Using Absorbable Suture For Traumatic Wound Closure To Avoid Additional Hospital Visit For Suture Removal During The Covid 19 Pandemic: A Randomized Controlled Trial

Introduction: The COVID-19 pandemic worldwide forced governments to undertake intervention measures to encourage social distancing. Meanwhile, traumatic skin lacerations require multiple hospital visits for dressing, changings, and suture removal since they are usually repaired with non-absorbable sutures. In a matter of fact, these visits can be avoided by using absorbable sutures instead. However, absorbable sutures carry the theoretical risk of wound infection. In this study, our aim was to determine whether absorbable sutures are better than non-absorbable sutures in repairing lacerations during the COVID-19 pandemic. The first and second objectives were to assess the rate of infection and the number of postoperative hospital visits. Method(s): A sample of 469 patients with traumatic skin lacerations were analysed during the COVID-19 pandemic in April-July 2020. In the control group, wounds were repaired using non-absorbable sutures, while rapid-onset absorbable sutures were used in the treatment group. By conducting a phone call follow-up after 21 days, several parameters regarding infection signs and hospital visits were compared between both groups. Result(s): No statistically significant difference was observed between both groups regarding wound infection (p-value= 0.623). Using absorbable sutures resulted in fewer postoperative hospital visits than non-absorbable sutures (p-value= 0.001). This study is limited because the assessment of wound infection was subjective to the patient by a phone call follow-up. Conclusion(s): Using absorbable sutures to close traumatic skin lacerations is safe. They should be considered during a pandemic to reduce hospital visits for suture removal, which will subsequently enhance social distancing and relieve hospital load.

Surgical staples: Current state-of-the-art and future prospective

Wound closing is one of the widely performed and prominent clinical practices in the surgical intervention process. A physician or surgeon has several options ranging from surgical sutures and adhesive strips to fibrin glue for effective wound closure to close the commonly occurring surgical cuts and deep skin tissue injuries. However, all the commercially available wound closure devices have some limitations in each and another perspective. From the beginning of the late 90s, surgical staples got tremendous attention as efficient wound closure devices for their time-effective and sufficient mechanical strength, performance feasibility, fewer chances of surgical site infection and require minimal expertise characteristics in consideration of remote location. Even in the context of the recent COVID19 pandemic, the clinical acceptance and patient compliance for the staples have increased due to minimizing the chances of prolonged interaction between the patient and physicians. The surgical staples application is extensive and diversified, ranging from common external cuts to highly complex surgery procedures like laparoscopic appendectomy, intestinal anastomosis, etc. Thus, in this literature review, we try to give a comprehensive glimpse of the development and current state-of-the-art surgical staples in consideration with research from a commercial point of view. On a special note, this review also describes a very brief outline of the regulatory aspects and some common internationally acceptable 'de jure standards for the development of commercially viable surgical staples. Copyright © 2022 The Author(s)

Assessing the natural history of recessive dystrophic epidermolysis bullosa wounds using a home photography app

Recessive dystrophic epidermolysis bullosa (RDEB) is a devastating, genetic, blistering condition caused by the absence of type VII collagen (C7) resulting in wounding. One major barrier to clinical trial development is the lack of understanding of the natural history of RDEB wounds, as the measurement of wound change has not been studied prospectively or validated. We conducted a longitudinal observational study of 13 participants with RDEB, that were not currently participating in interventional clinical trials. They used a mobile phone photography application with built-in machine learning to outline and track RDEB wounds autonomously. Participants used this mobile application to capture weekly photographs of chronic or recurrent wounds for up to six months and reported associated pain and itch. In total, 773 photos were collected from 72 wounds, of which 39 were chronic wounds (54.2%). The median time for wound closure (≥90% decrease in size from the first photo) was 249 days for chronic open wounds and 68 days for recurrent wounds. A chronic open wound was defined as a wound that has not healed for more than 12 weeks and a recurrent wound heals in less than 12 weeks, but re-opens. For chronic open wounds, wound size was positively correlated with pain and itch using spearman correlation coefficients (0.76, p<0.001 and 0.74, p<0.001, respectively). Wound size for recurrent wounds were also positively associated with pain and itch (0.37, p<0.001;0.32, p<0.005). The COVID-19 travel restrictions have shown the value of remote wound monitoring to assess the natural history of RDEB wounds. Challenges included patient difficulties in navigating the mobile application, uploading regularly, and limited participation due to enrollment in other clinical trials. The next step of this work is to compare our findings of the closure time for chronic versus recurrent wounds against published wound size data of 60 participants from a recent clinical trial, which will enable our group to test definitions of chronic and recurrent wound duration.

