Teaching hypospadias repair by utilising a novel 3D-printed silicon model: An initial assessment using structured trainee and trainer feedback.

INTRODUCTION: Simulated paediatric surgical training is inherently advantageous and flourishing. Moreover, several working conditions resulted in reduced training hours, index and subspecialty cases encountered, and the COVID-19 pandemic affected elective surgery backlogs, hence training opportunities. Hypospadias repair is technically-demanding and requires a spectrum of dissective and reconstructive skills. We therefore aimed to test a 3D-printed silicon model for hypospadias repair, in the context of hands-on surgical training. MATERIAL AND METHODS: Twenty-Seven trainees, under the supervision of 15 instructors, completed the activity. They were given a seminar to show the relevant anatomy, and 8 key steps of the exercise: (1)-degloving; (2)-urethral plate marking; (3)-incision; (4)-tubularisation; (5)-glansplasty/glanuloplasty; (6)-dartos layer preparation; (7)-preputioplasty and (8)-skin closure. Each trainee completed a structured feedback assessment. An on-site trainer supervised and evaluated each exercise. Trainees and trainers rated the model through the above steps from unsatisfactory-(1/5) to excellent-(5/5), presented herein via cross-sectional analysis. RESULTS: Eleven-(40.7 %) trainees were in years:1-3 of specialist training, 10-(37 %) were in years:4-6, and 6-(22.2 %) were beyond year-6. Two-(7.4 %) trainees had nil-hypospadias experience, 16-(59.2 %) previously assisted in procedures or performed steps, 5-(18.5 %) performed whole procedures supervised and 4-(14.8 %) independently. Twenty-(74 %) trainees and 15-(100 %) instructors judged the model to resemble the anomaly. Seventeen-(63 %) trainees and 13-(86.6 %) instructors rated the material needle-penetrability ≥3/5, compared to human tissue. Sixteen-(59 %) trainees and 13-(86.6 %) instructors rated the material suture holding ≥3/5. Eleven-(73.3 %) trainees and 13-(86.6 %) instructors rated sutures' evenness and edge coaptability ≥3/5. DISCUSSION: Hypospadias is an index operation, which requires precision skills. Simulated training in Paediatric Surgery and Urology is gaining importance. 3D-printed models are gaining a key role in simulated training. The study presents a novel 3D-printed high-fidelity silicon-based hypospadias model designed for hands-on training. A structured pathway to divide a standard hypospadias repair into key steps is displayed to ensure skill acquisition and stabilisation. CONCLUSION: This 3D-printed silicon-based hypospadias model is proven useful for hands-on training. The fidelity can still improve, especially regarding suture holding of the material. LEVEL OF EVIDENCE: LEVEL III.

Postoperative Necrotizing Enterocolitis Following Inguinal Hernia Repair in an Infant: Case Report and Review of the Literature.

Necrotizing enterocolitis (NEC) following postoperative stress is a rare but life-threatening condition in infants. We report a 3-month-old infant who underwent bilateral inguinal hernia repair and developed NEC. This is the first reported case of an infant developing recurrent NEC with stricture formation after herniotomy. Timely recognition and management are vital due to potentially high mortality rates in severe cases. High index of suspicion is crucial for accurate diagnosis and appropriate management.

Conflict-related excess mortality and disability in Northwest Syria.

INTRODUCTION: The Syrian conflict that started in 2011 has been ongoing for over a decade without an end in sight. Estimates regarding excess mortality and conflict-related disability vary widely, and little field research has been done to address this topic. METHODS: A population-based field survey was conducted from 10 to 18 November 2020 in Northwest Syria. Forty-nine clusters were selected using staged sampling based on predefined population distribution maps. Data were collected for the period from 2000 to 2020 and were divided into pre-conflict (2000-2010) and conflict (2011-2020) periods. Mortality rates were compared using the Mann-Whitney U test, and p<0.05 was considered statistically significant. RESULTS: A total of 1483 households were surveyed, for a population of 12 268 people. The crude mortality rate increased 3.55 times between the two periods (p>0.001). In total, 54.3% of war-related deaths were caused by aerial attacks. Despite the continued increase in mortality rates during the conflict period, most deaths from 2017 onwards were related to non-violent causes. Overall, directly and indirectly, the conflict seems to have caused approximately 874 000 excess deaths. A total of 14.9% of households reported having at least one substantial violence-related disability since 2011. CONCLUSION: The conflict caused the tripling of mortality rates in Syria. The estimated excess mortality in our study is higher than previous estimates. From 2017 onwards, most conflict-related deaths were due to non-violent causes. There is a high prevalence of violence-related disabilities in the studied communities. Our data could prove useful for health policymakers.

Bipolar circumcision: A new technique for an old procedure with quantified cosmetic outcome.

