The Effect of Topical Agents on the Tensile Strength of Absorbable and Non-absorbable Suture Materials-An in Vitro Study.

INTRODUCTION: Topical agents are sometimes applied to surgical wounds after closure; these may include antiseptics or antibiotics. Minimal research has been undertaken to investigate the effect of topical regimens on the tensile strength of suture materials. AIM: To investigate the effect of four commonly used wound care regimens on the tensile strength of suture materials. METHODS: The failure load of 9 different suture materials was tested using the Instron Electroplus E3000 tensile testing machine (Instron Corporation, Norwood, Massachusetts). Tensile strength was represented as the failure load, measured in Newtons (N), and defined as the maximal load that could be applied across the suture prior to failure. Each suture was tested dry and after immersion in one of 4 products for 7 days and tested on day 7. The immersion agents tested were: sodium chloride 0.9%, MicroSafe® (Sonoma Pharmaceuticals, Petaluma, CA), Aqueous Povidone-iodine 10% solution (Betadine-Mundipharma), and Fucidin ointment. RESULTS: Sodium chloride 0.9%, MicroSafe®, Aqueous Povidone-iodine 10%, and Fucidin seem to increase the failure load of most absorbable and non-absorbable sutures. However, the failure load of Polyglactin 910 suture (Surgilactin, coated, violet-Ethicon) is reduced by long-term exposure to either sodium chloride 0.9% or MicroSafe®, while the failure load of the Polydioxanone suture (PDS Plus-Ethicon) is reduced by long-term exposure to MicroSafe® only. CONCLUSION: In our experiment, the commonly used wound care products have been shown to alter the tensile strength of suture materials. Further human studies are required to ascertain the clinical validity and applicability of our findings.

Operative Management of Extensor Carpi Ulnaris Instability: A Systematic Review.

Background Posttraumatic extensor carpi ulnaris (ECU) instability is an increasingly recognized cause of ulnar-sided wrist pain that occurs when the ECU subsheath is disrupted. Purpose The purpose of this systematic review was to assess outcomes of operatively treated posttraumatic ECU instability. Methods A systematic search of Medline, Embase, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases was performed using "extensor carpi ulnaris" as the keyword. Studies were systematically screened and data extracted independently by two reviewers. Results Eight retrospective studies met the inclusion criteria with a total of 97 wrists. The mean age was 32 years (13-61). Patients underwent either primary repair (40%) using sutures and anchors, or reconstruction (60%) using extensor retinaculum flaps. One study performed deepening of the osseous ulnar groove. Two studies compared preoperative and postoperative values. They both reported a significant improvement in pain scores, functional scoring instruments, satisfaction, and grip strength. The rest of the studies reported similarly favorable outcomes across the same outcomes. Concomitant pathologies were identified in 66% of the study population. Complications occurred in 9% of the sample size, including ECU tendinitis, ulnar sensory nerve irritation, and reintervention for concomitant pathology. None of the studies reported recurrence or reruptures. However, five patients (6.7%) did not return to their previous activity level. Conclusion Patients can expect favorable outcomes with a potentially low complication rate. Nevertheless, the heterogeneity of the sample population, operative techniques, and outcome measures warrant further standardized studies. Level of Evidence IV.

A Streamlined Algorithmic Process for Creating Three-dimensional Printed Forearm Casts.

Three-dimensional (3D) printing is a rapidly evolving field that has found its way into the medical field, providing unsurpassed contributions to the provision of patient-centered care. Its utilization lies in optimizing preoperative planning, the creation and customization of surgical guides and implants, and the designing of models that can be used to augment patient counseling and education. We integrate a simple yet effective method of scanning the forearm using an iPad device with Xkelet software to obtain a 3D printable stereolithography file, which is then incorporated to our suggested algorithmic model for designing a 3D cast, utilizing Rhinocerus design software and Grasshopper plugin. The algorithm implements a stepwise process of retopologizing the mesh, division of the cast model, creating the base surface, applying proper clearance and thickness to the mold, and creating a lightweight structure through the addition of ventilation holes to the surface with a joint connector between the two plates. In our experience, scanning and design of the patient-specific forearm cast using Xkelet and Rhinocerus, alongside implementing an algorithmic model through Grasshopper plugin has dramatically reduced the designing process from 2 to 3 hours to 4-10 minutes, further increasing the number of patient scans that can be sequenced in a short duration. In this article, we introduce a streamlined algorithmic process for the use of 3D scanning and processing software to create forearm casts that are tailored to the patients' dimensions. We emphasize the implementation of computer-aided design software for a quicker and more accurate design process.

