Triple Barrel Free Fibula Flap for Sternal Stabilization: A Case Report

Sternal non-union is a rare complication of median sternotomies following cardiac surgery. It results in sternal instability and is associated with a high rate of morbidity. Patients with sternal non-union usually complain of pain and sternal clicking with movement of the chest wall. Diagnosis is confirmed on computed tomography showing a gap between two sternal halves. Surgical correction of sternal instability is challenging. The key objective is to reconstruct a thoracic cage that allows for biomimesis and preserves normal physiologic cardiac and pulmonary functions all whilst achieving an aesthetically pleasing result. In this article, we describe a novel technique for sternal instability reconstruction using a triple-barrel vascularized free fibula flap fixed with rib titanium plates. This approach provides rigid long-lasting stability while preserving chest wall biomechanics.

Assessing COVID-19 knowledge, attitudes, and practices among hospital employees: identifying sociodemographic determinants for improved public health strategies

Background

The working environment of healthcare institution during pandemic puts all hospital employees at high-risk of being exposed to contagious infections. An individual's behavior and response are largely determined by their level of knowledge, attitudes and practices (KAP) toward a disease. Therefore, the present study aimed to evaluate and assess the KAP toward COVID-19 among hospital employees working in various positions and to identify the sociodemographic determinants associated with the level of KAP.

Methods

A cross-sectional survey was conducted from July 1 to July 15, 2020 in Almoosa Specialist Hospital, Alhasa, Eastern Province, Saudi Arabia in which 221 hospital employees with varied job titles participated. The data for demographics and history of COVID-19 exposure, KAP related to COVID-19 spread and prevention were collected online using a web-based platform (Survey Monkey). Student's t-test/One-way ANOVA were used to compare total mean and standard deviation of KAP scores with demographic profiles and history of exposure.

Results

89.1% employees knew that COVID-19 virus is mostly transmitted from human-to-human, and 76.0% employees acknowledged droplet transmission. 64.7% employees preferred to take a sick person with unconfirmed COVID-19 to a health facility. Physicians had higher knowledge scores for COVID-19 infection and non-medical employees had the lowest scores (7.47 ± 1.23 and 6.47 ± 1.44, respectively). Nurses had the highest practice scores and non-medical employees lowest practice score (6.16 ± 0.74 and 5.37 ± 1.14, respectively). Attitude scores were similar among all the employees. All employees reported an increase in hand-washing frequency and physical contact avoidance.

Conclusion

The study results revealed socio-demographic factors; level of education, nationality, and field of service are associated with COVID-19 KAP. The study highlights that there is a gap in the level of knowledge about COVID-19, especially among nonmedical employees. Targeted interventional programs need to be planned and implemented to improve COVID-19 awareness among non-medical employees.

Diamonds in the appendix

Background

An uncommon cause of appendicitis is the entrapment of ingested foreign objects in the appendix. Although a rare event, it could remain asymptomatic for a prolonged time. The presence of foreign bodies in the gastrointestinal tract has a high potential for complications, in particular if sharp or large enough in size to cause obstruction. However, most often an ingested foreign object would be eliminated in the stool. Rarely, it may reside in the appendix depending on various factors such as the nature of the ingested body and the appendiceal peristaltic movements.

Case presentation

We report a case of abdominal pain due to a diamond earring trapped in the appendix for 2 years. A plain X-ray of the abdomen confirmed the diagnosis which prompted a laparoscopic appendectomy resulting in resolution of symptoms.

Conclusion

The initial presentation of an ingested foreign object can be similar to signs of symptoms of acute appendicitis and the patient must be monitored for several days to follow the trajectory of the foreign body in order to prevent complications. Even though the incidence is more common among the pediatric population, vigilance among adults should also be undertaken with a history of ingesting a foreign object, as this case demonstrates the importance of keeping a high index of suspicion when encountering such cases.

A review of materials currently used in orbital floor reconstruction

Orbital fractures are common fractures of the midface. As such, numerous techniques and materials exist for the repair of this region, each with inherent advantages and disadvantages. But does the ideal implant material exist? Should we stop and simply use readily available materials, or should the cycle of need and discovery continue? A comprehensive review of materials used in orbital reconstruction and possible new directions in orbital floor reconstruction are presented.

Recurrent venous thrombosis following free flap surgery: The role of heparin-induced thrombocytopenia

Complications following free tissue transfer have been well established in the literature. Common and rare causes of free flap failure must be addressed by the treating surgeon when microvascular patency is threatened. With the evolution and prevalence of microsurgery, 'rare' causes of free flap failure will become increasingly frequent. A high index of suspicion must be established in patients with multiple failed operative interventions. A case of recurrent free flap failure secondary to heparin-induced thrombocytopenia is presented in a patient with a history of squamous cell carcinoma of the floor of the mouth, and a long-standing history of alcohol and tobacco consumption.

Beyond the borders of keloid formation: A case report

The keloid scar is a cutaneous mass characterized by nodular fibroblastic proliferation of dermis and a predilection for distinctive anatomical locations. However, keloid extension to neighbouring tissue as a nonsyndromic entity has not been described. In the present report, a case involving a 48-year-old woman with extensive bilateral keloids of the ear lobules and neck following ear piercing is presented.

Mechanical failure of a Fogarty catheter in a microsurgical procedure: a case report

Although microvascular free-tissue transfer has become a reliable reconstructive method, vascular compromise of the flap necessitating surgical exploration and attempts at flap salvage commonly occurs. Thrombectomy using Fogarty vascular catheters can be used in the setting of vascular pedicle thrombosis. However, this is not without potential complications. The following report describes a case in which the use of a Fogarty vascular catheter during a thrombectomy for microsurgical flap salvage resulted in complete separation of the balloon from the catheter.

