had been told by a health care worker that they might need surgery, and of this group, 35% had undergone the relevant procedure.

Conclusion:

For the first time, questions on surgery have been included in a nationwide DHS. We have shown that it is feasible to integrate these questions into a large-scale survey to provide insight into surgical needs at a national level. Based on the DHS design and implementation mechanisms, a country interested in including a set of questions like the one included in Zambia, could replicate this data collection in other settings, which provides an opportunity for systematic collection of comparable surgical data, a vital role in surgical health care system strengthening.

Access to paediatric surgery: the geography of inequality in Nigeria

Background

About 96.3 million children and adolescents aged 0–19 years reside in Nigeria, comprising 54% of the population. Without adequate access to surgery for commonly treatable diseases, many face disability and increased risk of mortality. Due to this population’s unique perioperative needs, increasing access to paediatric surgical care requires a situational evaluation of the distribution of paediatric surgeons and anaesthesiologists. This study’s aim is to identify the percentage of Nigerian youth who reside within 2 hours of paediatric surgical care at the state and national level.

Methods

The Association of Paediatric Surgeons of Nigeria and the Nigeria Society of Anaesthetists provided surgical and anaesthesia workforce data by state. Health facilities with paediatric surgeons were converted to point locations and integrated with ancillary geospatial layers and population estimates from 2016 and 2017. Catchment areas of 2 hours of travel time around a facility were deployed as the benchmark indicator to establish timely access.

Results

Across Nigeria’s 36 states and Federal Capital Territory, the percentage of Nigeria’s 0–19 population residing within 2 hours of a health facility with a paediatric surgical and anaesthesia workforce ranges from less than 2% to 22.7%–30.5%. In 3 states, only 2.1%–4.8% of the population can access a facility within 2 hours, 12 have 4.9%–13.8%, and 8 have 13.9%–22.6%.

Conclusion

There is significant variation across Nigerian states regarding access to surgical care, with 69.5%–98% of Nigeria’s 0–19 population lacking access. Developing paediatric surgical services in underserved Nigerian states and investing in the training of paediatric surgical and anaesthesia workforce for those states are key components in improving the health of Nigeria’s 0–19 population and reducing Nigeria’s burden of surgical disease, in line with Nigeria’s National Surgical, Obstetrics, Anaesthesia and Nursing Plan.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

BACKGROUND

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

METHODS AND FINDINGS

The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.

CONCLUSIONS

To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Geospatial mapping of access to timely essential surgery in sub-Saharan Africa

INTRODUCTION

Despite an estimated one-third of the global burden of disease being surgical, only limited estimates of accessibility to surgical treatment in sub-Saharan Africa exist and these remain spatially undefined. Geographical metrics of access to major hospitals were estimated based on travel time. Estimates were then used to assess need for surgery at country level.

METHODS

Major district and regional hospitals were assumed to have capability to perform bellwether procedures. Geographical locations of hospitals in relation to the population in the 47 sub-Saharan countries were combined with spatial ancillary data on roads, elevation, land use or land cover to estimate travel-time metrics of 30 min, 1 hour and 2 hours. Hospital catchment was defined as population residing in areas less than 2 hours of travel time to the next major hospital. Travel-time metrics were combined with fine-scale population maps to define burden of surgery at hospital catchment level.

RESULTS

Overall, the majority of the population (92.5%) in sub-Saharan Africa reside in areas within 2 hours of a major hospital catchment defined based on spatially defined travel times. The burden of surgery in all-age population was 257.8 million to 294.7 million people and was highest in high-population density countries and lowest in sparsely populated or smaller countries. The estimated burden in children <15 years was 115.3 million to 131.8 million and had similar spatial distribution to the all-age pattern.

CONCLUSION

The study provides an assessment of accessibility and burden of surgical disease in sub-Saharan Africa. Yet given the optimistic assumption of adequare surgical capability of major hospitals, the true burden of surgical disease is expected to be much greater. In-depth health facility assessments are needed to define infrastructure, personnel and medicine supply for delivering timely and safe affordable surgery to further inform the analysis.

