Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of... more Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of extensive severe facial injury and tissue loss. Despite the risk of allograft rejection and the post-operative need for lifelong immunosuppression, facial CTA can be used to restore the normal structural appearance and function of the face. Areas of socioeconomic deprivation and armed conflict zones have a high preponderance of patients with facial burns and other severe injuries. However, these regions often also suffer from lack of resources, expert surgical care and limited facilities. The purpose of this manuscript is to provide a comprehensive review of key principles relevant to facial CTA and their potential applicability in such austere environments. We present a concise literature review of the surgical and immunological basis of facial CTA aimed at the plastic surgery readership, as well as issues surrounding organ transplantations in low-and middle-income countries. We then consider the particular challenges posed by austere settings and countries of active armed conflict and discuss how these may impact the suitability of facial CTA for treating severe facial injuries in these circumstances. Facial CTA is recognised as giving huge benefits for patients with severe facial defects with potentially superior results compared with conventional autograft techniques. Its performance in austere settings is limited by scarce resources and increased pre-, intra-and post-operative risks. However, a case can be made for its use even in these more challenging situations when general organ transplantation compliance and expertise input have been addressed.
Plastic and reconstructive surgery. Global open, 2017
Supermicrosurgery is becoming a commonly used technique in various subspecialties of reconstructi... more Supermicrosurgery is becoming a commonly used technique in various subspecialties of reconstructive surgery. However, there is a lack of standardization and validation in novel supermicrosurgical training. Current simulation training programs are not adequately focused on the challenges encountered during clinical supermicrosurgery practice. This article describes the authors' experience utilizing a supermicrosurgery competency-based training curriculum, in a simulation-based environment, toward safe clinical practice for lymphatic submillimeter supermicrovascular surgery. This article demonstrates the senior authors' (I.K.) Halstedian competency-based curriculum for lymphaticovenous anastomosis training. Further, a step-by-step training utilizing the chicken thigh and the living rat high fidelity simulation models, which subsequently allows supervised one-to-one clinical training with verified clinical competency outcomes, are demonstrated.
Background The aim of this article is to evaluate the difference in skills acquisition of two end... more Background The aim of this article is to evaluate the difference in skills acquisition of two end-to-end microvascular anastomosis techniques-the triangulation and biangulation-in early microsurgery training. Method In this study, 32 candidates ranging from medical students to higher surgical trainees underwent a 5-day basic microsurgery course. On days 3 and 5 of the course, candidates performed two end-to-end anastomoses on cryopreserved rat aortas. One anastomosis was performed using the biangulation technique and the other using the triangulation technique. Candidates were randomized to the order of technique performed. Structural patency, errors performed, and suture distribution were evaluated randomly by a blinded reviewer using the anastomosis lapse index score and ImageJ (U.S. National Institutes of Health, Bethesda, MD) Software. Results A total of 128 anastomoses were evaluated during the study period. A total of six anastomoses performed with the biangulation technique, and four anastomoses with the triangulation technique, were physically occluded on day 3 of the course. On day 5, two biangulation technique anastomoses and one triangulation technique produced a nonpatent outcome. There was a statistically significant difference of patency rate between the 2 days of evaluation confirming evidence of skill acquisition but no statistically significant difference between the two techniques in relation to anastomotic patency, errors performed, or suture placement quality. Conclusion The biangulation and triangulation techniques of microvascular anastomosis produce similar outcomes in relation to vessel structural patency and quality of anastomosis when taught in early stages of microsurgery training. Our results suggest that both techniques are equally suitable in training novices, basic microsurgical skills.
Familial hypertrophic cardiomyopathy (FHC) is a genotypically heterogenous disease produced by mu... more Familial hypertrophic cardiomyopathy (FHC) is a genotypically heterogenous disease produced by mutations in sarcomeric proteins. A missense mutation in the o~-tropomyosin gene at amino acid residue 180 (TMGIul80GIy) is a recently reported cause of FftC. Transgenic mice (TG) with mutant TM driven by the MHC promotor (4 lines, 10-40 copy number), die at 3-4 months of age, and at necropsy exhibit 3-fold cardiac enlargement, ventricular hypertrophy, and atrial fibrosis. In order to evaluate in vivo effects of TMGIuI80Gly on LV function and geometry, 2D-guided M-mode and color flow-guided Doppler were performed in 6 TG and 6 littermate controls (WT) aged 3 months. LV mass normalized to body weight (LV/BW) and the ratio of LV wall thickness to cavity (h/r) were significantly greater in TG than WT:
More precise characterization of risk factors for occurring ventricular arrhythmia in patients (p... more More precise characterization of risk factors for occurring ventricular arrhythmia in patients (pts) with primary prevention implantable cardioverter-defibrillator (ICD) therapy is critical. We sought to investigate whether biomarkers of nitric oxide metabolism can predict the occurrence of ventricular tachyarrhythmias and might be used as risk markers in these pts.
