Surgical Care Research Articles

Disparities in Access to Outpatient Surgery Related to Removal of Procedures from Medicare's Inpatient Only List.

We assessed the shift from inpatient to outpatient surgical care related to changes to the Inpatient Only List in 2020 and 2021 compared to 2019. The extent to which procedures shift from the inpatient to outpatient setting following removal from Medicare's Inpatient Only List is unknown. Many health systems also encouraged a shift from inpatient to outpatient surgery during the COVID-19 pandemic. Assessing the relative change in outpatient surgical utilization for procedures removed from the Inpatient Only List during COVID-19 would provide empirical data on whether reimbursement policy changes or inpatient capacity needs during the pandemic were more likely to shift care from the inpatient to outpatient setting. We used administrative data from the PINC AI Healthcare Database across 723 hospitals to determine the within-facility relative change in outpatient vs inpatient procedural volume in 2020 and 2021 compared to 2019 using a multivariable conditional fixed-effects Poisson regression model. We also assessed whether outpatient surgical utilization varied by race and ethnicity. Using a multivariable linear probability model, we assessed the absolute change in risk-adjusted 30-day complication, readmission, and mortality rates for inpatient and outpatient surgical procedures. In 2020 and 2021 compared to 2019 respectively, there was a 5.3% (95% CI, 1.4% to 9.5%) and 41.3% (95% CI 33.1% to 50.0%) relative increase in outpatient elective procedural volume. Outpatient procedural volume increased most significantly for hip replacement which was removed from the Inpatient Only List in 2020 (increase in outpatient surgical utilization of 589.3% (95% CI, 524.9% to 660.3%)). The shift to outpatient hip replacement procedures was concentrated among White patients; in 2021, hip replacement procedural volume increased by 271.1% (95% CI, 241.2% and 303.7%) for White patients and 29.5% (95% CI, 24.4% and 34.9%) for Black patients compared to 2019 levels. There were no consistent or large changes in 30-day complication, readmission, or mortality risk in 2020 and 2021 compared to 2019. There was a modest increase in elective outpatient surgeries and a pronounced increase in outpatient orthopedic surgeries which were removed from the Inpatient Only List during the COVID-19 pandemic. Utilization of outpatient surgical procedures was concentrated among White patients.

Laparoscopic cholecystectomy performed by a surgical care practitioner: a review of outcomes.

Surgical care practitioners (SCPs) are non-medical workers involved in various aspects of the management of surgical patients. The role includes assisting and performing surgical procedures. More than 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever-increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP. A retrospective review of a prospectively collected database was performed. The primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission. In total, 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis in 30 (17.6%) and pancreatitis in 13 (7.6%). Mean operating time was 65min (range 35-152min). Fifty-three operations were assisted by a consultant, 110 by a specialist or associate specialist grade (SAS) doctor and 7 by a core trainee (CT2). Some 139 (81.7%) patients were discharged on the day of surgery and 24 (14.1%) stayed one night in hospital. There were no major complications. Five patients required readmission, three with pain and two with port site infections. There were no conversions or transfusions required. There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach, SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP.

Bridging the Gap: Addressing Social Determinants to Enhance Access to Surgical Care and Improve Survival in Early-Stage Colon Cancer.

Bridging the Gap: Addressing Social Determinants to Enhance Access to Surgical Care and Improve Survival in Early-Stage Colon Cancer.