Safe and sustainable: the extracranial approach toward frontoethmoidal meningoencephalocele repair

OBJECTIVE Although rare, frontoethmoidal meningoencephaloceles continue to pose a challenge to neurosurgeons and plastic reconstructive surgeons. Especially when faced with limited infrastructure and resources, establishing reliable and safe surgical techniques is of paramount importance. The authors present a case series in order to evaluate a previously proposed concise approach for meningoencephalocele repair, with a focus on sustainability of internationally driven surgical efforts. METHODS Between 2001 and 2016, a total of 246 patients with frontoethmoidal meningoencephaloceles were treated using a 1-stage extracranial approach by a single surgeon in the Department of Neurosurgery of the Yangon General Hospital in Yangon, Myanmar, initially assisted by European surgeons. Outcomes and complications were evaluated. RESULTS A total of 246 patients (138 male and 108 female) were treated. Their ages ranged from 75 days to 32 years (median 8 years). The duration of follow-up ranged between 4 weeks and 16 years (median 4 months). Eighteen patients (7.3%) showed signs of increased intracranial pressure postoperatively, and early CSF rhinorrhea was observed in 27 patients (11%), with 5 (2%) of them requiring operative dural repair. In 8 patients, a decompressive lumbar puncture was performed. There were 8 postoperative deaths (3.3%) due to meningitis. In 15 patients (6.1%), recurrent herniation of brain tissue was observed; this herniation led to blindness in 1 case. The remaining patients all showed good to very good aesthetic and functional results. CONCLUSIONS A minimally invasive, purely extracranial approach to frontoethmoidal meningoencephalocele repair may serve well, especially in middle- and low-income countries. This case series points out how the frequently critiqued lack of sustainability in the field of humanitarian surgical missions, as well as the often-cited missing aftercare and dependence on foreign supporters, can be circumvented by meticulous training of local surgeons.

Lip Attractiveness: A Cross-Cultural Analysis

Background

Perception of beauty is influenced by the individual's geographic, ethnic, cultural, and demographic background. However, objective measurements remain the foundation for aesthetic evaluations. In the quest for to better define "ideal" lip characteristics, this study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception.

Objectives

This study will increase surgeons' awareness with respect to different lip size preferences. The provided information might enhance and clarify communication among plastic surgeons and aid to put often quoted "ideal proportions" in context.

Methods

An online survey was designed. Modifiable ranges of lip fullness were achieved via digital alteration, enabling participants to interactively change the shape of a single model's lips. The questionnaire was sent to more than 9000 plastic surgeons and laypeople worldwide. Demographic data were collected and analysis of variance was used to elucidate lip shape preferences.

Results

A total of 1011 responses (14% response rate) from 35 different countries were gathered. Significant differences regarding lip fullness were identified. Surgeons who practice in Asia or non-Caucasian surgeons prefer larger lips, while those in Europe and Caucasians prefer smaller lips. Lastly, laypersons living in Asia prefer the smallest lips.

Conclusions

Country of residence, ethnic background, and profession significantly impact individual lip shape preferences. These findings have implications for patients and surgeons, because differences in aesthetics' preferences can lead to dissatisfaction of patients and surgeons alike. In our increasingly global environment, cultural differences and international variability must be considered when defining new aesthetic techniques, treating patients, and reporting outcomes.

Global aesthetic surgery statistics: a closer look

INTRODUCTION

Obtaining quality global statistics about surgical procedures remains an important yet challenging task. The International Society of Aesthetic Plastic Surgery (ISAPS) reports the total number of surgical and non-surgical procedures performed worldwide on a yearly basis. While providing valuable insight, ISAPS' statistics leave two important factors unaccounted for: (1) the underlying base population, and (2) the number of surgeons performing the procedures.

METHODS

Statistics of the published ISAPS' 'International Survey on Aesthetic/Cosmetic Surgery' were analysed by country, taking into account the underlying national base population according to the official United Nations population estimates. Further, the number of surgeons per country was used to calculate the number of surgeries performed per surgeon.

RESULTS

In 2014, based on ISAPS statistics, national surgical procedures ranked in the following order: 1st USA, 2nd Brazil, 3rd South Korea, 4th Mexico, 5th Japan, 6th Germany, 7th Colombia, and 8th France. When considering the size of the underlying national populations, the demand for surgical procedures per 100,000 people changes the overall ranking substantially. It was also found that the rate of surgical procedures per surgeon shows great variation between the responding countries.

CONCLUSION

While the US and Brazil are often quoted as the countries with the highest demand for plastic surgery, according to the presented analysis, other countries surpass these countries in surgical procedures per capita. While data acquisition and quality should be improved in the future, valuable insight regarding the demand for surgical procedures can be gained by taking specific demographic and geographic factors into consideration.