A rare presentation of OEIS variant with a recto-bladder neck fistula: A case report and literature review.

INTRODUCTION: Omphalocele, bladder extrophy, imperforate anus and spinal defect (known as OEIS) is a very rare congenital anomaly with an unknown etiology. In this report we describe a case of an OEIS variant associated with a wide pubic diastasis, bladder extrophy with a recto-bladder neck fistula and a high ano-rectal malformation. This work has been reported in line with the SCARE 2020 criteria. PRESENTATION OF THE CASE: A 30-year-old mother delivered a male baby at 39 weeks through a normal vaginal delivery. Examination revealed multiple congenital anomalies in the form of an Omphalocele, extrophied bladder, imperforate anus, ambiguous genitalia and a large pelvic diastasis. Fecal matter was noted at the most inferior point of the extrophied bladder, raising the suspicion of a recto- vesical fistula. An exploratory laparotomy showed a fistula between the rectum and the neck of the extrophied bladder. A sigmoid colostomy was carried out in addition to a mucous fistula. The fascial defect of the Omphalocele was approximated to the upper border of the extrophied bladder. At the age of 2 years, the baby underwent a bladder extrophy repair, a posterior sagittal anorectoplasty and bilateral osteotomies. DISCUSSION: OEIS complex has been reported to occur with a wide variety of associated anomalies, and this necessitates a thorough investigation in order to formulate an appropriate treatment plan. A prenatal diagnosis of OEIS complex can be made by ultrasound stressing the importance of antenatal follow up and a multidisciplinary approach in management. CONCLUSION: We described a rare variant of an OEIS complex and management of such anomalies requires a multidisciplinary input.

Emergency Separation of Extreme VLBW Omphalopagus Twins: Case Report.

The classification of conjoint twins is based according to the site of attachment. The challenges in management of such anomalies span the entire continuum of care from delivery to resuscitation to separation and finally discharge. Scheduled separation is ideal, occasionally the caring team is faced with no option but to perform an emergent separation. Omphalopagus is a type of conjoined twinning characterized by union of the peritoneal cavities through an infraumbilical abdominal wall defect. In this report we describe our experience with a successful emergency separation of extremely preterm omphalopagus twins. This is the first case of conjoint twins in Kuwait, we highlight the challenges faced, stressing the importance of adhering to antenatal care as well as management by a multidisciplinary team.

Erratum to: Emergency Separation of Extreme VLBW Omphalopagus Twins: Case Report.

[This corrects the article DOI: 10.1055/s-0042-1750134.].

A Low-cost, Sterile System for Fat Collection Using a Syringe Tube as a Reservoir.

Fat grafting is a widely performed procedure in the field of plastic surgery. It involves fat extraction, processing, and injection into a recipient site. It is imperative that the fat is collected and processed in a sterile system. A wide variety of equipment is required to perform the procedure (eg, a liposuction device, a vacuum pump, and syringes). Limitations often arise in the operating room, especially in low-resource areas, where task-specific equipment might be unavailable. This can present an opportunity for the surgeon to improvise and create a temporary solution. In this report, we describe our solution in dealing with the unavailability of a sterile vacuum pump canister during a large volume fat grafting procedure. We constructed a sterile reservoir using two syringes, through which negative pressure was delivered without breaking sterility. The items used were a 60-cm3 syringe barrel, a 10-cm3 syringe barrel, a 60-cm3 syringe plunger seal, a tube connected to the nonsterile vacuum pump, and the liposuction cannula. This technique allowed us to extract the fat in a sterile environment under the assistance of a suction device. Our novel technique was used for harvesting fat in a sterile reservoir, while still utilizing the assisted suction from the nonsterile vacuum pump, without breaking sterility.