Improving the surgical teaching opportunities: A QI project to deliver a course at a local hospital level during COVID-19 pandemic

Aim: During the COVID-19 pandemic, the training opportunities were markedly disrupted particularly, the surgical teaching which usually requires face to face teaching to help the acquisition of procedural skills. We implemented a QI project in a district hospital to improve the training opportunities for medical students & foundation doctors. The project was a face-to-face free course for teaching generic procedural and clinical skills in surgery. Method: The course was a mixture of two well-known surgical courses in the UK, Basic Surgical Skills and the CCrISP courses. It included clinical and procedural skills sessions on models which simulated the basic wound closure techniques and types of knots, as well as skin lesion excision training. The course was delivered to medical students, foundation year one & two doctors and core surgical trainees. The improvement achieved by the course was measured by a questionnaire assessing the level of confidence between the candidates before and after each session. The questionnaire's answers were categorised into (not confident, neutral, confident & very confident). The course was delivered on two occasions. Results: The qualitative analysis of the results on two different occasions showed a considerable improvement in the level of confidence between the candidates. They were able to demonstrate engagement throughout the course especially with the procedural skills sessions. Conclusions: Formulating a course at a local hospital level was an efficient alternative for maximising the training opportunities reduced during the pandemic. It was an impressive opportunity for newly graduated doctors and medical students having any surgical placement.

A Better Way to Manage Paediatric Maxillofacial Trauma;A Retrospective Study Examining the Presentation of Maxillofacial Soft Tissue Injuries and Management over 3-year period at a Regional Children's Hospital

Introduction: Maxillofacial treatment is evolving with changing paediatric lifestyles and clinical limitations, including COVID-19. The aim of this study is to assess trends in the presentation of maxillofacial soft tissue injuries and subsequent management within a regional paediatric hospital. Methods: Retrospective study over a 3-year period (from 2019-2021 between January and April). Inclusion of all paediatric patients seen on the emergency department by OMFS team. Results: Between 2019 and 2021, the total number of patients dropped by over half. The average age dropped from 5.9 in 2019 to 3.8 in 2021. Males were more commonly seen. Extraoral injuries increased by 21%. Intraoral injuries reduced by 8%. Less complicated communicating injuries and associated dental trauma were seen in 2021. Lip lacerations accounted for most injuries. In 2020, there was 21% reduction in conservative management of injuries. Wound closure under LA increased by 12% in 2020. There has been an overall increase in wound closure under GA by 5% between 2019 and 2020. Falls accounted for most injuries, however, there has been an increase in dog bite injuries by 5% in 2021. Conclusions: The average age has dropped between 2019-2021 and hence treatment options remain limited. Age, cooperation, and severity of injury are important factors. The number of overall lacerations has decreased but a greater proportion required formal closure under general anaesthesia. It is vital OMFS surgeons are aware of the changes in presentation and current trends in management. This will help to better equip surgical teams for the changing landscape of paediatric maxillofacial trauma.

Loose scrotal wound edge approximation in the setting of pyoderma gangrenosum after COVID-19 infection.

Pyoderma gangrenosum (PG) is a rare autoinflammatory skin disease characterized by recurrent ulcers. It is a diagnosis of exclusion and treatment can be challenging due to limited evidence-based therapies. While surgical management is typically avoided due to the risk of pathergy, it can be warranted in specific cases. Here, we have illustrated a unique case of genital PG that began after COVID-19 infection and which resulted in scrotal prolapse with testicular exposure. Loose closure with a horizontal mattress suture while the patient was on immunosuppression allowed for complete wound healing.

