The Use of E-Learning in Peyton's 4-Step Approach: Evaluation of Facial Computed Tomography Scans.

Imparting procedural skills is challenging. Peyton's approach is an effective face-to-face teaching technique increasingly used in complex skills training. Institutions are beginning to incorporate online training as part of their procedural curriculum. We developed E-Peyton's to employ Peyton's approach through an electronic learning platform. The efficacy of E-Peyton's approach in teaching the interpretation of facial computed tomography (CT) scans is evaluated in this study. Naïve learners (n=41) were randomized into 2 groups based on teaching techniques employed: E-Peyton's (n=20) and Peyton's (n=21) approaches. The distance between the infraorbital margin and the posterior ledge was measured using a 3-part standardized measuring protocol on OsiriX. Twenty measurements were assessed for accuracy against the benchmark (±2 mm) at week 0 and week 1. Training durations were compared. Questionnaires were administered before and after the study to identify learners' acceptance of teaching techniques and their confidence in interpreting facial CT scans. Learners in both teaching techniques had comparable skills retention. Gap scores indicate significant improvement in learner's confidence levels regardless of teaching technique (P<0.05). Both teaching techniques were well-accepted by learners. E-Peyton's and Peyton's approaches required a similar training duration. The COVID-19 pandemic highlights the importance of effective remote learning platforms. E-Peyton's approach is comparable to that of Peyton's in all areas of assessment. E-Peyton's approach effectively automates Peyton's approach, allowing for standardized, high-quality procedural skills training while reducing manpower burden.

Planes of Reference for Orbital Fractures: A Technique for Reproducible Measurements of the Orbit on Computed Tomography Scans.

PURPOSE: Planes of reference for orbital fractures (PROF) was developed to standardize measurements made on orbital computed tomography scans. This study describes the use of PROF in determining the location along the orbital floor where the posterior ledge (PL) most commonly occurs. The transverse inclination and anterior-posterior inclination of the orbital floor will also be measured. METHODS: This study evaluates 104 patients with unilateral orbital fracture. Fifty-two patients had intact infra-orbital margin (IM) and 52 had fractured IM. Facial computed tomography scans were analyzed using Osirix Lite Digital Imaging and Communications in Medicine Viewer version 7.0.1 (Geneva, Switzerland). All skull positions were standardized by orientation according to Frankfurt and mid-sagittal planes. Measurements of distance of PL from IM were determined in the sagittal view. Measurements of the inclination of the orbital floor in the transverse and anterior-posterior sections were done on the coronal and sagittal views respectively. RESULTS: For patients with intact and fractured IM, the mean distances of PL from IM were 22.1 mm (95% CI: 21.2-23.0) and 21.1 mm (95% CI: 20.2-21.9) respectively. Mean transverse inclination was 19.4° (95% CI: 18.3-20.5). Mean anterior-posterior inclination was 15.5° (95% CI: 14.5-16.5). CONCLUSION: Planes of reference for orbital fractures is a simple and effective method to acquire standardized measurements of the orbital cavity on computed tomography scans. Understanding the commonest location of PL and the orientation of the orbital floor in 3-dimensional space allows surgeons to perform dissection with greater precision.

Pen Torch Transillumination: Difficult Venepuncture Made Easy.

INTRODUCTION: Our novel technique of pen torch transillumination (PTI) uses a cheap and easily available instrument (Penlite-LP212®, Energizer®, Missouri, USA) to visualize superficial veins invisible to the naked eye. We evaluate the efficacy of PTI in improving venepuncture success rate (SR) for patients with poor venous access. METHODS: This prospective randomized controlled trial looked at adult patients (n = 69) aged 21-90 with difficult venous access (history of ≥3 consecutive attempts required for successful cannulation during the current admission) requiring non-emergent venepuncture. Patients underwent venepuncture over the upper-limb using one of the following: conventional venepuncture (control); Veinlite® EMS (TransLite®, Texas, USA), a commercial transillumination device; PTI. Outcome measures were: successful cannulation within 2 attempts and total duration of venepuncture. Fisher's exact and Kruskal-Wallis tests were performed. RESULTS: A significantly larger number of patients had successful venepuncture within 2 attempts using PTI (22/23, 95.7%) and Veinlite (23/23, 100%), compared to the controls (7/23, 30.4%) (p < 0.05). The total duration required for successful venepuncture was significantly shorter for Veinlite (mean 3.7 min, 1.0-5.3 min) and PTI (mean 8.5 min, range 1.08-27 min) compared to the controls (mean 23.2 min, range 1.88-46.5 min) (p < 0.05). CONCLUSIONS: PTI allows users to visualize veins invisible to the naked eye. Thrombosed/tortuous veins, branch points and valves, are easily identified and avoided. It has comparable efficacy to Veinlite® and is cheaper (Veinlite®-USD 227 vs. Penlite-LP212®-USD 7.00) and more easily available. PTI improves patient care, especially in developing regions where costs are a concern.