Professional Societies in Surgical Infection Care

Professional Societies in Surgical Infection Care

Current status and issues regarding surgical education in the region: a questionnaire survey in Oita prefecture in Japan

BackgroundThe shortage and aging of surgeons in regional surgical care has been remarkable, and the importance of surgical education for young surgeons in the region is only increasing. However, there are very few reports about regional surgical education. This study aimed to clarify the current status and issues regarding surgical education in regional surgical care and to examine the ideal way to provide surgical education in the region.MethodsTwo questionnaire surveys were carried out. (1) “Survey on the awareness regarding the education of young surgeons” was conducted by mail in institutions where surgeons worked. (2) “Survey on the current status of surgical education for young surgeons” was conducted via the Internet with surgeons under 40 years old and mentors at the same facility.ResultsThere were 175 respondents to survey (1), among whom 131 (75%) surgeons were interested in educating young surgeons, and 112 (64%) were actively participating in this educating. Regarding the best evaluation methods for mentors who are educating young surgeons, the most frequent answer was “I don’t know (51%)”. The number of respondents in survey (2) was 87, including 27 (31%) young surgeons and 60 (69%) mentors. Although there was no difference between young surgeons and mentors in the level of satisfaction with the current status of young surgeons, 37% of young surgeons in urban areas were dissatisfied with their current status, compared to 0% in the regional area (p < 0.05).ConclusionsAlthough surgeons did not have confidence in their own education, the level of satisfaction among young surgeons was high even in those providing regional surgical care. Development of an evaluation system for surgical education is necessary for young surgeons to receive more effective surgical education in the region.

Prospective with historical control, case-matched cohort study of the tertiary survey beneficial in critically severe trauma patients

Background The tertiary survey is an evaluation process conducted after the primary and secondary surveys. It aims to identify missed injuries. This research aims to study the benefits of tertiary surveys in severely traumatized patients. Methods This prospective with historical control, case-matched cohort was conducted on critically-ill trauma patients who were admitted to the surgical intensive care unit (SICU) of Thammasat University Hospital. The study compared the period before and after the implementation of the tertiary survey. Tertiary survey record form was used in all severely traumatized patients with Injury Severity Score (ISS) &gt; 15 within the first 24 hours and before discharge from SICU between August 2022 and February 2023. The comparison data were retrieved from electronic medical records of patients admitted to SICU with ISS &gt; 15 between April 2020 and July 2022. Results We identified 55 type II missed injuries in 39 of 100 cases prior to implementation and 1 type II missed injury after implementation. Type II missed injury decreased from 31% to 4%, and the missed injury detection rate was 56% after implementing the tertiary survey. However, there is no statistically significant difference in morbidity and mortality rates from missed injuries before and after implementation. Conclusions Using tertiary surveys can reduce missed injury rates and increase missed injury detection rates. This research highlights the importance of implementing tertiary surveys as a routine part of trauma evaluation to improve patient care. However, there is no effect on the outcomes, which may require more sample size. Clinical Trials Registry (reference number TCTR20230625001).

The concomitant occurrence of hidradenitis suppurativa and Fournier’s gangrene

Background: Fournier’s gangrene represents a life-threatening necrotising infection affecting the perineal region, while hidradenitis suppurativa is characterised by a chronic inflammatory skin condition. The simultaneous occurrence of both conditions is exceedingly rare. Case description: A 42-year-old female with a documented history of severe untreated hidradenitis suppurativa presented for shortness of breath, fever and lethargy, along with extensive wounds and skin breakdown involving the left axilla, perineum, lower back, lumbosacral region and bilateral gluteal areas, extending to the perineum. Upon presentation, the patient was in a state of septic shock, and a diagnosis of actively manifesting Fournier’s gangrene was established at the site of the pre-existing hidradenitis suppurativa lesions. Despite the implementation of an aggressive multidisciplinary approach incorporating surgical interventions, antibiotic therapy and intensive care measures, the patient’s condition deteriorated, culminating in septic shock, multi-organ failure and eventual demise. In this report, we discuss both clinical entities, their similarities and differences, and the possible mechanisms by which they may have co-occurred. Conclusion: The co-existence of hidradenitis suppurativa and Fournier’s gangrene poses unique challenges, given the rapid progression of Fournier’s gangrene within the context of hidradenitis suppurativa, potentially suggesting the latter as a predisposing factor. This case underscores the importance of vigilant screening and management of hidradenitis suppurativa.