Could surgery under local anaesthetic be the default for Pilonidal Sinus Disease? A systematic review

Aims: Pilonidal sinus disease (PSD) is a significant cause of morbidity. The purpose of this systematic review and meta-analysis is to determine the totality of evidence regarding the effectiveness of Local Anaesthesia (LA) when compared to spinal or general anaesthesia in individuals undergoing definitive surgery for PSD. Methods: A systematic review of literature was conducted. Studies included randomized controlled trials comparing LA with other anesthetics and non-randomized studies focusing on ambulatory procedure of excising pilonidal sinus aiming wound closure, all performed under local anesthetics. We used Cochrane risk of bias tool. The statistical analysis was done using Revman and Excel. Results: Four original RCTs and 10 observational studies were included, with a total of 1801 patients. There was no significant difference in operative time between the groups Patients in the local anaesthetic group experienced less pain than those in other group, lower rates of anaesthetic related complications, early return to work and increased satisfaction. However, the mode of anaesthesia used had no relation with recurrence. Conclusion: Our findings support the use of LA in adult patients undergoing definitive surgical treatment for PSD. We aggregate the published evidence to demonstrate clear benefits clinically, patients' preference, and economic benefits. Patient selection, and adequate dose of local anaesthetic, is the key. In the context of the current COVID-19 pandemic, novel care pathways need to be developed in all medical fields, and we would propose that surgery for Pilonidal Sinus Disease under local anaesthesia should now be the default.

The SARS-CoV-2 Spike protein alters human cardiac pericyte function and interaction with endothelial cells through a non-infective mechanism involving activation of CD147 receptor signalling

Background: Human cardiac pericytes (PC) were proposed as the main cellular target for SARS-CoV-2 in the heart due to high transcriptional levels of the angiotensin-converting enzyme 2 (ACE2) receptor. Emerging reports indicate CD147/Basigin (BSG), highly expressed in endothelial cells (EC), is an alternative SARS-CoV-2 receptor. To date, the mechanism by which the virus infects and disrupts the heart vascular cells was not identified yet. Moreover, cleaved Spike (S) protein molecules could be released into the bloodstream from the leaking pulmonary epithelial-endothelial barrier in patients with severe COVID-19, opening to the possibility of non-infective diseases in organs distant from the primary site of infection. Purposes: (1) to confirm that human primary cardiac PC express ACE2 and CD147;(2) to verify if PC are permissible to SARS-CoV-2 infection;(3) to investigate if the recombinant SARS-CoV-2 S protein alone, without the other viral elements, can trigger molecular signalling and induce functional alterations in PC;(4) to explore which viral receptor is responsible for the observed events. Methods and results: Cardiac PC express both the ACE2 and CD147 receptors at mRNA and protein level. Incubation of PC for up to 5 days with SARS-CoV-2 expressing the green fluorescent protein (GFP) did not show any evidence of cell infection or viral replication. Next, we exposed the PC to the recombinant S protein (5.8 nM) and confirmed that the protein engaged with cellular receptors (western blot analysis of S protein in treated and control PC). Incubation with the S protein increased PC migration (wound closure assay, P<0.01 vs ctrl) and reduced the formation of tubular structures between PC and EC in a Matrigel assay (P<0.01 vs ctrl). Moreover, the S protein promoted the production of pro-inflammatory factors typical of the cytokine storm in PC (ELISA measurement of MCP1, IL-6, IL-1β, TNFα, P<0.05 vs ctrl), and induced the secretion of proapoptotic factors responsible for EC death (Caspase 3/7 assay, P<0.05 vs ctrl). Signalling studies revealed that the S protein triggers the phosphorylation/ activation of the extracellular signal-regulated kinase 1/2 (ERK1/2) through the CD147 receptor, but not ACE2, in cardiac PC. The neutralization of CD147, using a blocking antibody, prevented ERK1/2 activation in PC, and was reflected into a partial rescue of the cell functional behaviour (migration and pro-angiogenic capacity). In contrast, blockage of CD147 failed to prevent the pro-inflammatory response in PC. Conclusions: We propose the novel hypothesis that COVID-19 associated heart's microvascular dysfunction is prompted by circulating S protein molecules rather than by the direct coronavirus infection of PC. Besides, we propose CD147, and not ACE2, as the leading receptor mediating S protein signalling in cardiac PC.