Surgical confidence when operating among residents in surgery - a cross-sectional study (SCAR study).

BACKGROUND: Self-confidence, is one of the critical variables influencing surgical resident's abilities, and lack of confidence maybe a reason for not entering medical practice immediately. Measuring the level of confidence of senior surgical residents (SSRs) is a crucial step in assessing preparedness to practice. In this study, we aim to measure their confidence level and the factors that might contribute to it. METHODS: Cross-sectional survey conducted at King Abdulaziz University Hospital on SSRs in Saudi Arabia (SA). We approached 142 SSRs, 127 responded. Statistical analysis was performed using RStudio v 3.6.2. Descriptive statistics were performed using counts and percentages for categorical variables and using mean ± standard deviation for continuous variables. Multivariate linear regression (t-statistics) was used to assess the factors associated with confidence in performing essential procedures, while the association between demographics and residency-related factor with the number of completed cases was tested using Chi-square. The level of significance was determined as 0.05. RESULTS: Response rate was 89.4%. Among surveyed residents, 66% had completed < 750 cases as a primary surgeon. More than 90% of SSRs were confident in performing appendectomy, open inguinal hernia repair, laparoscopic cholecystectomy, and trauma laparotomy, while 88% were confident in being on-call in level-I trauma center. No difference was noted in confidence level in relation to the number of performed cases. Residents from the Ministry of Health accounted for 56.3% of the study population and showed a higher confidence level compared to others. 94% of SSRs plan to pursue fellowship training program. CONCLUSION: The study showed that the confidence of SSRs in performing common general surgery procedures was as expected. However, it's important to recognize that confidence doesn't necessarily reflect competence. Considering the majority of SSRs planned to pursue fellowship training programs, it may be time to consider changing the structure of surgical training in SA to a modular format to allow earlier and more intensive exposure.

The efficacy of laser haemorrhoidoplasty (LHP) in the treatment of symptomatic haemorrhoidal disease: An observational cohort study.

AIM: Laser haemorrhoidoplasty (LHP) is an emerging nonexcisional surgical procedure in which the arteriovenous flow of the haemorrhoidal plexus is interrupted through laser coagulation. The aim of this cohort study was to assess efficacy of LHP in treating symptomatic haemorrhoidal disease through patient satisfaction, remission of symptoms (blood loss, pain, itching, soiling, mucosal prolapse) and recurrence of haemorrhoids. METHODS: Patients who underwent treatment for symptomatic haemorrhoids (degrees 1-4) through an LHP procedure between 2015 and 2021 were included in the study. A 1470 nm-diode laser was used. A total of 200 patients (71% male, average age 51 years) were analysed. Primary outcomes were patient satisfaction and/or complete recovery of symptoms. Secondary outcomes were operating time, complications and recurrence rates. Patient satisfaction, postoperative blood loss, pain and complications were evaluated 6-7 weeks postoperatively. Room turnover time and operating time were documented. Recurrence of haemorrhoids following LHP treatment within 1 year was evaluated. RESULTS: Patient satisfaction regarding LHP treatment was reached in 155 (84,7%) patients. Postoperative blood loss was reported by 44 (24,0%) patients during time of evaluation. Twenty-four (13,1%) patients reported postoperative pain after 6-7 weeks. Postoperative complications occurred in seven patients (3 anal fissures, 2 perianal abscess, 1 perianal fistula, 1 postoperative anaemia). Room turnover time (patient in to patient out) was 21 min with an average operating time of 7 min. Recurrence of haemorrhoids within 1 year occurred in 50 (27,3%) patients. CONCLUSIONS: Laser haemorrhoidoplasty appears to be a promising and effective nonexcisional surgical procedure in the treatment of symptomatic haemorrhoidal disease with high patient satisfaction, acceptable postoperative symptoms, minimal complications and short operating times.

Body Microbiota and Its Relationship With Benign and Malignant Breast Tumors: A Systematic Review.

Breast cancer is the most frequent type of cancer as well as one of the main causes of cancer-related mortality in women. Human microbial dysbiosis, which has been related to a range of malignancies, is one of the variables that may impact the chance of developing breast disorders. In this review, we aimed to investigate the relationship between breast cancer and benign breast tumors with dysbiosis of the microbiome at different body sites. We performed a systematic review of MEDLINE, Scopus, Ovid, and Cochrane Library to identify original articles published until July 2020 that reported studies of breast disease and microbiota. Twenty-four original articles were included in the study, which looked at the features and changes in breast, gut, urine, lymph node, and sputum microbial diversity in patients with benign and malignant breast tumors. In breast cancer, the breast tissue microbiome demonstrated changes in terms of bacterial load and diversity; in benign breast tumors, the microbiome was more similar to a malignant tumor than to normal breast tissue. Triple-negative (TNBC) and triple-positive (TPBC) types of breast cancer have a distinct microbial pattern. Moreover, in breast cancer, gut microbiota displayed changes in the compositional abundance of some bacterial families and microbial metabolites synthesis. Our review concludes that breast carcinogenesis seems to be associated with microbial dysbiosis. This information can be further explored in larger-scale studies to guide new prophylactic, diagnostic, and therapeutic measures for breast cancer.