The Importance of Scar Cosmesis across the Surgical Specialties: Factors, Perceptions, and Predispositions.

Existing disparities in the perception of scars between patients and practitioners can translate into undesirable physical and psychological outcomes. An understanding of the determinants of surgeons' perceptions on the importance of scar cosmesis is a first step toward bridging this gap. Methods: In an online survey, surgeons were asked about the extent to which various patient and technical factors affect the importance of scar cosmesis. Additional data were obtained on surgeon characteristics, including their specialty, gender, years of experience, and work sector to investigate potential relationships. Results: A total of 303 responses were obtained from surgeons across six specialties. Based on the survey, the importance of scar cosmesis was rated highest among plastic surgeons and obstetricians and gynecologists, and lowest among orthopedic and vascular surgeons. Compared with surgeons in private practice, publicly employed surgeons' rating of the importance of cosmesis was lower. The patient's request for a cosmetic outcome was the most highly rated factor. Regarding the influence of patient demographics on surgeons' attitudes, scar cosmesis in young and female patients was favored in comparison with older and male patients. Factors that reduced the importance of cosmesis were emergency and late-night surgeries followed by lengthy procedures, large incisions, and busy operative lists. Conclusions: These initial findings highlight a need to investigate means of fostering a more holistic, impartial approach toward scar cosmesis, as well as addressing potential workplace barriers that may prevent surgeons from seeking a more cosmetic result. Greater alignment between the priorities of surgeons and patients may manifest in objective and subjective improvements in patient's scars and well-being.

Access to Breast Reconstruction in Kuwait: Assessing Surgeon-related Factors as a Barrier to Referral.

It is not uncommon for breast cancer patients to undergo a mastectomy without receiving or being presented with the option of having a breast reconstruction. With a low rate of breast reconstruction in Kuwait, we aim to assess physician-related factors as a barrier to referral. Methods: This is an online questionnaire-based study to investigate the variation in the referring general surgeons' knowledge and perception towards breast reconstructive surgery. Results: A total of 141 general surgeons responded to the questionnaire, and only 63 (44.7%) always discuss the available options for reconstruction with their breast cancer patients. When asked about referral to a plastic surgeon, only 49 (34.8%) responded with always, and the majority (N = 61; 43.3%) responded with sometimes. More than half (N = 73; 51.8%) believe that the general surgeon should determine patient suitability for referral to a plastic surgeon, while only 53 (37.6%) agree that breast cancer patients should always be referred to a plastic surgeon for consideration of reconstruction. The mean knowledge score was 6.6 of 8, while the mean perception score was 8.9 of 12. Responders with a higher total knowledge score were more likely to discuss with patients the availability of reconstruction. Conclusions: Despite the acceptable knowledge scores in our general surgeons, there is a low rate of referral for breast reconstruction in Kuwait. There is a pressing need to generate legislations and a streamlined protocol for referral that facilitate access to breast reconstructive services.

The Utilization of Three-Dimensional Printing in Creating a Surgical Instrument: An Areola Cookie Cutter.

Three-dimensional (3D) printing is a rapidly evolving technology with many applications in the medical field. It involves printing solid objects from a digital file. In this paper, we describe our experience with the use of 3D printing in creating an areola cookie cutter that is compatible with sterilization. The objective of this study is to explore accurate and cost-effective methods of producing patient-specific areola cookie cutters. Auto computer-aided design (CAD) 3D software was used to design a digital model that was subsequently converted to a standard tessellation language (STL) file. The models were printed with the Formlabs Form 3+ SLA printer (Somerville, MA) using a resin material. Washing and curing were then performed followed by autoclave sterilization of the models. A total of 3 areola cookie cutters were created, each with different sizes (33, 38, and 42 mm) using resin material (Formlabs BioMed Clear Resin; Somerville, MA). All 3 models were able to withstand autoclave sterilization. The use of 3D printing has proven to be a valuable tool in Plastic surgery. We describe our experience of designing and producing an areola cookie cutter using a 3D printer; our model is compatible with the process of sterilization. We emphasize the advantages of a quick production time and accuracy in design.