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.

Plastic Surgery Statistics in the US: Evidence and Implications

BACKGROUND

The American Society of Plastic Surgeons publishes yearly procedural statistics, collected through questionnaires and online via tracking operations and outcomes for plastic surgeons (TOPS). The statistics, disaggregated by U.S. region, leave two important factors unaccounted for: (1) the underlying base population and (2) the number of surgeons performing the procedures. The presented analysis puts the regional distribution of surgeries into perspective and contributes to fulfilling the TOPS legislation objectives.

METHODS

ASPS statistics from 2005 to 2013 were analyzed by geographic region in the U.S. Using population estimates from the 2010 U.S. Census Bureau, procedures were calculated per 100,000 population. Then, based on the ASPS member roster, the rate of surgeries per surgeon by region was calculated and the interaction of these two variables was related to each other.

RESULTS

In 2013, 1668,420 esthetic surgeries were performed in the U.S., resulting in the following ASPS ranking: 1st Mountain/Pacific (Region 5; 502,094 procedures, 30 % share), 2nd New England/Middle Atlantic (Region 1; 319,515, 19 %), 3rd South Atlantic (Region 3; 310,441, 19 %), 4th East/West South Central (Region 4; 274,282, 16 %), and 5th East/West North Central (Region 2; 262,088, 16 %). However, considering underlying populations, distribution and ranking appear to be different, displaying a smaller variance in surgical demand. Further, the number of surgeons and rate of procedures show great regional variation.

CONCLUSIONS

Demand for plastic surgery is influenced by patients' geographic background and varies among U.S. regions. While ASPS data provide important information, additional insight regarding the demand for surgical procedures can be gained by taking certain demographic factors into consideration.

LEVEL OF EVIDENCE V

This journal requires that the 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.

Nutrient emissions from diffuse and point sources into the River Danube and its main tributaries for the period of 1998-2000--results and problems

Nutrient emissions by point and diffuse sources were estimated for 388 sub-catchments of the Danube river basin for the period 1998-2000 by means of the Model MONERIS. For nitrogen total emissions of 684 kt/a N were estimated for the Danube basin. 80% of these emissions were caused by diffuse sources (mainly groundwater, urban areas and tile drainage). For phosphorus the emission was 57 kt/a P, with a contribution of diffuse sources to this sum of 58%. The comparison of calculated and observed loads shows that the mean deviation for the investigated sub-catchments of the Danube river basin is 20% for dissolved inorganic nitrogen and 34% for phosphorus. The spatial resolution of the emission calculations allows the identification of regional hot spots and the derivation of specific regional measures to reduce the emissions into the Danube and consequently into the Western Black Sea.

The role of pre-ischaemic application of the nitric oxide donor spermine/nitric oxide complex in enhancing flap survival in a rat model

Spermine/nitric oxide complex (Sper/NO) is a new nitric oxide (NO) donor with a long half-life providing controlled biological release of NO in vivo. The purpose of this study was to determine whether flap survival could be improved by pre-ischaemic or post-ischaemic intravenous administration of Sper/NO. We divided 37 male Wistar rats into four experimental groups. An extended epigastric adipocutaneous flap was raised in each animal. The mean area of flap necrosis was assessed for all groups on the fifth postoperative day, using planimetry software. The average area of flap necrosis was mean +/- s.d. = 68.2%+/-18.1% in the control group, and 29.7% +/- 13.3% in the non-ischaemic controls. The group with pre-ischaemic application of Sper/NO demonstrated an average flap necrosis of mean+/-s.d. = 11.2%+/-5.9%, whereas this increased to 59.2%+/-14.4% in the group receiving Sper/NO 5 min prior to reperfusion. The group with pre-ischaemic application of Sper/NO showed a significantly lower area of flap necrosis than either of the control groups or the group receiving Sper/NO just prior to reperfusion (P < 0.05). The group receiving Sper/NO just prior to reperfusion demonstrated a significantly higher mean area of flap necrosis than the non-ischaemic controls (P < 0.05), but did not differ significantly from the control group. Our data show that pharmacological preconditioning and enhancement of flap survival can be achieved by intravenous administration of Sper/NO. The application of Sper/NO at the end of the ischaemia period or in the early reperfusion period provides no protection against ischaemia-reperfusion injury.