BACKGROUND: Circumcision using bipolar diathermy is well established and used widely. It seems to be superior in terms of post operative complications. The cosmetic outcome of the procedure has never been quantitatively described though. AIMS: To describe a modification to performing circumcision with bipolar that involves applying four clamps to the foreskin as it is being amputated with the bipolar so that a consistent length of the mucosal cuff can be obtained with a single almost bloodless cut. METHODS: Prospective case series of all patients circumcised using the 4 clamps traction and bipolar cut technique. The cosmetic outcome was assessed in terms of the length of the mucosal cuff in absolute numbers and in proportion to the penile and glanular length. RESULTS: Seventy four patients were recruited with a median age of 3.5 months. No complications were encountered. The average length of the penis was 40 ± 13 mm and the glans 12 ± 3.6 mm. The average length of the mucosal cuff was 8.4 ± 2.9 mm, and the proportion to total penile length was 21.1% ± 4.7% and to glans length 72% ± 24.1%. CONCLUSION: The four clamp traction method with bipolar circumcision is safe and has a satisfactory cosmetic outcome.

Case Report: Expanding the Phenotypic Spectrum of Timothy Syndrome Type 1: A Sporadic Case With a de novo CACNA1C Pathogenic Variant and Segmental Ileal Dilatation.

Background: Long QT syndactyly syndrome (long QT syndrome type 8), also known as Timothy Syndrome (TS) was first described in 1994 with still <50 case reported in the literature. The full spectrum of the syndrome is not yet known. Results: Here we report a girl who presented with new onset refractory seizures and an undiagnosed cause of intermittent abdominal distention. She also had syndactyly of her fingers and toes and was found to have prolonged QT. Upon further investigations she was found to have a de novo pathogenic variant in CACNA1C, along with Segmental Ileal Dilatation (SID), and subsequently diagnosed with Timothy syndrome. Conclusion: To our knowledge, the association of Timothy Syndrome with Segmental Ileal Dilatation, was not described before.

The "Silk Road": A novel method for inserting transpyloric feeding tubes in low resource settings.

INTRODUCTION: Transpyloric tube (TPT) feeding is used in a multitude of conditions including gastroesophageal reflux disease. We here describe a new simple method to insert TPTs. METHODS: 6 French feeding tube is premeasured nose to xiphisternum, and then another 7cm of length is added and 3-5 silk (4-0) ties are applied to the end of the tube spaced 0.5-1cm apart. The knots are placed in different radial directions, and multiple throws are placed on each knot so as to add bulkiness. The tube is then inserted transnasally to the premeasured length and secured. The child is given a single dose of metoclopramide and placed on his right side for 4h. A plain abdominal x-ray is then performed to confirm adequate TP placement. Following correct placement the patient is tube fed with small volumes every 15-20min. Descriptive data was prospectively collected. RESULTS: 34 patients were recruited, median age 3.5months. All presented with vomiting, and 26 had failure to thrive. 24had successful TP tube placement from the first attempt, 6 from the second attempt, 2 on third attempt, and in 2 placement was unsuccessful. In 28 patients vomiting almost stopped completely. 9 patients had fundoplication, and 1 had gastrostomy placement. 3 patients died during the study because of unknown reasons. CONCLUSION: The silk tie technique is a safe and simple way to treat persistent vomiting and may prove useful in low resourced environments. LEVEL OF EVIDENCE: IV.

Unexplained abdominal distention in a neonate: culprit femoral central venous line extravasation.

Central venous lines are an essential part of neonatal intensive care and are used for infusion of medications and parenteral nutrition (PN). PN is usually given via either peripherally inserted central lines or umbilical venous lines. Occasionally, central venous catheters (CVCs) are inserted in the femoral veins. Extravasation of femoral venous catheter leading to ascites is a rare entity. This report describes the case of a neonate with a femoral CVC, who developed ascites as a result of extravasation of PN. Ascites resolved following the removal of the catheter.

Paediatric inflammatory bowel disease: review with a focus on practice in low- to middle-income countries.

Inflammatory bowel disease (IBD) should be considered in any child with a persistently altered bowel habit. Growth failure may be a consequence and there may also be extra-intestinal manifestations. Oesophago-gastroduodenoscopy and colonoscopy and conventional histopathology are the diagnostic tools of choice in IBD. The identification and management of children with IBD in resource-poor settings is difficult and there are few data on its prevalence in low- and middle-income countries. The main challenges are a lack of resources and infrastructure including trained personnel in settings where there are other priorities for maintaining the health and wellbeing of children. The identification and management of children with inflammatory bowel conditions often depends on the enthusiasm, skill and commitment of a few dedicated individuals. Abbreviations: ADA: Adalimumab; CD: Crohn disease; ECCO: European Crohn's and Colitis Organisation; EEN: exclusive enteral nutrition; ESPGHAN: European Society for Paediatric Gastroenterology Hepatology and Nutrition; FMT: faecal microbiota transplantation; GDP: gross domestic product; HIC: high-income countries; IBD: inflammatory bowel disease; IBDU: inflammatory bowel disease unclassified; IC: ileocolonoscopy; IFX: infliximab; IPAA: ileal pouch anal anastomosis; LMIC: low- and middle-income countries; MH: mucosal healing; OGD: oesophago-gastroduodenoscopy; PCDAI: Paediatric Crohn's Disease Activity Index; PIBD: paediatric inflammatory bowel disease; PUCAI: Paediatric Ulcerative Colitis Activity Index; UC: ulcerative colitis; UGIT: upper gastrointestinal tract; VEO-IBD: very early-onset IBD; WLE: white light endoscopy; 5-ASA: 5 aminosalicylic acid; 6-MP: 6-mercaptopurine.