Straight-segment mandibulectomy: a reproducible porcine mandibular critical-size defect model.

Porcine mandibular defect models are commonly used for the preclinical evaluation of reconstruction techniques. Existing studies vary in technique, complexity, and postoperative outcomes. The procedures are complex and often described without sufficient detail. We describe in detail a simple and reproducible method for creating a critical-size mandibular defect in a porcine model. Seven hemimandibular critical size defects were created in five male Yorkshire-Landrace pigs, three with unilateral defects and two with bilateral defects. A transverse incision was made over the mandibular body. Periosteum was incised and elevated to expose the mandibular body and a critical-size defect of 30 × 20 mm created using an oscillating saw. The implant was inserted and fixed with a titanium reconstruction plate and bicortical locking screws, and the wound closed in layers with resorbable sutures. Intraoral contamination was avoided. Dentition was retained and the mental nerve and its branches preserved. The marginal mandibular nerve was not encountered during dissection. All pigs retained normal masticatory function, and there were no cases of infection, wound breakdown, haematoma, salivary leak, or implant-related complications. The procedure can be performed bilaterally on both hemimandibles without affecting load-bearing function. All pigs survived until the end point of three months. Postoperative computed tomographic scans and histology showed new bone formation, and a three-point bend test showed the restoration of biomechanical strength. Straight-segment mandibulectomy is a simple and reproducible method for the creation of critical-size mandibular defects in a porcine model, simulating a load-bearing situation.

Computer-assisted navigational surgery improves outcomes in orbital reconstructive surgery.

Orbital reconstruction is a difficult procedure, success of which is dependent on the surgeon's experience. The lack of objective methods requires a fair amount of estimation is its execution. This study evaluates the efficacy of Kolibri (BrainLab, Munich, Germany), an intraoperative navigation device, in improving outcomes. From 2004 to 2009, 58 patients with orbital trauma who underwent surgery at the National University Hospital, Singapore, were included in this prospective matched control trial. Twenty-nine consecutive patients underwent surgery with Kolibri. The control group underwent surgery without the device. Both groups were matched for age, sex, orbital wall fracture, preoperative ophthalmologic features, etiology and severity of trauma, surgical approach, and types of implant used. The postoperative follow-up was at 1, 3, 6, and 12 months. For subjective assessment, the postoperative ophthalmologic features, including diplopia, infraorbital hypoesthesia, ophthalmoplegia, and enophthalmos, were compared. At 1, 3, 6, and 12 months, respectively, there were fewer patients with postoperative ophthalmologic complications in the study group (italicized; n = 29) compared with the control group (n = 29; P < 0.05): 12/29 (41%) versus 21/29 (72%), 8/29 (28%) versus 19/29 (66%), 5/29 (17%) versus 15/29 (52%), and 2/29 (7%) versus 12/29 (41%). For objective assessment, using the Kolibri workstation, operative plans were created and fused with postoperative computed tomographic scans. Vertical distances between the actual reconstructed and planned orbital floors were measured. On average, the vertical distance measured from the boundaries of floor defects for patients in the study group was 3.24 mm (95% confidence interval, 1.56-4.91) lower than the control group (P = 0.001). In conclusion, navigation minimizes postoperative complications, reduces the need for repeat procedures, and helps surgeons with planning, execution, and postoperative assessment.

Prophylactic Intraoperative Nasolacrimal Duct Intubation in Surgical Treatment of Facial Fractures-Is There a Role?

Nasolacrimal duct (NLD) damage is associated in the majority of type II and III naso-orbito-ethmoid (NOE) fractures. 1 Our study aims to investigate the efficacy and safety of prophylactic NLD intubation in the setting of facial fractures, by comparing incidence of postoperative epiphora and wound infection. A retrospective matched control study was conducted on all patients with surgically treated facial fractures from 2008 to 2013 ( n = 280) (IRB ref number: DSRB 2013/01198). Patients with the following fracture types were included: NOE ( n = 16), frontal sinus ( n = 2), Le Fort II/III ( n = 8), and > 1 type ( n = 48). All patients in this study were included with the intention to treat. The study group comprised patients who were intubated, while the control group patients were not intubated. Each group had 37 patients matched for age, gender, fracture type, and injury type. A single oculoplastic surgeon skilled in lacrimal surgery performed the procedure for all intubated patients. Patients with more severe and complex facial fractures were intubated with bicanalicular Crawford stents. Postoperative epiphora and infective complications (both facial wound and dacryocystitis) were assessed at 1, 3, 6, and 12 months. There was no significant difference in incidence of either postoperative epiphora ( p = 0.152) or wound infection ( p = 0.556) comparing both groups. Reduced incidence of postoperative epiphora in the study group is statistically not significant and does not support the need for prophylactic intubation. If radiographic evidence of NLD disruption or regurgitation seen on syringing on the NLD intraoperatively is present, intubation is safe and efficacious only if performed by an expert.

Dermointegration in the exposed titanium cranioplasty: a possible protective phenomenon.