Massive peritoneal inclusion cyst with secondary abscessation

AbstractPeritoneal inclusion cysts are rare intra‐abdominal cystic lesions of controversial pathogenesis and nomenclature. Postulated to be of neoplastic or reactive origin, they are characterised by progressive expansion and variable symptomatology in classically reproductive‐aged females. Local recurrence is frequent while malignant transformation is plausible. Herein, we review a presentation of a massive peritoneal inclusion cyst with secondary abscessation and septic shock in a 58‐year‐old female, reviewing the available literature to highlight the potential acuity of this pathology, the standard of surgical care, and the need for caution by treating surgeons in its evaluation as an entirely benign process.

Systemic inflammation and delirium during critical illness.

The purpose of this study was to determine associations between markers of inflammation and endogenous anticoagulant activity with delirium and coma during critical illness. In this prospective cohort study, we enrolled adults with respiratory failure and/or shock treated in medical or surgical intensive care units (ICUs) at 5 centers. Twice per day in the ICU, and daily thereafter, we assessed mental status using the Richmond Agitation Sedation Scale (RASS) and the Confusion Assessment Method-Intensive Care Unit (CAM-ICU). We collected blood samples on study days 1, 3, and 5, measuring levels of C-reactive protein (CRP), interferon gamma (IFN-γ), interleukin (IL)-1 beta (IL-1β), IL-6, IL-8, IL-10, IL-12, matrix metalloproteinase-9 (MMP-9), tumor necrosis factor-alpha (TNF-α), tumor necrosis factor receptor 1 (TNFR1), and protein C using validated protocols. We used multinomial logistic regression to analyze associations between biomarkers and the odds of delirium or coma versus normal mental status the following day, adjusting for age, sepsis, Sequential Organ Failure Assessment (SOFA), study day, corticosteroids, and sedatives. Among 991 participants with a median age (interquartile range, IQR) of 62 [53-72] years and enrollment SOFA of 9 [7-11], higher concentrations of IL-6 (odds ratio [OR] [95% CI]: 1.8 [1.4-2.3]), IL-8 (1.3 [1.1-1.5]), IL-10 (1.5 [1.2-1.8]), TNF-α (1.2 [1.0-1.4]), and TNFR1 (1.3 [1.1-1.6]) and lower concentrations of protein C (0.7 [0.6-0.8])) were associated with delirium the following day. Higher concentrations of CRP (1.4 [1.1-1.7]), IFN-γ (1.3 [1.1-1.5]), IL-6 (2.3 [1.8-3.0]), IL-8 (1.8 [1.4-2.3]), and IL-10 (1.5 [1.2-2.0]) and lower concentrations of protein C (0.6 [0.5-0.8]) were associated with coma the following day. IL-1β, IL-12, and MMP-9 were not associated with mental status. Markers of inflammation and possibly endogenous anticoagulant activity are associated with delirium and coma during critical illness.

Harnessing the power of artificial intelligence: A new door for quick surgery in Pakistan