Obesity is a serious health hazard. Despite advances in burn care severely obese patients with la... more Obesity is a serious health hazard. Despite advances in burn care severely obese patients with large burns have higher mortality compared with normal-weight patients. The Body Mass Index is the universal measure to define and classify obesity. This study aims to evaluate the effect of Body Mass Index (BMI) on mortality of severe burn patients. A retrospective study of 95 patients treated over 2-year period in a dedicated burn ITU. Mortality was studied in relation to BMI as well as demographic, burn characteristics well as length of hospital stay. Logistic regression model and non-parametric comparison tests were used for analysis. Mean age was 42 ± 22 years (mean ± SD), Total Burn Surface area (TBSA) 33 ± 16%, BMI 29 ± 7.5 (kg/m²) and hospital stay was 37 ± 33 days. Incidence of inhalation injury was 29% and over all mortality was 19%. By logistic regression age, TBSA and inhalation injury were separately associated with mortality. Patients with BMI ≥ 35 (kg/m²) had significantly higher mortality compared with patients with BMI < 25 (kg/m²) [p=0.037 (Fisher's exact test)]. Body Mass Index ≥ 35 (kg/m²) is a tilt point, which is associated with a higher than predicted mortality following burns when compared to burned patients with a normal BMI.
Winning Abstract -Trauma '12, The national conference on trauma medicine. Peer-reviewed at confer... more Winning Abstract -Trauma '12, The national conference on trauma medicine. Peer-reviewed at conference.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2015
Extravasation is an iatrogenic injury that may produce soft tissue necrosis requiring surgical re... more Extravasation is an iatrogenic injury that may produce soft tissue necrosis requiring surgical reconstruction (Rose et al., 2008) and (Goon et al., 2006).(1)(,2) Previous review of extravasation injuries within our hospital showed that early referral to plastic surgeons and washout of high-risk cases lead to favourable outcome in 86% of patients (Gault, 1993).(3) Hospital-wide guidelines were introduced in 2005. This paper closes the audit loop by evaluating extravasation injuries outcome following the introduction of these guidelines. All patients referred to the plastic surgery department for extravasation injuries between October 2008 and October 2009 were reviewed. A favourable outcome was defined as resolution without tissue loss requiring surgical reconstruction. Patients were excluded if they sustained the extravasation in other institution. A total of 82 extravasation injuries in 78 patients were reviewed during the audit period. Mean age was 3.2 years (Median 0.2 years, Minimum 0 day, and maximum 16.7 years). The injuries were more frequent on the left half of the body (52%) and involving the upper limbs (59%). Mean time to referral was 8 h, with 60% of patients referred within 6 h of the injury, 30% in 6-12 h, and 10% referred after more than 12 h 26% of the injuries required washout treatment - the rest was treated conservatively. Tissue necrosis occurred in 3 cases (4%) but required no surgical intervention due to the small area affected. Our audit showed an improved outcome of extravasation injury following introduction of hospital-wide guidelines of early referral to specialist team and washout of high-risk cases.
The widespread use of microsurgery in numerous surgical fields has increased the need for basic m... more The widespread use of microsurgery in numerous surgical fields has increased the need for basic microsurgical training outside of the operating room. The traditional start of microsurgical training has been in undertaking a 5-day basic microsurgery course. In an era characterised by financial constraints in academic and healthcare institutions as well as increasing emphasis on patient safety, there has been a shift in microsurgery training to simulation environments. This paper reviews the stepwise framework of microsurgical skill acquisition providing a cost analysis of basic microsurgery courses in order to aid planning and dissemination of microsurgical training worldwide.
Current educational interventions and training courses in microsurgery are often predicated on th... more Current educational interventions and training courses in microsurgery are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess current training tools in microsurgery education and devise alternative methods that would enhance training. Simulation is an increasingly important tool for educators because, whilst facilitating improved technical proficiency, it provides a way to reduce risks to both trainees and patients. The International Microsurgery Simulation Society has been founded in 2012 in order to consolidate the global effort in promoting excellence in microsurgical training. The society's aim to achieve standarisation of microsurgical training worldwide could be realised through the development of evidence based educational interventions and sharing best practices.