Comparison of pain and extent of anesthesia in digital blocks for isolated finger lacerations: A randomized controlled trial.

OBJECTIVES: Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block (SV) technique. Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. METHODS: This is a single-center prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anesthesia along with the anesthesia onset time. RESULTS: A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anesthesia was more predictable in the dorsal block compared to the volar block. CONCLUSION: The single-injection volar subcutaneous blocks are less painful with a similar anesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anesthesia of the region.

The SARS-CoV-2 Vaccine Hesitancy Among the General Population: A Large Cross-Sectional Study From Kuwait.

Although the approved COVID-19 vaccines have proven to be safe and effective, multiple beliefs and misconceptions still exist influencing the vaccine uptake rates around the world. The multifaceted complex phenomenon of vaccine hesitancy could jeopardize the efforts to overcome this pandemic. The aim of this study is to identify the prevalence and examine the factors associated with vaccine hesitancy in Kuwait. This is a web-based cross-sectional study conducted in Kuwait from March 2021 until April 2021, during the second wave of the COVID-19 pandemic. Our questionnaire examined basic demographic information, attitudes towards the COVID-19 vaccines as well as reasons for and against accepting the vaccine. Out of the 2345 responders, the majority are fully convinced to take the vaccine (83%) and the rate of vaccine hesitancy is 17%. Vaccine hesitancy is higher among non-healthcare workers, those previously positive for the COVID-19 virus, and those against vaccines in general. Vaccine hesitancy could jeopardize the efforts to overcome this pandemic; therefore, intensifying nationwide education and dismissal of falsified information is an essential step towards addressing vaccine hesitancy.

The analysis and accuracy of mortality prediction scores in burn patients admitted to the intensive care burn unit (ICBU).

BACKGROUND: To date, multiple scoring systems have been utilised in predicting outcomes in burn patients. The aim of this study is to determine the accuracy of three established scoring systems used for burn patients admitted to the intensive care unit and to determine the risk factors associated with poor outcomes. METHODS: A total of 211 patients who were admitted to the ICBU in a tertiary care centre in Kuwait from January 2017 to December 2019 were analysed retrospectively. Data were collected using patient medical records. The FLAMES, BOBI and revised Baux scores were calculated, and the survivor and non-survivor scores of patients were analysed to determine the sensitivity, specificity and Area Under the Receiver Operating Characteristics (AUROC) of the different scoring modalities. RESULTS: The majority of the analysed population were male patients (165/211) and the most common mechanism of burns was flame burns (166/211). Most of the patients admitted to the ICBU survived (188/211). Female gender was associated with a higher mortality rate, whilst inhalational injury and co-morbidities were not associated with a higher mortality rate. The revised Baux score had a sensitivity value of 96% and 90% specificity. The BOBI score had a sensitivity of 91% and 76% specificity. The FLAMES score had a sensitivity of 96% and the highest specificity of 99%. All 3 scores had AUC values exceeding 90%. CONCLUSION: Statistically, FLAMES score had the highest accuracy of predicting outcomes in burn patients, however all three scores demonstrated acceptable predictive rates when it comes to practical application, permitting the use of either one of the studied scores with satisfactory prognostic outcomes.

Intra-gastric balloons - The past, present and future.

Obesity is a complex metabolic illness that is interrelated to a plethora of complications that predispose to avoidable morbidity and mortality. The considerable impact of obesity has invited various therapies ranging from lifestyle advice, pharmacotherapy, endoscopic bariatric therapy and ultimately surgery. Intragastric balloons are space-occupying therapies that aim to increase satiety through mechanical and neuroendocrine mechanisms. Their prevalence is owed to their ease of administration and general safety. However, long term data concerning safety and efficacy is scarce when considering the various types of balloons in use. In this review, we discuss the intragastric balloon comprehensively in terms of efficacy, safety, limitations and future direction.