Artificial intelligence (AI) has the potential to transform surgery in Pakistan, improving results, reducing complications, and increasing patient safety. Deep learning, a branch of machine learning, can assist surgeons in making wise judgments. Pubmed and Research Gate discuss the promise of AI in surgery. Incorporating AI in healthcare systems can expedite diagnosis and management while avoiding injudicious resource allocation. AI-based techniques in cardiology, nephrology, and neurology enable high-accuracy detection of cardiovascular disease risks, kidney disease treatment, and epileptic episode identification. Neurological devices like bispectral index monitor (BIS) and Near-infrared spectroscopy (NIRS) utilize advanced technology for reliable monitoring and objective diagnosis of neurological issues (Ahmed, 2022). AI uses electronic data and neural network methods to evaluate operating room logistics, time management, and anesthesiologist activities using electronic data and neural network methods (Khan F. H., 2019). AI algorithms are effectively detect minute differences for accurate diagnosis, with studies showing high specificity, sensitivity, and inter-operator repeatability. AI can be used to train and assess neurosurgical residents and early mid-career surgeons, improving diagnosis and 3D simulation labs (Shlobin, 2022). Surgeons play a crucial role in adopting AI-based technologies for surgical care by partnering with data scientists to capture novel clinical data and generate meaningful interpretations. They should demand transparency and interpretability in algorithms to hold AI accountable for its predictions and recommendations.AI advancements in plastic surgery practice, research, and education offer opportunities for improvement. Combining AI-enabled decision-making tools with predictive analytics and human intuition, surgeons can make real-time decisions based on 3D planning, anatomical localization, and navigation (Rasteau, 2022). While current AI tools cannot perform complex surgical procedures, advancements may enable them to perform more complex tasks in the future. Pakistan is a significant market for AI-based solutions, utilizing technology in various industries to address challenges and boost demand. The country has enhanced its self-security systems, including AI-powered missiles, cyber security, and effective cameras (Khan, 2022). AI allows tasks to be completed more precisely and efficiently, with machine learning and deep learning being advanced subtypes. In developing countries like Pakistan, AI tools are needed for patient-centred diagnosis and treatment assistance, especially in emergency surgery such as cardiac illnesses or life threatening bleeding caused road traffic accident. Hence insuring patient receive care timely. An appropriate budget should be allocated for AI technologies in the health sector.

Defining Types of Leadership Within an Academic Surgery Department to Promote Change for Decreasing Rates of Burnout.

Successful leaders influence the group they represent. Effective surgical care is tied to its leadership climate. However, most surgical providers are not attuned to their individual strengths which if known they could leverage them within their teams. This study identifies leadership types within a department of surgery which may be used to better understand and cultivate their strengths. In 2022, 172 providers in an academic surgery department were offered the GallupTM CliftonStrengths assessment, a proprietary instrument that maps 34 strengths across 4 domains of leadership. The assessment provides a respondent with their top 5 strengths and the domain in which they naturally "lead". Of 172 providers, 127 (74%) completed the assessment. While providers have strengths in multiple domains, they "lead with" a specific domain. Mapped from the providers' top 10 strengths, the most common "lead with" domain for surgical providers was Executing: the ability to implement ideas and produce results. Strategic Thinking: those who are analytical and push teams forward and Relationship Building: the ability to create strong and effective teams were followed by the least common domain. Influencing: the ability to communicate ideas and lead others. Formal leaders were significantly more likely to lead with Strategic Thinking. There were no significant differences between APPs and physicians. A majority of surgical providers "lead with" the GallupTM Executing domain. Those who lead with executing skills work tirelessly to produce outcomes. Learning to leverage the strengths of our teams to create cohesion and efficiency may improve engagement and retention.

Application of Time-Driven Activity-Based Costing for Head and Neck Microvascular Free Flap Reconstruction.

Traditional hospital accounting fails to provide an accurate cost of complex surgical care. Here we describe the application of time-driven activity-based costing (TDABC) to characterize costs of head and neck oncologic procedures involving free tissue transfer. Retrospective cohort study. Single tertiary academic medical center. An analysis of head and neck oncologic procedures involving microvascular free flap reconstruction from 2018 to 2020 (n = 485) was performed using TDABC methodology to measure cost across operative case and postoperative admission, using quantity of time and cost per unit of each resource to characterize resource utilization. Univariate and generalized linear mixed models were used to examine associations between patient and hospital characteristics and cost of care delivery. The total cost of care delivery was $41,905.77 ± 21,870.27 with operating room (OR) supplies accounting for only 10% of the total cost. Multivariable analyses identified significant cost drivers including operative time, postoperative length of stay, number of return trips to the OR, postoperative complication, number of free flaps performed, and patient transfer from another hospital or via emergency department admission (P < .05). Operative time and postoperative length of stay, but not operative supplies, were primary drivers of cost of care for head and neck oncology cases involving free tissue transfer. TDABC offers granular cost characterization to inform cost optimization through unused capacity identification and postoperative admission efficiencies.