Hypoadrenalism as the Single Presentation of Autoimmune Polyglandular Syndrome Type 1.

Type 1 autoimmune polyglandular syndrome (APS1) is a rare hereditary disease affecting nearly 600 patients worldwide. The first of its cardinal manifestations, chronic mucocutaneous candidiasis, hypoparathyroidism, or Addison's disease, presents in childhood. Additional nonclassical landmarks of APS1 continue to develop as late as the fifth decade of life. Two thirds of patients develop the full triad before 25 years of age. Only 20% of patients develop the entire triad simultaneously. Addison's disease is rarely reported as the first manifestation. According to APS1 classifications, restricted criteria for a single cardinal component, although elements of suspicion are not sufficient to diagnose APS1. This case report is peculiar as hypoadrenalism was the first and only manifestation of APS1 for nearly 3 decades since its diagnosis. Theoretically, exceptions from the protocol of APS1 diagnostic criteria would be recognized as acceptable for diagnosis in the future, when similar case reports of only 1 component of APS1 appear.

Factors Affecting Ulcerative Colitis Flare-Ups: Associations With Smoking Habits and Other Patient Characteristics.

Background and study aims Currently, there are no studies conducted in the Kingdom of Saudi Arabia (KSA) that have assessed the relationship between ulcerative colitis (UC) flare-ups and smoking. The present study aims to assess the risk of UC flare-ups and evaluate the relationship between UC flare-ups and smoking in adult patients following up at King Abdulaziz University Hospital in Jeddah, KSA. Patients and methods This was a retrospective study involving patients with confirmed UC between January 2015 and December 2020. Various information was examined, including demographic, clinical, endoscopic, radiologic, and laboratory data. Descriptive statistics were used for summarizing findings and a logistic regression analysis was applied to test for possible associations. Results Eighty-nine patients with UC were included in the study. Almost half (48.3%) had recurrent UC flare-ups during follow-up. A non-significant relationship was found between recurrent UC flares and all types of smoking habits (cigarette smoking, P = 0.15; shisha smoking, P = 0.88; and vape smoking, P = 0.09). Participants who were underweight (P = 0.041), had family history of UC (P = 0.013), depression (P = 0.033), fecal incontinence (P = 0.003), iron deficiency anemia (P = 0.009), or a malignancy (P = 0.039) had a significantly higher probability of experiencing recurrent flares. Binary logistic regressions revealed that family history of UC (OR = 5.3, P = 0.007) and fecal incontinence (OR = 4.7, P = 0.006) were associated significantly with recurrent flares. Conclusion There was no clear association between smoking and recurrent UC flares identified in this cohort. Of the variables considered, UC patients with fecal incontinence or family history of UC were at the highest risk of developing recurrent flares.

Locally Advanced Breast Cancer: Treatment Patterns and Predictors of Survival in a Saudi Tertiary Center.

Background  Breast cancer (BC) is the most common cancer in the Kingdom of Saudi Arabia (KSA) and the second leading cause of cancer-related mortality. About 40% of BC in KSA is locally advanced BC (LABC), which has been associated with poorer survival compared with early diagnosed BC. Objective To review the presentation and outcomes of LABC, including the characteristics of the disease, different treatment modalities, overall survival (OS), disease-free survival (DFS), and local recurrence in relation to different radiotherapy (RT) techniques. Methods  We retrospectively reviewed the medical records of 153 female patients with pathologically proven LABC diagnosed at King Abdulaziz University Hospital, Jeddah, KSA, between 2009 and 2017. We obtained data on patient demographics, stage of cancer at diagnosis, tumor characteristics (subtype and receptor status), type of surgery, systemic treatments received (hormonal, targeted therapy, and chemotherapy), RT variables, and recurrence and death dates. Data were analyzed to assess OS and DFS by using Kaplan-Meier analyses and the log-rank test. Univariate and multivariate Cox proportional hazard regression analyses were used to explore and identify factors associated with survival. Results  The median survival time in the study population was 9.16 years. Older age (65+ years) was associated with worse OS and DFS than was younger age (<65 years) (hazard ratio (HR) 3.20, 95% CI 1.48-6.90, P = 0.003 and HR 2.21, 95% CI 1.12-4.36, P = 0.022, respectively). Regarding the type of surgery, having a mastectomy was associated with worse OS and DFS than was having a lumpectomy (HR 2.44, 95% CI 0.97-6.12, P = 0.05 and HR 2.41, 95% CI 1.13-5.14, P = 0.023, respectively). Positive estrogen and progesterone receptor status was associated with better OS and DFS than was a negative estrogen or progesterone receptor status (HR 0.13, 95% CI 0.05-0.30, P < 0.001 and HR 0.21, 95% CI 0.11-0.41, P < 0.001, respectively). Patients who received RT had a lower risk of recurrence than did those who did not receive RT (P = 0.011). Moreover, three-dimensional conformal RT was associated with lower local recurrence than intensity-modulated RT or volumetric-modulated arc therapy (P = 0.003). Conclusion  Multiple factors can affect the OS and DFS in LABC. Younger patients, having hormone-positive disease, and undergoing lumpectomy were associated with better outcomes. Adjuvant RT may improve local control and the use of three-dimensional conformal RT was superior for local control. Prospective studies with larger sample sizes are needed to further highlight these findings and to assess the role of chemotherapy and targeted therapy in patients with LABC.