With an increasing emphasis on microsurgery skill acquisition through simulated training, the nee... more With an increasing emphasis on microsurgery skill acquisition through simulated training, the need has been identified for standardised training programmes in microsurgery. We have reviewed microsurgery training courses available across the six continents of the World. Data was collected of relevant published output from PubMed, MEDLINE (Ovid), and EMBASE (Ovid) searches, and from information available on the Internet of up to six established microsurgery course from each of the six continents of the World. Fellowships and courses that concentrate on flap harvesting rather than microsurgical techniques were excluded. We identified 27 cen tres offering 39 courses. Total course length ranged from 20 hours to 1,950 hours. Student toteacher ratios ranged from 2:1 to 8:1. Only twothirds of courses offered in-vivo animal models. Instructions in microvascular endtoend and endtoside anastomoses were common, but peripheral nerve repair or free groin flap transfer were not consistently offered. Methods of assessment ranged from no formal assessment, where an instructor monitored and gave instant feedback, through immediate assessment of patency and critique on quality of repair, to delayed reassessment of patency after a 12 to 24 hours period. Globally, training in micro surgery is heterogeneous, with variations primarily due to resource and regulation of animal experimentation. Despite some merit to diversity in curricula, there should be a global min imum standard for microsurgery training.
Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with t... more Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with the introduction of formal training curricula and work-based assessment tools. Part of this process has been the introduction of revalidation and a greater use of simulation in training delivery. Simulation is an increasingly important tool for educators because it provides a way to reduce risks to both trainees and patients, whilst facilitating improved technical proficiency. Current microsurgery training interventions are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess the potential benefits of alternative models, particularly cross-training, a model now widely used in non-medical areas with significant benefits. Furthermore, with the proliferation of microsurgery training interventions and therefore diversity in length, cost, content and models used, appropriate standardisation will be an important factor to ensure that courses deliver consistent and effective training that achieves appropriate levels of competency. Key research requirements should be gathered and used in directing further research in these areas to achieve on-going improvement of microsurgery training.
Background The continued Israeli blockade of the Gaza Strip, occupied Palestinian territory (oPt)... more Background The continued Israeli blockade of the Gaza Strip, occupied Palestinian territory (oPt), has detrimental eff ects on health care. Palestinian health-care workers have few opportunities for continuous professional development outside the oPt. e-learning and video-conferencing are seen as being key solutions to address the barriers in health care and education in the Gaza Strip. We report the results of a 2 year postgraduate programme in which teleconferencing and e-learning were combined for medical and nursing practitioners working in burn care in the Gaza Strip. The aims in the programme were to improve clinical services, research, and continued education in burn care. We also present a health-care-worker-focused assessment of the programme after the completion of the fi rst academic year.
Keloid scars cause pain, itching, functional limitation, and disfigurement, leading to psychologi... more Keloid scars cause pain, itching, functional limitation, and disfigurement, leading to psychological distress. Progress in treatment regimens is hindered by the lack of a universally accepted outcome measure. The Patient and Observer Scar Assessment Scale is a tool for the assessment of scars, incorporating an assessment by both clinician and patient. This study evaluates its application to keloids and compares it to the widely used Vancouver Scar Scale, which is considered the standard mode of assessment for scars. Three observers using the two scales assessed 34 patients with 41 keloid scars independently. Patients evaluated their own scars simultaneously using the patient component of the Patient and Observer Scar Assessment Scale. Internal consistency, interobserver reliability, and convergent validity were examined. Both components of the Patient and Observer Scar Assessment Scale had high internal consistency (0.82 and 0.86 for patient and observer components, respectively); those rates were higher than the rate for the Vancouver Scar Scale (0.65). Interobserver reliability was "substantial" for the Vancouver Scar Scale (0.65) and "almost perfect" for the observer component of the Patient and Observer Scar Assessment Scale (0.85). Convergent validity was very strong (0.83, p < 0.01), although the patient component did not correlate well with either of the observer scales. Patients rated their scars worse than the observer average for 83 percent of the scars, and were influenced by color, stiffness, thickness, and irregularity (p < 0.05). The findings support the use of the Patient and Observer Scar Assessment Scale as a reliable and valid method of assessing keloid scars in a clinical context. Diagnostic, II.
Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of... more Facial composite tissue allotransplantation (CTA) is a powerful reconstructive option in cases of extensive severe facial injury and tissue loss. Despite the risk of allograft rejection and the post-operative need for lifelong immunosuppression, facial CTA can be used to restore the normal structural appearance and function of the face. Areas of socioeconomic deprivation and armed conflict zones have a high preponderance of patients with facial burns and other severe injuries. However, these regions often also suffer from lack of resources, expert surgical care and limited facilities. The purpose of this manuscript is to provide a comprehensive review of key principles relevant to facial CTA and their potential applicability in such austere environments. We present a concise literature review of the surgical and immunological basis of facial CTA aimed at the plastic surgery readership, as well as issues surrounding organ transplantations in low-and middle-income countries. We then consider the particular challenges posed by austere settings and countries of active armed conflict and discuss how these may impact the suitability of facial CTA for treating severe facial injuries in these circumstances. Facial CTA is recognised as giving huge benefits for patients with severe facial defects with potentially superior results compared with conventional autograft techniques. Its performance in austere settings is limited by scarce resources and increased pre-, intra-and post-operative risks. However, a case can be made for its use even in these more challenging situations when general organ transplantation compliance and expertise input have been addressed.
Plastic and reconstructive surgery. Global open, 2017
Supermicrosurgery is becoming a commonly used technique in various subspecialties of reconstructi... more Supermicrosurgery is becoming a commonly used technique in various subspecialties of reconstructive surgery. However, there is a lack of standardization and validation in novel supermicrosurgical training. Current simulation training programs are not adequately focused on the challenges encountered during clinical supermicrosurgery practice. This article describes the authors' experience utilizing a supermicrosurgery competency-based training curriculum, in a simulation-based environment, toward safe clinical practice for lymphatic submillimeter supermicrovascular surgery. This article demonstrates the senior authors' (I.K.) Halstedian competency-based curriculum for lymphaticovenous anastomosis training. Further, a step-by-step training utilizing the chicken thigh and the living rat high fidelity simulation models, which subsequently allows supervised one-to-one clinical training with verified clinical competency outcomes, are demonstrated.
Background The aim of this article is to evaluate the difference in skills acquisition of two end... more Background The aim of this article is to evaluate the difference in skills acquisition of two end-to-end microvascular anastomosis techniques-the triangulation and biangulation-in early microsurgery training. Method In this study, 32 candidates ranging from medical students to higher surgical trainees underwent a 5-day basic microsurgery course. On days 3 and 5 of the course, candidates performed two end-to-end anastomoses on cryopreserved rat aortas. One anastomosis was performed using the biangulation technique and the other using the triangulation technique. Candidates were randomized to the order of technique performed. Structural patency, errors performed, and suture distribution were evaluated randomly by a blinded reviewer using the anastomosis lapse index score and ImageJ (U.S. National Institutes of Health, Bethesda, MD) Software. Results A total of 128 anastomoses were evaluated during the study period. A total of six anastomoses performed with the biangulation technique, and four anastomoses with the triangulation technique, were physically occluded on day 3 of the course. On day 5, two biangulation technique anastomoses and one triangulation technique produced a nonpatent outcome. There was a statistically significant difference of patency rate between the 2 days of evaluation confirming evidence of skill acquisition but no statistically significant difference between the two techniques in relation to anastomotic patency, errors performed, or suture placement quality. Conclusion The biangulation and triangulation techniques of microvascular anastomosis produce similar outcomes in relation to vessel structural patency and quality of anastomosis when taught in early stages of microsurgery training. Our results suggest that both techniques are equally suitable in training novices, basic microsurgical skills.
Familial hypertrophic cardiomyopathy (FHC) is a genotypically heterogenous disease produced by mu... more Familial hypertrophic cardiomyopathy (FHC) is a genotypically heterogenous disease produced by mutations in sarcomeric proteins. A missense mutation in the o~-tropomyosin gene at amino acid residue 180 (TMGIul80GIy) is a recently reported cause of FftC. Transgenic mice (TG) with mutant TM driven by the MHC promotor (4 lines, 10-40 copy number), die at 3-4 months of age, and at necropsy exhibit 3-fold cardiac enlargement, ventricular hypertrophy, and atrial fibrosis. In order to evaluate in vivo effects of TMGIuI80Gly on LV function and geometry, 2D-guided M-mode and color flow-guided Doppler were performed in 6 TG and 6 littermate controls (WT) aged 3 months. LV mass normalized to body weight (LV/BW) and the ratio of LV wall thickness to cavity (h/r) were significantly greater in TG than WT:
More precise characterization of risk factors for occurring ventricular arrhythmia in patients (p... more More precise characterization of risk factors for occurring ventricular arrhythmia in patients (pts) with primary prevention implantable cardioverter-defibrillator (ICD) therapy is critical. We sought to investigate whether biomarkers of nitric oxide metabolism can predict the occurrence of ventricular tachyarrhythmias and might be used as risk markers in these pts.