The role of radiological diagnostic methods in complicated combat chest trauma

Objective. To evaluate the effectiveness of radiation methods for diagnosing combat chest trauma at the stage of specialised surgical care. Materials and methods. The results of diagnostic measures performed on 51 wounded with bilateral combat chest trauma were analysed. All the wounded underwent chest radiography (if necessary, in two projections). Ultrasound examination of the chest cavity was performed in real time. Spiral computed tomography was performed on multislice computed tomography scanners. Video thoracoscopy was performed in 20 (83.3%) of 24 wounded patients treated at the Department of Thoracoabdominal Surgery of the Zaitsev Institute of General and Emergency Surgery in 2022­2023. In 27 patients treated in the same department and the polytrauma department of the Kharkiv City Clinical Hospital of Emergency Medical Care named after Prof. O. I. Meshchaninov in 2014­2016, video thoracoscopy was not used as a diagnostic method. Results. An important advantage of spiral computed tomography was that this method makes it possible to accurately determine the nature of damage to the chest cavity organs, the bone skeleton of the chest, post­traumatic complications and plan surgical treatment (correction) of existing injuries at the stage of providing specialised thoracic surgical care, in particular, using thoracoscopic access. Conclusions. Combat chest trauma is a severe injury that should be considered within trauma protocols, where clinical signs are only informative in the early diagnostic stages for potentially fatal injuries.

Feasibility of Combining Functional Mobilisation with Resistance and Endurance Training for Mechanically Ventilated Patients in Intensive Care Unit Setting-A Pilot Study.

Background: Intensive-care-acquired weakness resulting in functional impairment is common in critical care survivors. This study aims to evaluate the feasibility of a combined early functional training with endurance and resistance training and its effect on the functional outcome. Methods: It is a pilot study performed in a 39-bed Medical and Surgical Intensive Care Unit (ICU). Patients who were premorbidly independent and were mechanically ventilated for ≥24 h were recruited to receive functional mobilisation (sit out of bed, ambulation), endurance (bed cycling), and resistance training (selected upper and lower limb muscle training using weights). The primary outcomes were feasibility of training, muscle strength, handgrip strength, quadricep strength, and Functional Status Score-Intensive Care Unit (FSS-ICU) collected at the first assessment in the ICU, at the ICU discharge, and at hospital discharge. Secondary outcomes were functional capacity (6-Minute Walk Distance) and quality of life measures, EQ-5D, at hospital discharge and at 3 months. Results: Out of the 11 patients, 6 (54.54%) patients achieved level 2 functional mobilisation, 2 (18.18%) patients achieved level 2 resistance training, and 1 (9.09%) patient achieved level 2 endurance training. There were no significant differences in the medical research council (MRC) score, quadricep strength, and handgrip strength between the first assessment in the ICU, at the ICU discharge, and at hospital discharge. However, there was a significant difference in FSS_ICU (p < 0.008) from the first assessment in the ICU up to hospital discharge. EQ-5D visual analogue scale also showed a change of 8.5% at 3-month follow-up. 6MWD showed significant difference (p < 0.043) at 3-month follow-up compared to that at hospital discharge. Conclusions: The study found low compliance to resistance and endurance training in patients with mechanical ventilation. However, functional mobilisation in terms of sit out of bed was possible in more than half of the recruited patients.