Paraspinous muscle flaps for the treatment and prevention of cerebrospinal fluid fistulas in neurosurgery

STUDY DESIGN

A prospective clinical study was conducted to evaluate the efficacy of paraspinous muscle flaps in preventing and managing cerebrospinal fluid fistulas in high-risk neurosurgery patients.

OBJECTIVES

To evaluate the efficacy of paraspinous muscle flap coverage using a "vest-over-pants" closure in the prevention and treatment of cerebrospinal fluid fistulas.

SUMMARY OF BACKGROUND DATA

Previous studies have described paraspinous muscle flaps for the closure of complex spinal wounds, but none has addressed their use for the prevention and treatment of cerebrospinal fluid fistulas.

METHODS

This prospective clinical study evaluated nine consecutive patients with either refractory cerebrospinal fluid fistulas or high risk for cerebrospinal fluid leaks after spinal surgery. Bilateral paraspinous muscle flaps were used as primary flaps and closed using an overlapping vest-over-pants technique in eight of nine cases. The latissimus dorsi and trapezius muscles were recruited as additional muscle flaps for closure of thoracolumbar and high thoracic deficits, respectively.

RESULTS

Paraspinous muscle flaps provided immediate wound coverage in seven high-risk patients undergoing spinal surgery and two patients with recurrent cerebrospinal fluid fistulas. Postoperative hospitalization averaged 14.4 days. There was no evidence of a cerebrospinal fluid fistula after an average follow-up of 176.7 days. No wound infections occurred. The only complications were a superficial hematoma, which was drained percutaneously on postoperative day 6, and a seroma, which was drained during the follow-up period and eventually resolved.

CONCLUSIONS

Paraspinous muscle flaps allow effective treatment and prevention of cerebrospinal fluid fistulas in selected high-risk patients and provide simple durable coverage of complex spinal wounds with minimal morbidity.

Adhesive strips: a simple and inexpensive trick for finger holding in hand surgery

Many finger holding devices have been developed to retract digits and provide exposure during hand surgery. We describe a simple, and cheap trick to keep fingers out of the way using adhesive strips that has proven efficient and helpful.

Long Term Complications of Orbital Floor Fracture Repair

Purpose

To search for complications of orbital floor fracture repair that occur late postoperatively, to reveal their natural course and to attempt to associate the complications with variables that are possibly involved in their genesis.

Methods

A retrospective comparative case series of all orbital floor fracture repair cases (158 eyes) from 1983 to 1998 was done. Synthetic prostheses were tailored to the orbital floor in clinically significant fractures. Bone grafts were chosen for large defects, comminuted fractures or if other reconstruction (eg, sinus) was required. Variables studied included age, sex, trauma to surgery time lag, surgeon, fracture type, length of surgery, antibiotics, prosthesis material, hospital stay and follow-up. These variables were tested for association with the following complications: altered vision, diplopia, dysesthesia, ectropion, pain, infection, enophthalmos and extrusion. Occurrence and resolution data were collected.

Results

One of four complications (often more than one per eye) resolved without surgery. Reintervention resolved one of three complications. Of all patients, 39.2% remain with long term unresolved complications. Altered vision is more probable with older patients and with longer surgeries. Diplopia was least likely to occur with orbitozygomatic or panfacial fractures and more probable with bone grafts. Ectropion and epiphora increased with a fracture's severity. Pain was mostly attributable to bone grafts. Enophthalmos was mainly due to large or comminuted fractures. Infection and extrusion were rare. Sex, surgeon and trauma to surgery time lag had no bearing on the incidence of complications.

Conclusions

Delaying surgery did not seem to influence complications. Lessening ocular manipulation during longer surgeries may reduce vision changes. The only truly modifiable variable was the material used for orbital floor repair. Alloplastic prostheses should be used, but if large or comminuted fractures are involved, bone grafting is an interesting first choice.

Morphometrics of domestic Panstrongylus rufotuberculatus in Bolivia

The trend to domesticity in Triatominae may represent a transitionary phase, towards increasing vectorial importance in the transmission of Chagas disease to humans, and requires sustained entomological surveillance. Although generally considered a sylvatic species, Panstrongylus rufotuberculatus has been recently captured inside human dwellings in the provinces of Nor Yungas and Muñecas in the Department of La Paz, Bolivia, providing evidence of this species' ability to colonise domestic habitats. The results of previous research on domestic and sylvatic specimens of other species of Triatominae indicate that morphometrics could be used to monitor this adaptive process. The most likely cause of differences seen in the size and shape of bugs from domestic colonies of P. rufotuberculatus from two neighbouring villages in Bolivia is probably genetic drift rather than environmental influences. Comparison with allopatric sylvatic specimens, including the holotype of P. rufatuberculatus, showed a general reduction in size from sylvatic to domestic specimens.

LDHk in the retina of diverse vertebrate species: a possible link to the Warburg effect

LDHk is a cancer-associated lactate dehydrogenase which is also found at high levels in normal mammalian retina. Such retinas share with most cancer tissues a dependence on aerobic glycolysis, leading to high production of lactate. However, retinas of lower vertebrate species are significantly less dependent on aerobic glycolysis. We find that retinas of species less dependent on aerobic glycolysis express significantly lower levels of an LDHk-like activity, less than or equal to the low levels seen in brains. The enzymes from lower species differ from the mammalian retinal enzyme in their pH optima and responsiveness to oxygen; but share a similar degree of inhibition by 5'-5'-dinucleoside tetraphosphates. Therefore, the expression pattern of LDHk in brain and retina of diverse vertebrate species suggests a link with the Warburg effect.