The predictors of depression and burnout among surgical residents: A cross-sectional study from Kuwait.

BACKGROUND: Surgical residency often poses a challenge to residents, with long working hours and a stressful work environment. Surgical residents are at an increased risk of burnout and depression. Such mental health burdens could go so far as to affect treatment outcomes. AIM: To assess the prevalence and risk factors for depression and burnout among residents across surgical specialties in Kuwait. MATERIALS AND METHODS: An online questionnaire was sent to the residents enrolled to the surgical residency programs in Kuwait, from the period of January 2020-February 2020. Variables collected included; age, gender, marital status, smoking history, exercise, specialty, year of training, on-call frequency, assessment of burnout (using the abbreviated Maslach Burnout Inventory (aMBI)) and assessment of depressive symptoms (using the Patient Health Questionnaire-9 (PHQ-9) score). RESULTS: A total of 85 surgical residents between the age of 20 and 40 years responded. Most (64.7%) were male and 35.3% female. More than half were married (51.8%) and 41.2% were single. The majority of the residents were in general surgery (43.5%), with the least being in otolaryngology (7.1%) and neurosurgery (5.9%). The prevalence of depressive symptoms was 55.3%, and 51.8% had a high overall burnout score. CONCLUSION: Addressing burnout at all stages during residency training is paramount in improving standard of care as well as increasing the wellness of residents.

Prognostic Factors and Predictors of In-Hospital Mortality Among COVID-19 Patients Admitted to the Intensive Care Unit: An Aid for Triage, Counseling, and Resource Allocation.

BACKGROUND:  The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) remains today a global health pandemic. Those with severe infection are at risk of rapid clinical deterioration; as a result, intensive care unit (ICU) admission is not uncommon in such patients. A number of determinants have been identified as predictors of poor prognosis and in-hospital mortality, ranging from demographic characteristics, laboratory and/or radiological findings. AIM: To identify determinants of in-hospital mortality and examine the accuracy of seven early warning scores in predicting in-hospital mortality. METHODS: This is a retrospective study conducted in Kuwait from July 2020 to March 2021, and participants were adult patients with a positive test on the real-time polymerase chain reaction (RT-PCR) for SARS-CoV-2 and who met the criteria for ICU admission. Data collected included: demographics, clinical status on hospital arrival, laboratory test results, and ICU course. Furthermore, we calculated seven early warning scores for each of our patients. RESULTS: A total of 133 patients were admitted to our COVID-19 ICU with a median age of 59 years. Arrival to ICU on mechanical ventilation (MV), developing in-hospital complications, having chronic kidney disease (CKD), having a high white blood count (WBC), lactate dehydrogenase (LDH), lactate, or urea levels were found to be significant predictors of in-hospital mortality. Furthermore, the 4C mortality score for COVID-19, VACO index for COVID-19 mortality, and the PRIEST COVID-19 clinical severity score proved to be the most superior in predicting in-hospital mortality. CONCLUSION: Identifying high-risk patients and those with a poor prognosis allows for efficient triaging and the delivery of high-standard care while minimizing the strain on the healthcare system.

Predictors of long-term respiratory insufficiency of exomphalos major.

