The Dorsal Skinfold Chamber as a New Tympanic Membrane Wound Healing Model: Intravital Insights into the Pathophysiology of Epithelialized Wounds

<b><i>Background:</i></b> Tympanic membrane perforations (TMPs) are a common complication of trauma and infection. Persisting perforations result from the unique location of the tympanic membrane. The wound is surrounded by air of the middle ear and the external auditory canal. The inadequate wound bed, growth factor, and blood supply lead to circular epithelialization of the perforation’s edge and premature interruption of defect closure. Orthotopic animal models use mechanical or chemical tympanic membrane laceration to identify bioactive wound dressings and overcome premature epithelialization. However, all orthotopic models essentially lack repetitive visualization of the biomaterial-wound interface. Therefore, recent progress in 3D printing of customized wound dressings has not yet been transferred to the unique wound setup of the TMP. Here, we present a novel application for the mice dorsal skinfold chamber (DSC) with an epithelialized full-thickness defect as TMP model. <b><i>Methods:</i></b> A circular 2-mm defect was cut into the extended dorsal skinfold using a biopsy punch. The skinfold was either perforated through both skin layers without prior preparation or perforated on 1 side, following resection of the opposing skin layer. In both groups, the wound was sealed with a coverslip or left unclosed (<i>n</i> = 4). All animals were examined for epithelialization of the edge (histology), size of the perforation (planimetry), neovascularization (repetitive intravital fluorescence microscopy), and inflammation (immunohistology). <b><i>Results:</i></b> The edge of the perforation was overgrown by the cornified squamous epithelium in all pre­parations. Reduction in the perforation’s size was enhanced by application of a coverslip. Microsurgical preparation before biopsy punch perforation and sealing with a coverslip enabled repetitive high-quality intravital fluorescence microscopy. However, spontaneous reduction of the perforation occurred frequently. Therefore, the direct biopsy punch perforation without microsurgical preparation was favorable: spontaneous reduction did not occur throughout 21 days. Moreover, the visualization of the neovascularization was sufficient in intravital microscopy. <b><i>Conclusions:</i></b> The DSC full-thickness defect is a valuable supplement to orthotopic TMP models. Repetitive intravital microscopy of the epithelialized edge enables investigation of the underlying pathophysiology during the transition from the inflammation to the proliferation phase of wound healing. Using established analysis procedures, the present model provides an effective platform for the screening of bioactive materials and transferring progress in tissue engineering to the special conditions of tympanic membrane wound healing.

Acute abdominal pain and nephrotic syndrome: pediatric case reports and review of the literature

Background Acute abdominal pain in nephrotic syndrome (NS) is a well-known clinical symptom and is mainly related to peritonitis. The presence, although rare, of red umbilicus may guide the diagnosis as a suggestive sign of peritonitis also in the non-neonatal period. Instead, the association between intussusception and NS is quite limited. We reviewed all published cases in the literature, and to our knowledge, this is one of the few pediatric cases of spontaneous resolution of intussusception in the setting of NS. Finally, a review of the causes of abdominal pain during the course of NS was made. Cases presentation We report two pediatric patient cases who complained of acute abdominal pain during a relapse episode of their NS. The first case is a 4-year-old boy with NS (fourth relapse) who presented with acute abdominal pain, ascites, and red umbilicus. Our suspect of primary peritonitis was clinically confirmed because of the subsequent appearance of the classical peritoneal signs. The second case is a 4-year-old boy who developed an ileo-ileal intussusception during the treatment of his first NS relapse, with spontaneous reduction. Conclusions Gastrointestinal disorders are frequently encountered in the course of NS. The appearance of acute abdominal pain in children with NS requires quick management, both clinical and instrumental. A multidisciplinary team approach needs to be encouraged to lead to an accurate diagnosis and a correct treatment.

MIDDLE PATH REGIMEN FOR THE MANAGEMENT OF TRAUMATIC DISLOCATION OF KNEE JOINT WITH VASCULAR DEFICIT.

Background: Dislocation of the knee joint is one of the most under-reported orthopaedic emergencies due to its ability to undergo spontaneous reduction. It carries a high risk of involving the popliteal artery and peroneal nerve both acutely, or in the long term. Due to this catastrophic potential of the condition, it has been well established that it warrants prompt diagnosis and management. It may be secondary to ultra-low, low or high velocity trauma which makes every dislocation case unique due to involvement of different joint structures, capsule or fractures of the articulating bones. A broad spectrum of treatment modalities (both conservative and surgical) has been documented for this condition, with the latter showing better results across most studies. In developing countries like India, the nancial chasm is relatively bigger with a major chunk of the population unable to bear the cost of complete surgical management. Objective: To assess the functional outcome in patients with frank knee dislocations with multiligamentous injuries and vascular decit treated by a middle path regimen of an extended period of external xator and immobilization. Method: A prospective study was undertaken from January 2018 to July 2020 involving 10 patients with knee joint dislocations with vascular decit and multiligamentous injury, treated by an extended period of external xator application and immobilization. Fasciotomy was done wherever needed, in association with split thickness skin grafting. The assessments were made using Lysholm knee scoring scale (LKSS), International Knee Documentation Committee Scores (IKDC), range of motion (ROM), antero- posterior tibial translation (AP translation) and overall patient satisfaction on every follow-up. Results: The mean LKSS score was 78.3±6.23, mean IKDC score was 68.17±5.34, mean ROM progressively increased to 135.8⁰ with a mean extension lag of 2.2⁰, while the mean AP tibial translation was noted to be 9.16 mm. No poor result or complication was reported. Conclusion: The middle path regimen provides an affordable alternative for providing a stable knee to patients who are ill-affording and are expected to have a sedentary lifestyle, without indulging into rigorous activities