Implant exposure is a known complication of titanium mesh cranioplasty and is usually managed by implant removal and/or exchange. We describe a case of exposed titanium mesh cranioplasty which was managed with implant exchange and bipedicled flap coverage, and showcase an interesting phenomenon of full-thickness skin present beneath the exposed mesh. This was confirmed on histopathology, which showed the presence of dermal appendages including pilosebaceous units and eccrine glands. We postulate that the mechanism behind this phenomenon involves islands of viable skin 'dropping' between holes in the mesh and coalescing beneath the exposed implant, as suggested by histopathology findings of nodular protrusions and varying degrees of epidermal hyperplasia. This protects the underlying dura from external infection. We propose for this phenomenon to be called dermointegration. Our findings suggest that similar cases, particularly patients who are not fit for general anaesthesia, may potentially be managed with a more conservative approach.

Tuberculosis care: enhancing directly observed therapy in a peri-urban, low socioeconomic status neighbourhood.

Tuberculosis (TB) is a major health issue in the Philippines. TB-Care was introduced in 2011 to tackle pulmonary TB among the urban poor in Payatas, Quezon City, Philippines. We evaluated the efficacy of TB-Care in increasing treatment success and compliance rates. This retrospective case series reviewed 44 patients with pulmonary TB enrolled in TB-Care from 2013 to 2014. Diagnosis and treatment of pulmonary TB was made in accordance with World Health Organization guidelines. Treatment outcomes included cure, completed treatment, successfully treated, failed treatment and transferred to another facility. 14 (73.7%) out of 19 patients tested were bacteriologically cured. The average 100% compliance rate was 90.8% over six months. The programme successfully treated 39 (88.6%) patients. This was comparable to the overall national treatment success rate of 90% for Philippines and 79% for Singapore, with higher compliance rates than were previously reported in this community.

Bio-conjugated polycaprolactone membranes: a novel wound dressing.

BACKGROUND: The combination of polycaprolactone and hyaluronic acid creates an ideal environment for wound healing. Hyaluronic acid maintains a moist wound environment and accelerates the in-growth of granulation tissue. Polycaprolactone has excellent mechanical strength, limits inflammation and is biocompatible. This study evaluates the safety and efficacy of bio-conjugated polycaprolactone membranes (BPM) as a wound dressing. METHODS: 16 New Zealand white rabbits were sedated and local anaesthesia was administered. Two 3.0×3.0 cm full-thickness wounds were created on the dorsum of each rabbit, between the lowest rib and the pelvic bone. The wounds were dressed with either BPM (n=12) or Mepitel (n=12) (control), a polyamide-silicon wound dressing. These were evaluated macroscopically on the 7th, 14th, 21st, and 28th postoperative days for granulation, re-epithelialization, infection, and wound size, and histologically for epidermal and dermal regeneration. RESULTS: Both groups showed a comparable extent of granulation and re-epithelialization. No signs of infection were observed. There was no significant difference (P>0.05) in wound size between the two groups. BPM (n=6): 8.33 cm(2), 4.90 cm(2), 3.12 cm(2), 1.84 cm(2); Mepitel (n=6): 10.29 cm(2), 5.53 cm(2), 3.63 cm(2), 2.02 cm(2); at the 7th, 14th, 21st, and 28th postoperative days. The extents of epidermal and dermal regeneration were comparable between the two groups. CONCLUSIONS: BPM is comparable to Mepitel as a safe and efficacious wound dressing.

Creation of consistent burn wounds: a rat model.

BACKGROUND: Burn infliction techniques are poorly described in rat models. An accurate study can only be achieved with wounds that are uniform in size and depth. We describe a simple reproducible method for creating consistent burn wounds in rats. METHODS: Ten male Sprague-Dawley rats were anesthetized and dorsum shaved. A 100 g cylindrical stainless-steel rod (1 cm diameter) was heated to 100℃ in boiling water. Temperature was monitored using a thermocouple. We performed two consecutive toe-pinch tests on different limbs to assess the depth of sedation. Burn infliction was limited to the loin. The skin was pulled upwards, away from the underlying viscera, creating a flat surface. The rod rested on its own weight for 5, 10, and 20 seconds at three different sites on each rat. Wounds were evaluated for size, morphology and depth. RESULTS: Average wound size was 0.9957 cm(2) (standard deviation [SD] 0.1845) (n=30). Wounds created with duration of 5 seconds were pale, with an indistinct margin of erythema. Wounds of 10 and 20 seconds were well-defined, uniformly brown with a rim of erythema. Average depths of tissue damage were 1.30 mm (SD 0.424), 2.35 mm (SD 0.071), and 2.60 mm (SD 0.283) for duration of 5, 10, 20 seconds respectively. Burn duration of 5 seconds resulted in full-thickness damage. Burn duration of 10 seconds and 20 seconds resulted in full-thickness damage, involving subjacent skeletal muscle. CONCLUSIONS: This is a simple reproducible method for creating burn wounds consistent in size and depth in a rat burn model.