INTRODUCTION: Exomphalos major (EM) is associated with significant morbidity and even mortality with an important risk of long-term pulmonary disease. AIM: To assess the outcomes of exomphalos in a single tertiary pediatric unit and to identify prognostic factors for patients with respiratory insufficiency who still require ventilatory assistance at six months. MATERIAL AND METHODS: All infants admitted to our institution over a 10-year period (2005 to 2015) with exomphalos were retrospectively reviewed. EM was defined when the abdominal wall defect measured >= 5 cm and/or contained liver within the sac. Data were collected on patient demographics, prenatal course and imaging, birth information, immediate and long-term outcomes. Those with long-term respiratory insufficiency were identified as the primary outcome and reviewed to assess prognostic factors. A p value of ≤0.05 was regarded as significant. Data are quoted as median(range). RESULTS: A total of 46 infants were diagnosed with exomphalos during the study period, with most (n = 30, 65%) defined as exomphalos major. Respiratory complications occurred in 16 (35%) with 8 (50%) of these requiring long-term (≥6 months) mechanical ventilation and 5 (31%) required a tracheostomy. On univariate analysis, resuscitation at birth (p = 0.0004), birth weight <3000 g (p = 0.008), use of nitric oxide (p = 0.004), high frequency oscillatory ventilation (HFOV) (p = 0.001), pulmonary hypoplasia (p<0.0001) and pulmonary hypertension (PHTN) (p = 0.02) were significantly associated with respiratory insufficiency. The strongest predictive model for ventilation support at six months was resuscitation at birth in combination with PH (OR = 1.57). Five infants (11%) died at 5(1-122) days. CONCLUSIONS: In patients with EM, the presence of pulmonary hypertension along with resuscitation at birth are the most important prognostic factors for long-term respiratory insufficiency. Acknowledgement of these factors allows for better parental counselling regarding respiratory outcomes.

Amyloid goiter - A rare case report and literature review.

INTRODUCTION: Amyloid goiter is a rare presentation of thyroid swelling, which occurs with either primary or secondary amyloidosis. This condition must be differentiated from other types of goiters or malignancies. Even though the thyroid is extensively involved by amyloid, patients are usually euthyroid, but many different presentations and overlaps have been reported. Currently the treatment is surgical resection of the thyroid gland. CASE PRESENTATION: We report a case of a 53-year-old previously healthy male who presented with a 2 year history of a progressively enlarging painless neck swelling. The patient was euthyroid and denied any associated symptoms. The patient subsequently underwent an uneventful total thyroidectomy along with an unremarkable follow up and was diagnosed with primary amyloidosis involving only the thyroid gland confirmed by histopathology. DISCUSSION AND CONCLUSION: Amyloid goiter is a rare entity; a high index of suspicion is required in patients with an enlarging thyroid gland and a concomitant history of chronic inflammatory processes or plasma cell dyscrasia. FNA biopsy should be performed to exclude the top differential of primary thyroid malignancy. Thyroidectomy is necessary for definitive diagnosis and symptom relief. Every effort should be made to delineate the extent of the disease, and in those previously healthy plasma cell dyscrasia should be excluded.

The psychological burden of the COVID-19 pandemic and associated lockdown measures: Experience from 4000 participants.

BACKGROUND: In February 2020 the first cases of COVID-19 were identified in Kuwait. Inevitably as many countries worldwide, the general public were negatively affected by the pandemic. Unemployment, uncertainty, distress, increasing deaths, lockdown measures all of which are potential burdens on mental health. AIM: To assess the impact of COVID19 outbreak on mental health in Kuwait, and to explore the potential influencing risk factors. METHODS: We conducted an online questionnaire-based study in Kuwait between 25th May 2020 to 30th May 2020. Questions were based on demographics, lifestyle during outbreak, depression and anxiety assessment. Total PHQ9 and GAD7 scores were calculated for each responder. RESULTS: We had 4132 responders. Most were females (69.31%), married (59.37%), between the age of 21-30 (23.84%) and non-smokers (81.46%). Only (7.96%) had a positive past psychiatric history, (32.04%) had a past history of a chronic medical disease. During the outbreak most of the responders lost their jobs (39.21%) and only (12.83%) were attending work regularly, only (6.82%) worked in the healthcare sector. 59.27% report increased social media use compared to before the lockdown. When asked about their daily time spent following COVID19-related news, most (37.8%) spend more than 2 hours and (7.74%) spend more than 4 hours. The overall prevalence of depressive symptoms was (30.13%) and the prevalence of anxiety symptoms was (25.28%). LIMITATIONS: In the cross-sectional nature of the study. CONCLUSION: The COVID-19 pandemic caused a burden on mental health. Psychological support and mental health awareness should be implemented and made accessible to all individuals during pandemics.