The risk of facial nerve palsy after benign parotidectomy. A quality project

Background Facial nerve palsy is a potential complication of parotidectomy for benign salivary gland tumours, necessitating a comprehensive understanding of its incidence and associated risk factors for improved patient counselling and preoperative planning. Aim/objectives This single-centre retrospective study aimed to assess the rate of facial nerve palsy following benign parotidectomy at a University Teaching Hospital. Material and methods Over a 3-year period, 160 patients undergoing parotid surgery for benign tumours were included. Data, encompassing sex, age, operation technique, tumour pathology, facial nerve function, and follow-up duration, were collected from medical records. Exclusion criteria comprised patients with prior parotid gland surgery or preoperative facial nerve palsy. Results The study revealed a 3.75% incidence of facial nerve palsy with no total paralysis post-parotidectomy for benign disease. Pleomorphic adenoma (50.6%) and Warthin’s tumour (44.4%) were the predominant tumour types. No significant differences were noted between groups with and without postoperative facial palsy based on obtained covariates. Conclusion and significance Our findings endorse partial superficial parotidectomy and extracapsular dissection as low-risk treatments for benign parotid tumours. However, prospective studies are warranted to elucidate recovery rates and long-term consequences of facial nerve palsy, contributing to refined surgical approaches and patient care in parotid surgery.

Instituting a Palliative Care Trigger in a Surgical Intensive Care Unit (SICU): Survey Results of SICU Team Members.

Increasing palliative care presence in the intensive care unit (ICU) improves symptom management, increases goals-of-care discussion, and reduces unnecessary procedures in ICU patients. An interdisciplinary study team developed a palliative care trigger program in a 17-bed surgical ICU (SICU). Surgical ICU patients who met 3 triggers (ICU length of stay > 10 days, repeat ICU admission, and metastatic cancer) automatically received a palliative care consult. The purpose of the current study was to survey SICU health care professionals before and after the institution of the palliative care trigger program. Overall, the palliative care trigger program was viewed positively by interdisciplinary team members with increased team communication and decreased resistance for the inclusion of palliative care in the SICU plan of care. The palliative care trigger program was successfully developed and implemented in a SICU and was accepted by the interdisciplinary team members caring for SICU patients. Team member feedback is being used to expand the palliative care trigger program to improve care for SICU patients.

Anchors Aweigh! The History of Women Surgeons at Sea.

Throughout history, the maritime nations of the world have employed surgeons in sea-going service. The history of women in surgery and the military is well described, but no previous report exists describing the gender breakdown of past and current sea-going US Navy general surgeons. Using literature review, primary sources, personal interviews, and correspondence with Navy Medicine administrative leaders, this historical review describes the evolution of women providing surgical care at sea. During the 1800s and early 1900s, some of the earliest women surgeons in England, America, and Russia began their surgical careers in military service or providing combat casualty care. Women at sea served unpaid nursing roles in the 1700s and provided informal medical care in the 1800s. In 1913 and 1941, 2 different women held medical leadership roles aboard sea-going vessels. Four years after Congress allowed women to serve aboard combatant vessels, Dr Beth Jaklic became the first woman to serve as Ship's Surgeon aboard a US Navy warship in 1997. From 1997 to 2020, 19% of surgeons serving on aircraft carriers were women and one-half of the 20 general surgeons assigned to maritime surgical billets were women in 2022. War and the military environment historically have offered opportunities for women to break boundaries in the world of surgery. Navy Medicine's experience with women surgeons at sea serves as a positive example to the broader surgical community, especially "austere" practices and subspecialties with limited female representation.

Urinary catheterisation among nurses in Sweden: A survey on routines and guideline adherence