Short-term outcomes of stents in obstructive rectal cancer: A systematic review and meta-analysis.

BACKGROUND: With acute obstruction due to rectal or recto-sigmoid cancer, the safety and success of deploying self-expandable metal stents has been controversial. The aim of this systematic review was to synthesize the existing evidence on the outcomes and complication rates of stent placement in these patients. METHODS: We performed a literature search of PubMed by using appropriate keywords, and manual reference screening of included articles was done. The article screening, data extraction, and quality assessment was done by four independent reviewers. A meta analyses was performed for the main outcome measures: technical and clinical success and complication rates. RESULTS: We identified 962 articles in the search. After applying inclusion and exclusion criteria, we included 32 articles in the meta-analysis. The pooled technical success rate across 26 studies that reported it was 97% [95% confidence interval (CI): 95%-99%] without evidence of significant heterogeneity (I2 = 0.0%, P = 0.84), and the clinical success rate across 26 studies that reported it was 69% (95% CI: 58%-79%) with evidence of significant heterogeneity (I2 = 81.7%, P < 0.001). The pooled overall complication rate across the 32 studies was 28% (95% CI: 20%-37%) with evidence of significant heterogeneity (I2 = 79.3%, P < 0.001). CONCLUSION: The use of rectal stents in obstructing rectal or recto-sigmoid tumors seems to be technically feasible. A high rate of technical success, however, does not always translate into clinical success. A considerable complication rate is associated with this approach. Randomized controlled trials are needed to compare the outcomes of rectal stent placement with those of surgery.

Towards detection of brain injury using multimodal non-invasive neuromonitoring in adults undergoing extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary bypass that provides life-saving support to critically ill patients whose illness is progressing despite maximal conventional support. Use in adults is expanding, however neurological injuries are common. Currently, the existing brain imaging tools are a snapshot in time and require high-risk patient transport. Here we assess the feasibility of measuring diffuse correlation spectroscopy, transcranial Doppler ultrasound, electroencephalography, and auditory brainstem responses at the bedside, and developing a cerebral autoregulation metric. We report preliminary results from two patients, demonstrating feasibility and laying the foundation for future studies monitoring neurological health during ECMO.

Children with heart transplants: Lessons learned from 774 visits at a primary community clinic.

Aims Unexpected decompensation of PHTRs may surprise, when the patient is at home. If the PHTR lives a distance from transplant center, the task of identifying risk factors of allograft rejection/dysfunction falls primarily on the PCP in the PCC, whether or not they are knowledgeable toward pediatric heart-transplantation. Methods We reviewed the medical reports of three heart-transplanted children in our periphery clinic between the years 2005 and 2019. Results The unexpected death of one patient, hours after he left our health facility, was the impetus for writing this article. Another heart transplant child attended our periphery clinic for 774 visits. Majority of visits were casual, others were scheduled, and the rest were for administrative affairs. We referred the PHTR to the transplantation center in 9% of all visits. In remaining 91% visits, we handled problems locally. Conclusions One of the important lessons we have learned through handling the PHTR at the PCC is that, during daily workflows and dealing with the occasional visits of a heart transplant child, related critical clinical information to allograft rejection or its dysfunction can easily evade from awareness of the attending physician. Through this study, we demonstrated that a program of summoning the PHTR to "initiated monthly visits" at the PCC enables the PCP to be maximally aware of critical clinical information, in addition to limiting futile referrals of 91% of the visits to specialized centers, without adversely affecting the prognosis.

A single-day paradigm of self-regulated human cocaine administration.