Obesity is a serious health hazard. Despite advances in burn care severely obese patients with la... more Obesity is a serious health hazard. Despite advances in burn care severely obese patients with large burns have higher mortality compared with normal-weight patients. The Body Mass Index is the universal measure to define and classify obesity. This study aims to evaluate the effect of Body Mass Index (BMI) on mortality of severe burn patients. A retrospective study of 95 patients treated over 2-year period in a dedicated burn ITU. Mortality was studied in relation to BMI as well as demographic, burn characteristics well as length of hospital stay. Logistic regression model and non-parametric comparison tests were used for analysis. Mean age was 42 ± 22 years (mean ± SD), Total Burn Surface area (TBSA) 33 ± 16%, BMI 29 ± 7.5 (kg/m²) and hospital stay was 37 ± 33 days. Incidence of inhalation injury was 29% and over all mortality was 19%. By logistic regression age, TBSA and inhalation injury were separately associated with mortality. Patients with BMI ≥ 35 (kg/m²) had significantly higher mortality compared with patients with BMI < 25 (kg/m²) [p=0.037 (Fisher's exact test)]. Body Mass Index ≥ 35 (kg/m²) is a tilt point, which is associated with a higher than predicted mortality following burns when compared to burned patients with a normal BMI.
Winning Abstract -Trauma '12, The national conference on trauma medicine. Peer-reviewed at confer... more Winning Abstract -Trauma '12, The national conference on trauma medicine. Peer-reviewed at conference.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2015
Extravasation is an iatrogenic injury that may produce soft tissue necrosis requiring surgical re... more Extravasation is an iatrogenic injury that may produce soft tissue necrosis requiring surgical reconstruction (Rose et al., 2008) and (Goon et al., 2006).(1)(,2) Previous review of extravasation injuries within our hospital showed that early referral to plastic surgeons and washout of high-risk cases lead to favourable outcome in 86% of patients (Gault, 1993).(3) Hospital-wide guidelines were introduced in 2005. This paper closes the audit loop by evaluating extravasation injuries outcome following the introduction of these guidelines. All patients referred to the plastic surgery department for extravasation injuries between October 2008 and October 2009 were reviewed. A favourable outcome was defined as resolution without tissue loss requiring surgical reconstruction. Patients were excluded if they sustained the extravasation in other institution. A total of 82 extravasation injuries in 78 patients were reviewed during the audit period. Mean age was 3.2 years (Median 0.2 years, Minimum 0 day, and maximum 16.7 years). The injuries were more frequent on the left half of the body (52%) and involving the upper limbs (59%). Mean time to referral was 8 h, with 60% of patients referred within 6 h of the injury, 30% in 6-12 h, and 10% referred after more than 12 h 26% of the injuries required washout treatment - the rest was treated conservatively. Tissue necrosis occurred in 3 cases (4%) but required no surgical intervention due to the small area affected. Our audit showed an improved outcome of extravasation injury following introduction of hospital-wide guidelines of early referral to specialist team and washout of high-risk cases.
The widespread use of microsurgery in numerous surgical fields has increased the need for basic m... more The widespread use of microsurgery in numerous surgical fields has increased the need for basic microsurgical training outside of the operating room. The traditional start of microsurgical training has been in undertaking a 5-day basic microsurgery course. In an era characterised by financial constraints in academic and healthcare institutions as well as increasing emphasis on patient safety, there has been a shift in microsurgery training to simulation environments. This paper reviews the stepwise framework of microsurgical skill acquisition providing a cost analysis of basic microsurgery courses in order to aid planning and dissemination of microsurgical training worldwide.
Current educational interventions and training courses in microsurgery are often predicated on th... more Current educational interventions and training courses in microsurgery are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess current training tools in microsurgery education and devise alternative methods that would enhance training. Simulation is an increasingly important tool for educators because, whilst facilitating improved technical proficiency, it provides a way to reduce risks to both trainees and patients. The International Microsurgery Simulation Society has been founded in 2012 in order to consolidate the global effort in promoting excellence in microsurgical training. The society's aim to achieve standarisation of microsurgical training worldwide could be realised through the development of evidence based educational interventions and sharing best practices.