The Impact of Suture Button Removal in Syndesmosis Fixation

The suture button (SB) device was introduced to negate the need for routine hardware removal in the treatment of syndesmosis injuries. However, a considerable SB removal rate has been reported, and the impact of removal is unknown. This study aimed to evaluate the radiographic and clinical outcomes after removal of SB for syndesmosis fixation. A total of 36 patients who underwent removal surgery after syndesmosis fixation using SB were identified. The mean postoperative time to removal was 12.2 months. On a plain radiograph, tibiofibular clear space (TFCS) was measured and compared at three follow-up time points. In patients with computed tomography (CT) imaging (n = 18), the anterior-to-posterior (A/P) ratio was measured to evaluate changes in quality of reduction. Additionally, clinical outcomes were assessed. There were no significant differences in TFCS between the three follow-up periods. None of the patients exhibited recurrent diastasis after SB removal. Although CT analysis demonstrated malreduction in six patients (33.3%), five of six patients had a subsequent spontaneous reduction of the syndesmosis. Clinically, all patients described the resolution of symptoms related to painful hardware at the final follow-up. Our results demonstrate that SB removal at one year following syndesmosis fixation leads to improved clinical symptoms without negatively impacting the quality of syndesmosis reduction.

Management of ileocolic intussusception in the Czech Republic

Introduction: Ileocolic intussusception is one of the most frequent causes of acute abdomen in infants and toddlers. The purpose of this study was to evaluate the treatment of ileocolic intussusception in the Czech Republic in 2019. Methods: Fourteen departments of paediatric surgery participated in this multicentre retrospective study. A SurveyMonkey Inc. questionnaire was used for anonymous data collection of patients with ileocolic intussusception. Results: In 2019, ileocolic intussusception was diagnosed in 162 patients; median age was 30 months (3 months to 9.5 years). Contrast enema was indicated in 133 patients, primary surgery in 14 patients and spontaneous reduction was found in 15 patients. All departments using contrast enema had a success rate of 89.5%; 12 departments approached the contrast enema procedure under general anaesthesia (including myorelaxation at 7 departments) and 2 departments under sedation. Contrast enema under general anaesthesia with/without myorelaxation was significantly more successful than contrast enema under sedation (108/113, 95.6% vs 11/20, 55%; p<0.0001). In total, 28 patients were treated surgically, in 14 primary surgery was performed. Both surgical treatment and bowel resection were statistically significantly more frequent in departments where contrast enema was performed under sedation in comparison to departments performing contrast enema under general anaesthesia (9/20, 45% vs 19/142, 13.4%; p=0.0018 and 7/9, 77.8% vs 5/19, 26.3% p=0.0166). Conclusion: The success rate of contrast enema in the Czech Republic was 89.5%. The highest success rate is achieved by performing contrast enema under general anaesthesia.

Intraoperative Endoscopy in Transient Adult Jejunojejunal Intussusception

Despite improvements in imaging modalities, causative lead points in adult intussusception may be difficult to diagnose. Such lead points can be malignant, causing recurrence or metastases if left unresected. We describe a case of transient adult jejunojejunal intussusception, in which intraoperative endoscopy was used to confirm the absence of a lead point. A 39-year-old woman with a history of laparoscopic oophorectomy presented with epigastric pain, nausea, and vomiting. Contrast computed tomography revealed jejunojejunal intussusception, with no visible lead point. Spontaneous reduction was confirmed during exploratory laparoscopy. After lysis of adhesions, intraoperative peroral jejunoscopy was performed with the surgeons’ assistance. Endoscopy confirmed the absence of tumor, and bowel resection was avoided. No recurrence has been observed during 24 months of follow-up. Intraoperative endoscopy may provide additional reassurance for the absence of a lead point in cases where preoperative enteroscopy cannot be performed and no lead points can be identified on imaging.

Social and Cognitive Interactions Through an Interactive School Service for RTT Patients at the COVID-19 Time

Background: The closure of all educational institutions and most rehabilitation centres represents a precautionary measure to face the COVID-19 pandemic, but the isolation and social distancing may be particularly challenging for children with special needs and disabilities (SEND), such as Rett Syndrome (RTT). The main aim of this study was to promote cognitive and social interactions among children with RTT through an interactive school program.Methods: The Interactive School palimpsest was composed of moments in which a teacher spoke directly to children with RTT and expected a response through eye gaze, and moments in which storeys-cartoon were presented while tracking the eye gaze of children. We investigated behavioural, social and cognitive parameters.Results: Children participated in both social and cognitive tasks with the spontaneous reduction of stereotypies and with increase in attention. They recalled more significant indexes when music or a song was presented together with a cartoon or a cognitive task.Conclusions: This study provides initial insights in promoting cognitive and social interactions and in the support needs of families with a child with RTT during the COVID-19 pandemic.