UNLABELLED: Prior work by our group has shown the feasibility, safety, and validity of a multi-day, multi-dose paradigm of self-regulated cocaine administration in humans. The current work sought to consolidate these methods in a single-day design focused on reducing logistical complexity, decreasing research burden to human subjects, and increasing suitability for medication development designs. METHODS: Eleven experienced cocaine users participated in a 6-hour, single-day design, consisting of one safety/eligibility and three experimental cocaine periods (during which subjects were allowed to self-administer 8, 16, and 32 mg/70 kg cocaine doses under a fixed-ratio 1:5 minute timeout schedule). Changes in cocaine-induced cardiovascular response, self-administration behavior, and subjective effects were assessed. RESULTS: Procedures were well tolerated by participants, and no significant adverse events were noted. Significant (p < 0.05), changes in measures of cocaine self-administration (e.g., responses, infusions, interinfusion intervals, consumption, and plasma levels), cardiovascular response (HR), and subjective effects ("high") were observed. In contrast, cocaine-induced increases in other vital signs (e.g., SBP, DBP) and subjective effect measures (e.g., paranoia) did not differ between doses. CONCLUSIONS: These data support the safety, tolerability and validity of our single-day design. Depending on the application, such methods may afford advantages for assessing the self-regulation of cocaine administration behavior in humans (e.g., including medication development designs).

Intracellular translocation of PKC isoforms in canine pulmonary artery smooth muscle cells by ANG II.

Our goals were to identify the isoforms of protein kinase C (PKC) present in primary cultures of canine pulmonary artery smooth muscle cells (PASMCs) and to determine whether angiotensin II (ANG II) triggers translocation of specific PKC isoforms to discreet intracellular locations. Isoform-specific antibodies and Western blot analysis were utilized to identify the isoforms of PKC in PASMCs. Indirect immunofluorescence and confocal microscopy were used to examine the subcellular distribution of PKC isoforms. Inositol phosphate production was used to assess phospholipase C activation, and fura 2 was utilized to monitor intracellular Ca2+ concentration in response to ANG II. Six isoforms (alpha, delta, epsilon, zeta, iota/lambda, and mu) of PKC were identified by Western blot analysis. Immunolocalization of 5 isoforms (alpha, delta, zeta, iota/lambda, and mu) revealed a unique pattern of staining for each individual isoform. ANG II caused translocation of PKC-alpha from the cytosol to the nuclear envelope and of PKC-delta to the myofilaments. In contrast, cytosolic PKC-zeta did not translocate, but nuclear PKC-zeta was upregulated. Translocation of PKC-alpha and PKC-delta and upregulation of PKC-zeta in response to ANG II were blocked by the ANG II type 1-receptor antagonist losartan. In addition, ANG II stimulated inositol phosphate production and intracellular Ca2+ concentration oscillations, which were blocked by losartan. Thus activation of ANG II type 1 receptors triggers the phosphoinositide signaling cascade, resulting in translocation or upregulation of specific PKC isoforms at discreet intracellular sites. The alpha and zeta isoforms may act to regulate nuclear events, whereas PKC-delta may be involved in modulating contraction via actions on the myofilaments.

Alterations in cell morphology and cytoskeletal proteins in gingival fibroblasts exposed to a Bacteroides gingivalis extract.

A soluble sonic extract (SSE) from Bacteroides gingivalis caused a dose-dependent inhibition of gingival fibroblast growth, reduced cell attachment and altered cell morphology. Most of its cytotoxic activity was destroyed by heating, indicating that the factor(s) was a protein rather than endotoxin. Cells, grown in the presence of, or on, root surfaces pretreated with 100-200 micrograms SSE/ml, partially retracted from the substratum and exhibited extensive surface blebbing and finger-like protrusions. Immunofluorescent staining showed that the morphological effects of Bacteroides gingivalis SSE are directed specifically at actin stress fibers and not microtubules of the cytoskeleton. Exposure to the SSE resulted in a dramatic relocalization of the bulk of F-actin from a fibrous form to a non-aggregated diffuse form. Disorganization of actin stress fibres occurred at concentrations of SSE that inhibited cell growth, but preceded any observable changes in cell attachment or morphology. The microtubular network remained intact, although it stained less intensely than that of controls. By contrast, Bacteroides intermedius SSE did not significantly influence growth, alter cellular morphology or affect the two cytoskeletal proteins.

Determination of cocaine concentrations in plasma by high-performance liquid chromatography.

We describe a procedure for measuring concentrations of cocaine in plasma by reversed-phase high-performance liquid chromatography, with ion-pairing. The procedure involves solvent extraction followed by back-extraction with dilute acid. The n-propyl ester of benzoylecgonine is used as an internal standard. An evaporation step is not required, and concentrations as low as 5 micrograms/L can be quantified. Plasma concentrations of cocaine determined by high-performance liquid chromatography correlated well with those determined by a previously reported gas-chromatographic procedure with nitrogen detection.