AbstractIntroduction and ObjectivesBladder catheterisation is a common and invasive procedure with guidelines that can prevent or minimize associated complications. However, healthcare workers often do not follow these guidelines. Healthcare systems' strategies, policies and practices which support quality of care could affect the level of guideline adherence. This could be explored by studying adherence in a high‐performing healthcare system with extensive monitoring of health outcomes, such as Sweden. Moreover, there is a lack of relevant literature about the knowledge, attitudes and practices of healthcare workers regarding CAUTI. This study therefore aims to investigate how nurses in Sweden perform bladder catheterisation and identify potential ways to improve adherence to guidelines in order to decrease complications.Materials and MethodsA cross‐sectional survey was performed between the 21st and 29th of May 2020. A survey including questions on supervision during bladder catheterisation, maintenance of sterility, accidental urine spillage, and potential advantages of a urinary catheter with an integrated valve was distributed through social media channels to Swedish nurses. Participants were anonymous and no personal data was collected. The data was tabulated and analysed using descriptive statistics (Microsoft Excel).ResultsA total of 910 nurses responded to the survey. Respondents worked across several settings, and 76.1% worked within surgical, internal medicine, prehospital, geriatrics or primary care clinics. Respondents had various levels of experience in placing catheters, with 40.3% having inserted less than 50 catheters, and 31.5% having inserted more than 100.54.9% reported that someone had checked that they followed guidelines during catheter insertion. A majority (66.5%) either often or sometimes received assistance during insertion, with only 9.3% always receiving help. Only 9.9% reported always being able to maintain sterility during insertion.58.6% reported inadvertently spilling urine on the material (protective sheet, diaper) 1–5 times during their last 10 catheter insertions, 24.8% reported spilling on the bed or linen, and 15.7% on themselves, the patient or other healthcare staff.When asked about the potential advantages of a urinary catheter with an integrated valve, the most significant advantage cited was the reduced risk of urine leakage (63%), followed by the absence of stress from not having to connect a urine bag or plug (52.1%). 96% of respondents see at least one advantage in such a device.ConclusionsNearly half of nurses have not been audited concerning guideline adherence during bladder catheterisation. Only 10% are able to always maintain sterility, and it is common to spill urine during the catheterization process. Virtually all nurses see at least one advantage in a urinary catheter with an integrated valve.

Suspect dyskeratotic neoformations in a 7-year-old child with keratitis-ichthyosis-deafness syndrome: diagnostic, surgical and wound care management

Keratitis-ichthyosis-deafness syndrome (KID) is a rare genetic disorder characterized by the triad of hyperkeratosis, ichthyosis, and congenital prelingual sensorineural deafness, with less than 100 cases described in the literature. In addition to many other extra-cutaneous manifestations, these patients are burdened by two principal increased risk factors involving the skin: the risk of developing infections and the risk of developing malignant skin tumors, especially Squamous Cell Carcinoma and Trichilemmal tumors. We present the case of a 7-year-old girl with a unique genetic variant described to date, who developed 4 dyskeratotic neoformation. Since the dermatoscopic examination was not sufficient to exclude malignancy, excisional and punch biopsies were used. Nonetheless, healing was challenging, with wound dehiscence and infection onset. Ad hoc wound care management resorting to negative pressure therapy and advanced medical honey-based dressings was necessary to achieve complete wound healing.

From intestinal failure to transplantation: Review on the current need for transplant indications under multidisciplinary transplant programs worldwide.

Intestinal failure, defined as the loss of gastrointestinal function to the point where nutrition cannot be maintained by enteral intake alone, presents numerous challenges in children, not least the timing of consideration of intestine transplantation. To describe the evolution of care of infants and children with intestinal failure including parenteral nutrition, intestine transplantation, and contemporary intestinal failure care. The review is based on the authors' experience supported by an in-depth review of the published literature. The history of parenteral nutrition, including out-patient (home) administration, and intestine transplantation are reviewed along with the complications of intestinal failure that may become indications for consideration of intestine transplantation. Current management strategies for children with intestinal failure are discussed along with changes in need for intestine transplantation, recognizing the difficulty in generalizing recommendations due to the high level of heterogeneity of intestinal pathology and residual bowel anatomy and function. Advances in the medical and surgical care of children with intestinal failure have resulted in improved transplant-free survival and a significant fall in demand for transplantation. Despite these improvements a number of children continue to fail rehabilitative care and require intestine transplantation as life-saving therapy or when the burden on ongoing parenteral nutrition becomes too great to bear.