With an increasing emphasis on microsurgery skill acquisition through simulated training, the nee... more With an increasing emphasis on microsurgery skill acquisition through simulated training, the need has been identified for standardised training programmes in microsurgery. We have reviewed microsurgery training courses available across the six continents of the World. Data was collected of relevant published output from PubMed, MEDLINE (Ovid), and EMBASE (Ovid) searches, and from information available on the Internet of up to six established microsurgery course from each of the six continents of the World. Fellowships and courses that concentrate on flap harvesting rather than microsurgical techniques were excluded. We identified 27 cen tres offering 39 courses. Total course length ranged from 20 hours to 1,950 hours. Student toteacher ratios ranged from 2:1 to 8:1. Only twothirds of courses offered in-vivo animal models. Instructions in microvascular endtoend and endtoside anastomoses were common, but peripheral nerve repair or free groin flap transfer were not consistently offered. Methods of assessment ranged from no formal assessment, where an instructor monitored and gave instant feedback, through immediate assessment of patency and critique on quality of repair, to delayed reassessment of patency after a 12 to 24 hours period. Globally, training in micro surgery is heterogeneous, with variations primarily due to resource and regulation of animal experimentation. Despite some merit to diversity in curricula, there should be a global min imum standard for microsurgery training.
Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with t... more Plastic surgery training worldwide has seen a thorough restructuring over the past decade, with the introduction of formal training curricula and work-based assessment tools. Part of this process has been the introduction of revalidation and a greater use of simulation in training delivery. Simulation is an increasingly important tool for educators because it provides a way to reduce risks to both trainees and patients, whilst facilitating improved technical proficiency. Current microsurgery training interventions are often predicated on theories of skill acquisition and development that follow a 'practice makes perfect' model. Given the changing landscape of surgical training and advances in educational theories related to skill development, research is needed to assess the potential benefits of alternative models, particularly cross-training, a model now widely used in non-medical areas with significant benefits. Furthermore, with the proliferation of microsurgery training interventions and therefore diversity in length, cost, content and models used, appropriate standardisation will be an important factor to ensure that courses deliver consistent and effective training that achieves appropriate levels of competency. Key research requirements should be gathered and used in directing further research in these areas to achieve on-going improvement of microsurgery training.
Background The continued Israeli blockade of the Gaza Strip, occupied Palestinian territory (oPt)... more Background The continued Israeli blockade of the Gaza Strip, occupied Palestinian territory (oPt), has detrimental eff ects on health care. Palestinian health-care workers have few opportunities for continuous professional development outside the oPt. e-learning and video-conferencing are seen as being key solutions to address the barriers in health care and education in the Gaza Strip. We report the results of a 2 year postgraduate programme in which teleconferencing and e-learning were combined for medical and nursing practitioners working in burn care in the Gaza Strip. The aims in the programme were to improve clinical services, research, and continued education in burn care. We also present a health-care-worker-focused assessment of the programme after the completion of the fi rst academic year.
Keloid scars cause pain, itching, functional limitation, and disfigurement, leading to psychologi... more Keloid scars cause pain, itching, functional limitation, and disfigurement, leading to psychological distress. Progress in treatment regimens is hindered by the lack of a universally accepted outcome measure. The Patient and Observer Scar Assessment Scale is a tool for the assessment of scars, incorporating an assessment by both clinician and patient. This study evaluates its application to keloids and compares it to the widely used Vancouver Scar Scale, which is considered the standard mode of assessment for scars. Three observers using the two scales assessed 34 patients with 41 keloid scars independently. Patients evaluated their own scars simultaneously using the patient component of the Patient and Observer Scar Assessment Scale. Internal consistency, interobserver reliability, and convergent validity were examined. Both components of the Patient and Observer Scar Assessment Scale had high internal consistency (0.82 and 0.86 for patient and observer components, respectively); those rates were higher than the rate for the Vancouver Scar Scale (0.65). Interobserver reliability was "substantial" for the Vancouver Scar Scale (0.65) and "almost perfect" for the observer component of the Patient and Observer Scar Assessment Scale (0.85). Convergent validity was very strong (0.83, p < 0.01), although the patient component did not correlate well with either of the observer scales. Patients rated their scars worse than the observer average for 83 percent of the scars, and were influenced by color, stiffness, thickness, and irregularity (p < 0.05). The findings support the use of the Patient and Observer Scar Assessment Scale as a reliable and valid method of assessing keloid scars in a clinical context. Diagnostic, II.
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Papers by Ali Ghanem